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Streamlining and Simplifying State HCBS Authorities

Congress is considering legislation to expand the availability of Medicaid home and community-based services (HCBS) by making additional resources available to states as part of a larger reconciliation bill. Although the reconciliation bill does not have bipartisan support, Democrats and Republicans have historically supported efforts to expand HCBS. Policymakers support expansion for several reasons, including a recognition that individuals prefer to receive services at home and in the community. Regardless of the outcome of the pending reconciliation legislation, Congress should consider additional steps beyond funding that would improve the administratively complex and piecemeal structure for HCBS authorities.

This report focuses on streamlining and simplifying states’ HCBS waiver and state plan authorities into a single state plan amendment (SPA), with the goal of reducing complexity for states administering the programs and for beneficiaries navigating the system. Streamlining and simplifying the program would make services more uniform from state to state and across populations within a state. Ultimately, this change should improve access to services.

The patchwork of waivers and SPAs that states use to deliver HCBS has created challenges for states and beneficiaries alike and has resulted in divergent levels of access to services both within and between states. Historically, states have relied on 1915(c) waivers to provide HCBS, as these waivers allow states to target services to certain subpopulations and provide states with budget certainty. In 2020, of the 254 active 1915(c) waivers, most targeted individuals with intellectual disabilities (91 waivers), those with physical disabilities (86 waivers), and seniors ages 65 and older (64 waivers). Multiple 1915(c) waivers have enabled states to target different populations or provide different services, with some states relying on up to 11 waivers at once.

The use of multiple waivers or a combination of waivers and state plan amendments creates an enormously complex system for states to manage and beneficiaries to navigate. States often have to administer multiple programs and benefit packages with different eligibility requirements. Beneficiaries must navigate the different sets of requirements to identify the pathway most likely to meet their needs. Additionally, the current structure encourages states to rely heavily on multiple waivers, which can lead to inequitable access to services within a state. For example, two residents of a state may have similar diagnoses and HCBS needs but may not be eligible to receive the same services due to targeting allowed under 1915(c) waivers.

Although most of the national conversation around HCBS expansion is focused on increasing the number of people served and strengthening the infrastructure and workforce that care for them, simplifying and streamlining states’ HCBS authorities by creating a single SPA would reduce complexity in the current system. This streamlining would enable states to better design and administer their HCBS programs around the needs of the beneficiary, while also improving the beneficiary experience.

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Summary of Recommendations

Streamlining and Simplifying Medicaid HCBS Authorities

A. Congress should streamline and simplify Medicaid HCBS waiver and SPA authorities by creating a single, consolidated SPA that retains much of the flexibility of the existing HCBS waiver authorities and state plan options. Congress should phase out existing HCBS waivers and SPAs and require states to deliver HCBS through the new SPA within five years of enactment.

B. The Centers for Medicare & Medicaid Services (CMS) should provide clarification on the 1915(i) option to phase-in coverage and extend that option to the new consolidated SPA.

C. 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.

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