Reimbursement Under the Medicaid Home and Community Based Services Waivers

Overview of Home and Community Based Services Waivers

The Medicaid Home and Community Based Services (HCBS) waiver program is authorized under Section 1915(c) of the Social Security Act. Through the HCBS waiver program, a Medicaid beneficiary can receive a wide range of services designed to allow the individual to live in their home or community and avoid institutionalized care.

Services under the HCBS waiver program may be a combination of standard medical services and non-medical services. Standard services may include, but are not limited to:

• Case management (support and service coordination);
• In-home care (home health aide and personal care attendants); and
• Habilitation services (both day and residential).

Currently, 47 states, including Kansas and the District of Columbia, have HCBS waivers approved with the Centers for Medicare and Medicaid Services (CMS). The only states that do not have an approved 1915(c) waiver with CMS are Arizona, Rhode Island, and Vermont.

In Kansas, the HCBS waiver programs are overseen by the Kansas Department for Aging and Disability Services (KDADS) in conjunction with the state Medicaid agency, the Kansas Department for Health and Environment (KDHE). The State has contracted with three Managed Care Organizations to deliver Medicaid services to eligible individuals, including individuals on HCBS waivers.

HCBS Waivers in Kansas

Currently, KanCare allows the State to administer all its HCBS waiver services through managed care. There are seven separate 1915(c) HCBS waivers: Autism (AU), Frail Elderly (FE), Intellectual and Developmental Disability (I/DD), Physical Disability (PD), Serious Emotional Disturbance (SED), Technology Assisted (TA), and Brain Injury (BI). The State is in the process of developing an additional waiver to serve individuals with I/DD.

To participate in a HCBS waiver, the individual requiring services must be financially and functionally eligible for Medicaid. Individuals are financially eligible at no additional cost to the individual if their income is less than 300 percent of the Federal Benefit Rate, which is the maximum amount payable under Supplemental Security Income. In 2023, this amount is $2,742 per spouse per month. If an individual’s income is above this amount, the individual must share in the cost of care. The cost sharing amount depends on the individual and is called the “client obligation.” The client obligation is paid directly by the client to a medical provider, not to the State of Kansas nor to a KanCare Managed Care Organization (MCO).

Individuals on the HCBS waivers receive services through individual providers that are contracted through MCOs. Those providers are then reimbursed through KanCare for providing those services. Rates vary by service and by waiver. This can result in different reimbursement rates for the same service if it is offered on multiple waivers. Due to rising costs to provide these services, there have been efforts to increase the rates at which HCBS services are reimbursed. Additional information for each of the seven HCBS waivers follows.

Autism (AU)

The AU waiver provides services to children who have been diagnosed with an Autism Spectrum Disorder. Children are eligible for services from the time of diagnosis until their sixth birthday. Autism services are limited to three years; however, an additional year may be submitted for approval.

The AU waiver offers the following services:

• Family Adjustment Counseling – This service offers counseling services from a licensed mental health provider to help the family address the child’s diagnosis and daily needs;
• Peer-to-peer Parent Support Training – This service assists family members in acquiring the knowledge and skills to address the child’s specific needs and to develop the family’s problem-solving skills, coping mechanisms, and strategies for the child’s symptom and behavior management; and
• Respite Care – This service offers temporary direct care and supervision of the child to provide relief to families and caregivers.

Additionally, the Medicaid state plan offers the following services which were previously part of the AU waiver:

• Consultative Clinical and Therapeutic Services – This service focuses on improving behavioral challenges related to the child’s diagnosis. The provider teaches skills based on the child and family’s strengths and needs, develops the individual behavior plan/plan of care (IBP/POC), coordinates services, provides training and technical assistance, and monitors the child’s progress within the program;
• Intensive Individual Supports – This service assists in acquiring, retaining, improving, and generalizing skills to successfully function in the home and community; and
• Interpersonal Communication Therapy (ICT) – This service aims to improve social communication symptoms related to the child’s diagnosis, including the development of conversation, unplanned communication, and verbal and nonverbal communication skills.

