II. Home and Community Based Services (HCBS) Waivers

A. Overview of Waivers

Section 1915 (c) of the Federal Social Security Act allows a state to operate Medicaid Home and Community-Based Services (HCBS) waivers within its Medicaid program if certain requirements are met. Please see VI. Waiver Activities and Services for descriptions of the covered waiver services/activities. The federal waiver requirements include:

The State must submit a request and receive approval from the federal Centers for Medicare and Medicaid Services (CMS) to operate a waiver. The approved waiver thus becomes the intergovernmental agreement that, together with applicable federal Medicaid regulations, governs operation of the waiver.
The waiver must be a cost-effective alternative to placement in a Medicaid-funded institutional setting, such as an ICF/DD). In Illinois, federal ICF/DDs include both private facilities and state-operated developmental centers.
The State and CMS limit the total annual expenditures and the number of people served in each waiver.
The State must have a quality management strategy in place to ensure the protection of each waiver individual's rights, health, safety and welfare.

B. Additional Federal Guidance

The Centers for Medicare and Medicaid Services (CMS) published additional HCBS Regulations on January 16, 2014 which became effective on March 17, 2014. The Regulations include Conflict of Interest Free Case Management, Person-Centered Planning and Settings Requirements. These regulations impact all three Developmental Disability (DD) HCBS Waivers and are outlined below.

Conflict of Interest Free Case Management is a CMS HCBS regulation that specifies States are required to separate case management functions (including the person-centered plan development) from service delivery functions. Case management includes determination of eligibility, provider identification, development and monitoring of the Personal Plan. "Conflict free" means Case Management must be performed by someone other than a relative of the person served, someone other than a direct provider of service, someone who does not have a financial interest in a provider, or someone who is not employed by a provider. In Illinois, the Independent Service Coordination (ISC) agencies serve as the Conflict-of-Interest Free Case Management entity and provide Individual Service and Support Advocacy (ISSA) to each person in a DD Waiver.
Person Centered Planning addresses the balance between what is important to a person and what is important for a person in service planning. Person Centered Planning:
1. Must be driven by the person.
2. Ensure services are delivered in a manner that reflects personal preferences and choices.
3. Must include evidence that setting is chosen by the individual.
4. Assist to achieve personally defined outcomes in the most integrated setting.
5. Contributes to the assurance of health and welfare of the person receiving services.
6. Must include opportunities to seek employment and work in competitive integrated settings.
7. Must include opportunities to engage in community life, control personal resources, and receive services in the community to the same degree of access as those not receiving Medicaid Home and Community Based Services.
8. Includes risk factors and measures to minimize risk.
9. Should be written in plain language that can be understood by the person who receives services and their guardian.
10. Reflects cultural considerations.
11. Include strategies for solving disagreements.

The Person-Centered Planning requirements are fully outlined in V. Person-Centered Planning of this manual.

The HCBS Settings Criteria requires waiver settings to have the following qualities, based on the needs of the individual as indicated in their Personal Plan:

The setting is integrated in and supports full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS.
The setting is selected by the individual from among setting options including non-disability specific settings and an option for a private unit in a residential setting. The setting options are identified and documented in the person-centered service plan and are based on the individual's needs, preferences, and, for residential settings, resources available for room and board.
Ensures an individual's rights of privacy, dignity and respect, and freedom from coercion and restraint.
Optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including but not limited to, daily activities, physical environment, and with whom to interact.
Facilitates individual choice regarding services and supports, and who provides them.

C. Waiver for Adults with Developmental Disabilities ("Adult Waiver")

Provides supports to eligible adults with developmental disabilities ages 18 and older. The number of individuals served each year is based on available State appropriation levels.
Provides supports designed to prevent or delay out-of-home residential services for individuals or alternative residential services for individuals who would otherwise need ICF/DD level of service. See III. Level of Care/Programmatic Eligibility for DD Waivers for eligibility criteria.
Choice between individual direction and more traditional service delivery or a combination of both.

The Adult Waiver provides services to waiver individuals through:

Home-Based Support Services (HBS): Individuals who are or will be enrolled in HBS, may select from a menu of services based on their individual needs within a monthly maximum. Typical services chosen by individuals and/or guardians, if applicable, may include, but are not limited to, community day programs, personal support workers and a variety of therapies.
Residential Services: Individuals who are or will be enrolled in adult waiver residential programs are provided with residential services and supports from the provider of their choice. These individuals and/or guardians, if applicable, may also select community day programs and have a variety of therapies and other services available to them.
Day Programs and vocational services: Day and vocational services include Community Day Services, Supported Employment, Adult Day Care, Enhanced Residential (Formerly "At Home") Day Services, and other day programs. These services are provided by community-based agencies and organizations to individuals throughout Illinois. These services are designed to enhance a person's skill levels in the major life areas, work-related activities, and employment skills.

D. Support Waiver for Children and Young Adults with Developmental Disabilities ("Children's Support Waiver")

Provides supports to eligible children and young adults with developmental disabilities ages 3 through 21 who live at home with their families. Children who are wards of the State are not eligible. The number of individuals served each year is based on available State appropriation levels.
Provides supports designed to prevent or delay the need for out-of-home residential services for these children and young adults who would otherwise need ICF/DD level of service.
Provides choice between individual direction and more traditional service delivery or a combination.
In combination with school-based services, natural supports, other community resources, and Medicaid State Plan services, services provided through the Children's Support Waiver assist the family in meeting the individual's needs. Within a monthly and annual allocation for each Waiver individual, families select from a menu of services based on the individual's needs. For Personal Support Workers, families may select from contracted provider agencies, as well as individual workers identified by the family.

E. Residential Waiver for Children and Young Adults with Developmental Disabilities ("Children's Residential Waiver")

Provides 24-hour residential support to eligible children and young adults with developmental disabilities from age 3 through age 21 as an alternative to ICF/DD level of care. Children who are wards of the State are not eligible for this program. The number of individuals served each year is based on available State appropriation levels.
Provides a structured environment to children and adolescents who cannot reside in their own home. Residential services are provided in a setting that is licensed by the Department of Children and Family Services as a Children's Group Home.