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It’s Time to Streamline and Simplify Medicaid’s Home and Community-Based Services

Washington, DC – Today, the Bipartisan Policy Center released federal policy recommendations to streamline and simplify Medicaid’s home and community-based services. The report, Streamlining and Simplifying State HCBS Authorities, identifies the opportunities to reduce administrative complexities and improve experiences of the millions of Americans needing long-term services and supports and home and community-based services (HCBS).

As the U.S. population ages, the need for a broad range of paid and unpaid medical and personal care assistance will grow. About half of 65-year-olds will need long-term services and supports at some point in their life. Home and community-based services include a wide range of medical and non-medical services, including:

  • Private duty nursing or homemaker/home health aide services;
  • Case management;
  • Rehabilitation services, including those related to behavioral health; and
  • Adult day health services.

All states offer home and community-based services, either through benefits, waivers, state plan amendments (SPAs), or a combination of those. Often, states combine waiver authorities and state plan amendments to design and administer multiple programs with different sets of services, eligibility rules, federal renewal periods, and other features. This creates a patchwork of services with inequitable access that is confusing for consumers to navigate and for states to administer.

In recent years members of Congress introduced numerous bills to expand the availability of Medicaid home and community-based services, but these measures have little bipartisan support. While most of the national conversation is focused on strengthening infrastructure and the workforce, Congress is considering expanding the availability of Medicaid home and community-based services as part of a larger reconciliation bill. Simplifying and streamlining the process would reduce administrative complexity—a proposal with support from both sides of the aisle.

BPC recommends:

  • Congress should streamline and simplify Medicaid home and community-based services waiver and state plan administration authorities by creating a single, consolidated plan that retains much of the flexibility of the existing programs. Congress should phase out existing HCBS waivers and SPAs and require states to deliver HCBS through the new SPA within five years of enactment.
  • The Centers for Medicare and Medicaid Services (CMS) should provide clarification on the 1915(i) option to phase-in coverage and extend that option to the new consolidated SPA.
  • CMS should provide comprehensive technical assistance to states during the transition to the new state plan authority. During this transition, CMS should collaborate with the Administration of Community Living, and Congress should provide additional resources to CMS for providing technical assistance.

“Our recommendations are especially timely in the wake of the high mortality rates in nursing homes during the pandemic,” said Katherine Hayes, BPC director of health policy. “There are millions of Americans who need assistance with daily activities but who prefer to receive care in their home. Streamlining home and community-based services into a single state plan option strikes a balance between simplifying administrative complexity and providing states with budget predictability, while expanding access to services.”

Arnold Ventures supported the health team’s work in writing this report.

Download the report