Home and Community Based Services (HCBS) is the umbrella under which Medicaid pays for medical care and services for those who are not eligible for straight Medicaid, but are unable to afford the needed services. When HCBS is referenced in context to seniors, usually it means the Elderly, Blind and Disabled (EBD) program, though HCBS programs exist for children, the mentally disabled, those with brain injuries and those with AIDS.
The goal of HCBS-EBD (hereafter referred to as just HCBS) is to serve individuals who might need nursing home care, but can be cared for more effectively (including cost-effectively) in the home and community. Individuals cannot require 24-hour supervision, unless an assisted living or family is providing it.
HCBS services include personal care services for activities of daily living, homemaker services, adult day care, transportation, respite care, home modifications or electronics for independence, assisted living facilities and community transition services. Applications must be managed through the Options for Long Term Care agency. In the agency’s assessment on the ULTC 100.2 and other associated forms an individual must score two “2s” in activities of daily living or one “2” in the need for supervision or behavior in order to receive HCBS. The cost of care must be less than providing the same care in an institutional setting.
How to apply for HCBS
If an individual is receiving Medicaid or needs to submit an application for Medicaid, the Options for Long Term Care agency must do an evaluation for eligibility. If the individual is deemed eligible for HCBS, services can begin as Medicaid-pending, if the provider is willing to accept post-approval payment (no payments will be made if the individual is not approved). Once the final approval of Medicaid is received, the Options for Long Term Care agency must submit a care plan to the fiscal agent for approval to begin delivering services. Any HCBS services must be included in the care plan to be covered.
Individuals who receive HCBS can have an annual income up to 300% of the federal poverty level (individuals with higher incomes must complete a Medicaid Qualifying Trust). For EBD they must be 65 or older, or determined to be disabled. Individuals cannot be residents of a nursing home (but can receive respite services from a nursing home) or in a hospital for more than 30 days, but individuals who are de-institutionalized from a nursing home can be eligible for HCBS.
A re-determination review must be conducted annually to determine continued eligibility. This can and is often done by mail. An individual has ten days to return the requested information, with the option for a 30 day extension.
Limits on HCBS services
The primary limit is whether services are cost effective compared to institutionalized care. The average Medicaid rate for nursing care is $5991/month in 2010 (this figure varies based on the exact county of residence). HCBS services should generally cost less than that.
In addition, though family members may provide services to recipients of HCBS, they must be employed and supervised by a home health agency. They also cannot be paid for more than 444 personal care units per year (approximately 1.2164 hours per day).
HCBS will cover reasonable and necessary home modifications, adaptations or improvements to maintain independence. This includes grab bars, ramps, widened doorways, modified bathrooms or kitchens and others. An individual is eligible for up to $10,000 of modifications in their lifetime, with modifications of over $1000 requiring approval from the fiscal agent in addition to the Options for Long Term Care agency. A bid process from Medicaid approved vendors is also required. The Options for Long Term Care maintains a list of approved vendors.
Individuals who require HCBS services may also be interested in Consumer Directed Attendant Support Services (CDASS), which give the individual many of the same services but is very flexible and allows the individual to control who provides services and when.