Frail Elderly (FE)

The FE waiver provides home and community based services to Kansas seniors as an alternative to nursing facility care. The waiver serves those individuals 65 and older who meet the Medicaid nursing facility threshold score and are financially eligible for Medicaid.

The FE waiver offers the following 12 services, which vary in reimbursement rates and frequency of utilization, though an individual may not want or need to use all services offered:

• Adult Day Care – This service provides activities meeting the needs and interests of the person to help them maintain physical and social function, including basic nursing and daily supervision or physical assistance with eating, mobility, bathing, and dressing;
• Assistive Technology – This service provides adaptive equipment, assistive technology, or home modifications to enhance an individual’s independence or abilities;
• Personal Care Services – This service provides supervision or physical assistance with instrumental activities of daily living, health maintenance activities, and in some cases, socialization or recreation;
• Financial Management Services – This service provides administrative and payroll services for individuals who choose to self-direct some or all of their services;
• Home Telehealth – This service is a remote monitoring system that includes education, counseling, and nursing supervision. It allows the person to manage their health and recognize issues before it declines. The system is monitored by a nurse who is alerted if survey responses or vital sign measurements show a need for follow-up;
• Medication Reminder – This service provides a scheduled reminder to the person when it is time to take their medications. This service may include a medication dispenser which stores and dispenses medication at the appropriate time;
• Nursing Evaluation Visit – This service offers an evaluation completed by a nurse to see which personal care services worker may best meet the needs and wants of the person;
• Oral Health Services – This service offers dental services based on the person’s level of need, including dental procedures and denture-related costs;
• Personal Emergency Response – This service provides electronic devices with portable buttons worn by the person to provide access to assistance or emergency help at any time of day;
• Wellness Monitoring – This service allows regularly scheduled nursing visits to check a person’s health status and to monitor for changes in health and wellbeing;
• Comprehensive Support – This service offers one-on-one support and observation to supervise and assist with incidental care as needed to meet the person’s health and welfare needs, not including hands-on nursing; and
• Enhanced Care Services – This service provides immediate supervision or physical assistance with tasks such as toileting, transferring, mobility, medication reminders, and contact with a medical professional in the event of an emergency while the participant is sleeping.

Intellectual and Developmental Disability (I/DD)

The I/DD waiver provides services to individuals five years of age and older who meet the definition of intellectual disability, have a developmental disability, or are eligible for care in an intermediate care facility for individuals with intellectual disabilities. Those with a developmental disability may be eligible if their disability was present before age 22 and they have a substantial limitation in 3 areas of life functioning.

The I/DD waiver offers the following 13 services, which vary in reimbursement rates and frequency of utilization, though an individual may not want or need to use all services offered:

• Assistive Services – This service provides adaptive equipment, assistive technology, or home modifications to enhance an individual’s independence or abilities;
• Adult Day Supports – This service offers out-of-home activities to help adults who are no longer eligible for school services to maintain or increase abilities, productivity, independence, integration, and community participation;
• Financial Management Services – This service provides administrative and payroll services for individuals who choose to self-direct some or all of their services;
• Medical Alert – This service provides an electronic device that alerts a medical professional in the event an individual’s medical condition has become critical;
• Overnight Respite – This service provides temporary direct care and supervision of the individual to provide relief to families and caregivers. This service may be self-directed for individuals on the the I/DD waiver;
• Personal Care Services – This service provides supervision or physical assistance with instrumental activities of daily living, health maintenance activities, and in some cases socialization or recreation. This service may be self-directed or agency-directed for individuals on the the I/DD waiver;
• Residential Supports for Adults – This service provides assistance and support in completing activities of daily living and the social and adaptive skills to people who live in a residential setting and do not live with a family member;
• Residential Supports for Children – This service provides placement for children ages 5 to 21 in a licensed foster care home to avoid placement in an institutional or other congregate setting when the child cannot remain in the family home;
• Enhanced Care Services – This service provides immediate supervision or physical assistance with tasks such as toileting, transferring, mobility, medication reminders, and contact with a medical professional in the event of an emergency while the participant is sleeping. This service may be self-directed for the I/DD waiver;
• Specialized Medical Care – This service provides long-term registered nurse or licensed practical nurse support for individuals who are medically fragile and technology-dependent;
• Supported Employment – This service provides job support to people who work in a competitive and integrated setting; and
• Wellness Monitoring – This service allows regularly scheduled nursing visits to check a person’s health status and to monitor for changes in health and wellbeing.

