Waiting Lists in Medicaid Section 1915(c) Waivers

Waiting Lists in Medicaid Section 1915(c) Waivers

March 21, 2017
Waiting Lists in Medicaid Section 1915(c) Waivers
Background
The Social Security Act (SSA) authorizes several waiver
Covered Services
and demonstration authorities that give states flexibility in
The Medicaid statute specifies a broad range of services
operating their Medicaid programs. Each waiver authority
that states may provide to waiver participants. These
has a distinct purpose and specific requirements. Medicaid
services include case management, homemaker/home
waivers provide states the opportunity to try new or
health aide, personal care, adult day health, habilitation,
different approaches to the delivery of health care services
rehabilitation, and respite care. States also have flexibility
or to adapt programs to the special needs of particular
to offer additional services, when approved by the HHS
geographic areas or groups of Medicaid enrollees. For
Secretary. For individuals with chronic mental illness,
example, waiver programs allow states to extend benefits
states may cover day treatment or other partial
that are, among other things, neither comparable across
hospitalization services, psychosocial rehabilitation
groups nor statewide.
services, and clinic services (whether or not furnished in a

facility) under a waiver. Section 1915(c) waivers may not
The term Medicaid “waiver” is so-named because states
cover room and board in a community-based setting, such
may request that the Secretary of the Department of Health
as an assisted living facility.
and Human Services (HHS) waive certain statutory
Target Population
requirements that would normally apply to services covered
States must target a Section 1915(c) waiver to a specific
under Medicaid state plans. For each waiver, states must
population, such as individuals under age 65 with physical
submit a waiver application for review and approval by the
disabilities, individuals with intellectual or developmental
Centers for Medicare & