Section 1915(b)/(c) Waiver Programs
Increasingly, States are expressing an interest in providing long-term care services in a managed care environment or using a limited pool of providers. In addition to providing traditional long-term care State plan services (e.g., home health, personal care, institutional services), many States are proposing to include non-traditional home and community-based "1915(c)-like" services (e.g., homemaker services, adult day health services, respite care) in their managed care programs. There is no authority under 1915(b) to cover individuals in a special eligibility category (the 42 CFR 435.217 group) who are only Medicaid eligible through a link to a 1915(c) waiver. For these reasons, several States have opted to simultaneously utilize authorities of the 1915(b) and 1915(c) programs to provide a continuum of services to disabled and/or elderly populations. In essence, States use the 1915(b) authority to limit freedom of choice, and use the 1915(c) authority to provide the home and community-based services and expand Medicaid eligibility to the 435.217 group.
Concurrent 1915(b)/(c) Programs:
States can implement 1915(b) and 1915(c) concurrent waivers as long as all Federal requirements for both waiver programs are met. Therefore, when submitting applications for concurrent 1915(b)/(c) programs, States must submit a separate application for each waiver type and satisfy all of the applicable requirements. For example, States must demonstrate cost neutrality in the 1915(c) waiver and cost effectiveness in the 1915(b) waiver. States must also comply with the separate reporting requirements for each waiver. Because the waivers are approved for different time periods, renewal requests must be prepared separately and submitted at different points in time. Meeting these separate requirements is somewhat cumbersome for States, and can be a potential barrier for States that are considering going forward with such a program. However, the ability to develop an innovative managed care program that integrates home and community-based services with traditional State plan services is appealing enough to some States to outweigh the potential barriers.
Current State Initiatives:
The Texas STAR+PLUS program, approved in January 1998, was the first concurrent 1915(b)/(c) program to be implemented. This mandatory program, which serves disabled and elderly beneficiaries in Harris County (Houston), integrates acute and long term care services through a managed care delivery system consisting of three managed care organizations (MCOs) and a primary care case management system (PCCM). The majority of STAR+PLUS enrollees are dually eligible for Medicaid and Medicare. Although STAR+PLUS is a Medicaid program and does not restrict Medicare freedom of choice, an enhanced drug benefit is provided as an incentive to dual eligibles who elect to enroll in the same MCO for their Medicaid and Medicare services. Care coordination is an essential component of the STAR+PLUS model.
Michigan's Medicaid Prepaid Specialty Mental Health and Substance Abuse Services and Combination 1915(b)/(c) Medicaid Prepaid Specialty Services and Supports for Persons with Developmental Disabilities program was approved in June 1998. Unlike the STAR+PLUS program, which integrates acute and long term care, Michigan's program "carves out" specialty mental health, substance abuse, and developmental disabilities services and supports, and provides these services under a prepaid shared risk arrangement. The purpose of this program is to provide beneficiaries an opportunity to experience "person-centered" assessment and planning approaches that provide a wider, more flexible, and mutually negotiated set of supports and services; thus, enabling such individuals to exercise and experience greater choice and control.
For more information regarding 1915(b)/(c) concurrent waivers, please E-mail dewaivers@cms.hhs.gov.
For more information about community-based managed care for long-term care, click here to go to HCFA's PACE site.