Additionally, an individual determined by a Community Developmental Disability Organization to be eligible for I/DD services is eligible for Targeted Case Management services to assist the individual in gaining access to medical, social, educational, and other services through assessment, support plan development, referral, and monitoring. If the individual is not eligible for KanCare, there may be a fee for this service.

Physical Disability (PD)

The PD waiver provides services to individuals 16 to 64 years of age who meet the criteria for nursing facility placement due to having a PD, have been determined disabled by the Social Security Administration, need assistance to perform activities of daily living, and are Medicaid-eligible.

The PD waiver offers the following seven services, which vary in reimbursement rates and frequency of utilization, though an individual may not want or need to use all services offered:

• Assistive Services – This service provides adaptive equipment, assistive technology, or home modifications to enhance an individual’s independence or abilities;
• Financial Management Services – This service provides administrative and payroll services for individuals who choose to self-direct some or all of their services;
• Home-delivered Meal Service – This service offers one or two prepared meals to be delivered to provide adequate nutrition and regular meals;
• Medication Reminder – This service provides a scheduled reminder to the person when it is time to take their medications. This service may include a medication dispenser which stores and dispenses medication at the appropriate time;
• Personal Emergency Response System – This service provides electronic devices with portable buttons worn by the individual to alert emergency personnel at any time of day;
• Personal Care Services – This service provides supervision or physical assistance with instrumental activities of daily living and activities of daily living, health maintenance activities, and in some cases, socialization or recreation; and
• Enhanced Care Services – This service provides immediate supervision or physical assistance with tasks such as toileting, transferring, mobility, medication reminders, and contact with a medical professional in the event of an emergency while the participant is sleeping.

Serious Emotional Disturbance (SED)

The SED waiver provides services to individuals ages 4 to 18 who have been diagnosed with a mental health condition that substantially disrupts the individual’s ability to function socially, academically, or emotionally. The waiver is designed to divert the individual from psychiatric hospitalization to intensive home and community based supportive services. There may be exceptions for children younger than 4 and an extension of services up to age 22, if an individual had initially applied before age 19.

The SED waiver offers the following six services, which vary in reimbursement rates and frequency of utilization, though an individual may not want or need to use all services offered:

• Parent Support and Training – This service is provided to family members of a child with SED to increase their ability to provide a safe and supportive environment for the child;
• Independent Living / Skills Building – This service aims to help young adults learn and retain skills necessary to obtain and maintain employment, housing, education, and community life as they transition to adulthood;
• Short Term Respite Care – This service provides temporary direct care and supervision to a child with SED to provide relief to families and caregivers;
• Wraparound Facilitation – This service is provided in addition to targeted case management services to address the unique needs of a participant living in the community. This service is used to bring the MCO, participant, family, and community members together to discuss and to complete an individualized plan of care;
• Professional Resource Family Care – This service provides short-term and intensive supports to a person in a surrogate family setting; and
• Personal Care Services – This service enables the participant to accomplish tasks or engage in activities that they would normally do themselves if they did not have a mental illness. This service offers direct support, supervision, and cuing to encourage the participant to perform the task. Assistance often relates to performance of activities for daily living and instrumental activities for daily living.

Additionally, an individual determined to be functionally eligible for the SED waiver is eligible for Targeted Case Management services to assist the individual in gaining access to medical, social, educational, and other services through assessment, support plan development, referral, and monitoring. If the individual is not eligible for KanCare, there may be a fee for the service.

