Home and Community Based Services

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Home and community based services (HCBS) provide opportunities for Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted populations groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses.

The Home and Community-Based Services (HCBS) rule creates a more outcome-oriented definition of home and community-based settings. It does not just look at location, geography or physical characteristics. It looks at how a person spends their day, where they spend their day and with whom they spend their day. The purpose of the HCBS rule is to enable people to receive services in their home and community, keeping them out of institutions.

People deserve to live their lives the way they want to live them; to be treated with dignity and respect. People deserve to say where they go during the day, and to be as independent as they are able to be. People deserve to have choices.

Home and Community-Based Services will help people become more independent.

Home and Community-Based Services will help people become more integrated within in their community.

In 2014, 53% of all Medicaid long term care spending was on home & community based services.

Other Services: $71.2 Billion

HCBS Services: $80.6 Billion

Source: 2014 LTSS Expenditure Report

Types of HCBS Care

Health Services meet medical needs

  • Home health care, such as:
    • Skilled nursing care
    • Therapies: Occupational, speech, and physical
    • Dietary management by registered dietician
    • Pharmacy
  • Durable medical equipment
  • Case management
  • Personal care
  • Caregiver and client training
  • Health promotion and disease prevention
  • Hospice care (comfort care for patients likely to die from their medical conditions)

Human Services support daily living

  • Senior centers
  • Adult daycares
  • Congregate meal sites
  • Home-delivered meal programs
  • Personal care (dressing, bathing, toileting,eating, transferring to or from a bed or chair, etc.)
  • Transportation and access
  • Home repairs and modifications
  • Home safety assessments
  • Homemaker and chore services
  • Information and referral services
  • Financial services
  • Legal services, such as help preparing a will
  • Telephone reassurance

Creating and maintaining an HCBS program benefits the community and the individuals served in many ways. However, there are several challenges to consider that come along with this type of program.

Benefits and Challenges of HCBS

Benefits

  • Cost effectiveness: usually less than half the cost of residential care
  • Culturally responsive: spiritual and cultural activities and support available
  • Familiarity: patient enjoys the comfort of their own home or small residential facility in the community
  • Can provide counseling or clergy to assist with bereavement
  • Some waivers permit family members to be paid caregivers

Challenges

  • Access to providers
  • Availability of qualified caregivers
  • Caregiver burnout
  • Lack of 24/7 medical professional availability
  • Nonfamily caregivers may have limited access in remote locations, especially during winter
  • Potential cultural bias or barriers in the acuity assessment process
  • Skilled nursing care includes only medical services performed by a registered nurse. Other daily tasks fall primarily to family members
  • Those needing care do not always want family members to act as their caregivers due to potential for abuse or financial manipulation
  • Tribes need to complete processes that are often long and complex, such as creating an elder abuse code or establishing a memorandum of understanding with the state, to create an HCBS program

​​​​1915(c) Home and Community-Based Services Waivers

Home and Community-Based Services (HCBS) Waivers allow states that participate in Medicaid, known as Medi-Cal in California, to develop creative alternatives for individuals who would otherwise require care in a nursing facility or hospital. Medi-Cal has an agreement with the Federal Government, which allows for waiver services to be offered in either a home or community setting. The services offered under the waiver must cost no more than the alternative institutional level of care. Recipients of HCBS Waivers must have full-scope Medi-Cal eligibility.

What Services are Offered under HCBS Waivers?

The services available under HCBS Waivers include case management, community transition services, private duty nursing, family training, home health aides, life-sustaining utility reimbursement, habilitation services, respite care, and other services required to maintain the health and safety of eligible participants in the community setting of their choice.

Who Provides the Services?

There are a variety of HCBS Waiver providers, including but not limited to, the following:

  • Licensed and certified Home Health Agencies;
  • Individually licensed HCBS Waiver Providers; and/or
  • Unlicensed caregivers.

How Long Can One Receive These Services?

The beneficiary may receive these home- and community-based services as long as they are medically necessary, cost-neutral, and he/she meets the nursing facility or acute hospital level of care.