What Does an “Option” Mean?

To explain this, we need a very quick overview of how Medicaid works.  In order to receive federal matching funds, states must abide by the federal Medicaid law.  This law basically defines what states: 1) must do; 2) can choose to do (referred to as an “option”); and 3) cannot do.  As long as states comply with the federal law, they are free to set their own guidelines regarding eligibility and services.

However, states can request to do other than that specified in the law by applying for a waiver. There are currently nearly 300 waivers in effect across the country.

States that wish to provide most services to people with disabilities in the community instead of institutional settings must apply for a Section 1915(c) Home and Community-Based Services (HCBS) Waiver.  While most states have these kinds of waivers, there are problems with them as they allow states to limit eligibility and services.

There are a number of reasons why the CFC option would be better for people with disabilities. The most important ones are outlined in the chart below comparing what states are allowed to do under each.

The other very important benefit is that an HCBS option would provide the legitimacy and prominence that a waiver does not have. For the first time, HCBS would be on the list of what states can chose to do instead of the exception to that list. In other words, the option would help to expedite an end to Medicaid’s institutional bias.

No. The 1915(c) waiver will still be allowed. States would simply be allowed to choose the CFC option. However, if a state chooses the CFC option, they would have to adhere to its higher standards (no caps on services, no waiting lists, no geographic restrictions.)

On July 24, President Obama met with twelve representatives of the disability community, along with Attorney General Holder and Secretary of Labor Solis.  The Arc and UCP’s Marty Ford participated in the meeting representing The Arc and UCP as well as the Consortium for Citizens with Disabilities.  A broad range of issues were addressed, including Olmstead enforcement, health care reform, and the need to end the institutional bias in Medicaid. The disability community representatives came away believing that the President, his Cabinet representatives, and his senior White House staff are committed to working with the disability community to improve home and community based services.

On August 27, as a follow-up to the meeting with President Obama and his cabinet heads, a group of advocates for home and community-based long-term services and supports met with Nancy-Ann DeParle, Counselor to the President and Director of the White House Office of Health Reform, and other senior staff at the White House to discuss the Community First Choice Option. The meeting participants had a frank and productive discussion concerning the possible opportunities and barriers of including CFC Option in the final health reform legislation. 

* Activities of daily living (ADLs). These include eating, toileting, grooming, dressing, bathing, and transferring.

 

* Instrumental activities of daily living (IADLs). These include meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; communicating by phone and other media; and traveling around and participating in the community.

* Health-related tasks.  Health-related tasks are defined as those tasks that can be delegated or assigned by licensed health-care professionals under state law. 

- Specify that services would be performed by an attendant through hands-on assistance, supervision, or cueing. 

- Specify that services would also include assistance in learning the skills necessary for the individual to accomplish these tasks him/herself; back-up systems; and voluntary training on selection and management of attendants. 

- Exclude certain expenditures, including room and board; services provided under IDEA and the Rehabilitation Act; assistive technology devices and services; durable medical equipment; and home modifications.

- Require that there be a written plan for home and community based services.

- Require that services are made available statewide and that they be provided in the most integrated setting appropriate for the individual.

- Require services to be provided regardless of age, disability, or type of services needed.

- Require states to establish and maintain a comprehensive, continuous quality assurance system.

- Require service delivery models to include consumer directed, agency-based, and other models, and require states to comply with all federal and state labor laws.

- Require states to establish a Development and Implementation Council, the majority of whose members must be individuals with disabilities, elderly individuals, and their representatives.

The federal government would provide more funding to states that use it. The CFC option provides a 6% increase in the federal medical assistance percentage (FMAP) for home and community based services.

There is no way to know at this point.  Now that health care reform has been signed into law, advocates will need to work hard to encourage their states to use the option. 

It is worth noting, however, that some states already provide community based services only and serve people with disabilities well despite the low bar set by the 1915(c) waiver. In Vermont, for example, all Medicaid funding goes toward community-based housing and everyone lives in homes with fewer than seven people.  Learn more about how state Medicaid HCBS programs rank in UCP’s report, “A Case for Inclusion 2009.”