Technology Assisted (TA)

The TA waiver provides services to people through the age of 21 who require substantial and ongoing daily care by a nurse comparable to the level of care provided in a hospital.

The TA waiver offers the following seven services, which vary in reimbursement rates and frequency of utilization, though an individual may not want or need to use all services offered:

• Health Maintenance Monitoring – This service offers regularly scheduled nursing visits to check the individual’s health status and to monitor for changes in health and wellbeing;
• Home Modification – This service offers modification or adaption to a person’s home through tangible equipment or hardware;
• Financial Management Services – This service offers administrative and payroll services for individuals who choose to self-direct some or all of their services;
• Intermittent Intensive Medical Care – This service offers nursing services to individuals using personal care services to meet specific skilled nursing care needs;
• Personal Care Services – This service provides supervision or physical assistance with instrumental activities of daily living and activities of daily living, health maintenance activities, and in some cases socialization or recreation. This is the only TA waiver service that may be self-directed;
• Medical Respite – This service provides the beneficiary’s family with short, specified periods of relief from caring for the individual; and
• Specialized Medical Care – This service provides long-term registered nursing or licensed practical nurse support for people who are medically fragile and technology-dependent. If the individual’s parent is a registered nurse and meets specific criteria, they may be eligible to be reimbursed for providing this service.

Brain Injury (BI)

The Brain Injury (BI) Waiver is a habilitative/rehabilitation and independent living program with an emphasis on the development of new independent living skills and/or relearning of lost independent living skills due to an acquired or traumatic brain injury.

The BI waiver offers the following nine services, which vary in reimbursement rates and frequency of utilization, though an individual may not want or need to use all services offered:

• Assistive Services – This service provides adaptive equipment, assistive technology, or home modifications to enhance an individual’s independence or abilities;
• Financial Management Services – This service offers administrative and payroll services for individuals who choose to self-direct some or all of their services;
• Home-delivered Meal Service – This service offers one or two prepared meals to be delivered to provide adequate nutrition and regular meals;
• Medication Reminder – This service provides a scheduled reminder to the person when it is time to take their medications. This service may include a medication dispenser which stores and dispenses medication at the appropriate time;
• Personal Emergency Response System – This service provides electronic devices with portable buttons worn by the individual to alert emergency personnel at any time of day;
• Personal Care Services – This service provides supervision or physical assistance with instrumental activities of daily living and activities of daily living, health maintenance activities, and in some cases socialization or recreation;
• Rehabilitation Therapies – This service assists with the restoration of physical and mental functioning and includes behavior therapy, occupational therapy, physical therapy, speech-language therapy, and cognitive rehabilitation;
• Enhanced Care Services – This service provides immediate supervision or physical assistance with tasks such as toileting, transferring, mobility, medication reminders, and contact with a medical professional in the event of an emergency while the participant is sleeping; and
• Transitional Living Skills – This service offers training exercises in which individuals with a BI practice skills in real-life situations in their homes and communities. Trainings are designed to prevent or minimize chronic disabilities while restoring the individual to an optimal level of physical, cognitive, and behavioral functioning within the context of the individual.

Recent Changes in Provider Reimbursement Rates

Providers of waiver services are reimbursed by the waiver participant’s MCO. Based on funding appropriated by the Legislature, KDHE and KDADS set floor rates that are the lowest rate the MCO may reimburse providers; however, a MCO may individually choose to reimburse providers at a higher rate based on a variety of factors.

Over a number of years, the Legislature has made the following efforts to increase reimbursement rates for HCBS waiver services.

2019 Legislative Session

The 2019 Legislature passed a budget with the following adjustments to funding for the HCBS waiver programs:

• The addition of $10.1 million, including $4.2 million SGF, to provide a 1.5 percent increase in the reimbursement rates for providers of all HCBS waiver services beginning in FY 2020; and
• The addition of language expanding the Traumatic Brain Injury waiver program to include individuals with acquired brain injuries.

