States can offer a variety of services under a State Plan Home and Community-Based Services (HCBS) benefit. People must meet State-defined criteria based on need and typically get a combination of acute-care medical services (like dental services, skilled nursing services) and long-term services (like respite, case management, supported employment and environmental modifications).

1915(i) State plan HCBS: State Options

• Target the HCBS benefit to one or more specific populations
• Establish separate additional needs-based criteria for individual HCBS
• Establish a new Medicaid eligibility group for people who get State plan HCBS
• Define the HCBS included in the benefit, including State- defined and CMS-approved “other services” applicable to the population
• Option to allow any or all HCBS to be self-directed

1915(i) State plan HCBS Guidelines

States can develop the HCBS benefit(s)to meet the specific needs of a population(s) within Federal guidelines, including:

• Establish a process to ensure that assessments and evaluations are independent and unbiased
• Ensure that the benefit is available to all eligible individuals within the State
• Ensure that measures will be taken to protect the health and welfare of participants
• Provide adequate and reasonable provider standards to meet the needs of the target population
• Ensure that services are provided in accordance with a plan of care
• Establish a quality assurance, monitoring and improvement strategy for the benefit. See HCBS Quality information. 

1915(i) HCBS Application & Approval Process

The State Medicaid agency must submit a State plan amendment to CMS for review and approval to establish a 1915(i) HCBS benefit. State plan HCBS benefits don’t have a time limit on approval except when States choose to target the benefit to a specific population(s). When a State targets the benefit, approval periods are for 5 years, with the option to renew with CMS approval for additional 5-year periods. 

Provisions States Can Choose Not to Apply

Comparability of Services: States can make waiver services available only to people with specific needs and risk factors.For example, States can use this authority to target services to the elderly, technology-dependent children, people with behavioral health conditions, or people with intellectual disabilities.States might also choose to target services on the basis of disease or condition, such as Acquired Immune Deficiency Syndrome. (Section 1902(a)(10)(B)) http://www.socialsecurity.gov/OP_Home/ssact/title19/1902.htm

Income & Resources Rules Applicable in the Community: States can provide Medicaid to people who would otherwise be eligible only in an institutional setting, often due to the income and resources of a spouse or parent. States can also use spousal impoverishment rules to determine financial eligibility for waiver services. (Section 1902(a)(10)(C)(i)(III)) http://www.socialsecurity.gov/OP_Home/ssact/title19/1902.htm#act-1902-a-10-c-i