2020 Legislative Session

The 2020 Legislature passed a budget with the following adjustments to funding for the HCBS waiver programs:

• The addition of $22.1 million, including $9.0 million SGF, to provide a 5.0 percent increase to reimbursement rates for I/DD waiver services beginning in FY 2021; and
• The addition of $6.4 million, including $2.7 million SGF, to increase the rate for the Specialized Medical Care (T1000) rate for the TA waiver from $31.55 per hour to $37.00 per hour, beginning FY 2021.

2020 Interim Allotment

On June 25, 2020, the Governor released an allotment plan due to projected shortfalls in state revenue resulting from the COVID-19 pandemic. The plan resulted in the following adjustments to funding for the HCBS waiver programs:

• The deletion of $22.1 million, including $9.0 million SGF, to provide a 5.0 percent increase to reimbursement rates for I/DD waiver services beginning FY 2021; and
• The deletion of $6.4 million, including $2.7 million SGF, to increase the rate for the T1000 rate for the TA waiver from $31.55 per hour to $37.00 per hour beginning in FY 2021.

As a result of removing these funds from the budget, the reimbursement rates remained at the FY 2020 rates for FY 2021.

2021 Legislative Session

The 2021 Legislature passed a budget with the following adjustments to funding for the HCBS waiver programs:

• The addition of $5.5 million, including $2.0 million SGF, in FY 2021 and $31.0 million, including $12.4 million SGF, in FY 2022 to provide an increase in reimbursement rates for providers of I/DD waiver services. This funded a 5.0 percent increase for the final four months of FY 2021 and an additional 2.0 percent increase for FY 2022;
• The addition of $16.1 million, including $6.2 million SGF, to increase the reimbursement rate for the T1000 rate from $32.55 per hour to $43.00 per hour for the TA waiver; and
• The addition of $9.6 million, including $4.3 million SGF, to increase the Protected Income Limit for HCBS participants from 15.0 percent to 300.0 percent of the federal Supplemental Security Income for FY 2022.

2022 Legislative Session

The 2022 Legislature passed a budget with the following adjustments to funding for the HCBS waiver programs:

• The addition of $23.2 million, including $9.3 million SGF, to standardize the personal care services rates for the FE, I/DD, PD, SED, TA, and BI waivers and to further increase the standard rate by 2.0 percent beginning in FY 2023;
• The addition of $1.8 million, including $716,493 SGF, to increase the cap on assistive services for all waivers. Previously, the lifetime cap was $7,500. The additional funds increased the lifetime limit to $10,000 beginning in FY 2023;
• The addition of $122.2 million, including $48.9 million SGF, to provide a 25.0 percent increase to the reimbursement rates for I/DD waiver services beginning in FY 2023. This increase excluded the T1000 rate, which was increased separately;
• The addition of $7.7 million, including $3.1 million SGF, to increase the reimbursement rate for the T1000 code from $43.00 per hour to $47.00 per hour for the I/DD and TA waivers beginning in FY 2023. This standardized the rate across both waivers and further increased the standardized rate; and
• The addition of $11.8 million, including $4.7 million SGF, to provide a 10.0 percent increase to the reimbursement rates for FE waiver services beginning in FY 2023.

2023 Legislative Session

The 2023 Legislature passed a budget with the following adjustments to funding for the HCBS waiver programs:

• The addition of $17.7 million, including $7.1 million SGF, to standardize Personal Care, Enhanced Care, Medication Reminder and Financial Management services on the BI, PD, AU and TA waivers to match increased rates approved by the 2022 Legislature for the FE waiver, beginning in FY 2024;
• The addition of $13.0 million, including $5.2 million SGF, to provide a 10.0 percent increase to reimbursement rates for the FE waiver beginning in FY 2024;
• The addition of $11.2 million, including $4.5 million SGF, to increase the Targeted Case Management rate for individuals with I/DD from $43.24 per hour to $75.00 per hour beginning in FY 2024; and
• The addition of language requiring the agency to submit to the Centers for Medicare and Medicaid Services an application for a community support waiver for individuals with I/DD for FY 2024.

by Dayton LaMunyon
Fiscal Analyst
785-296-4405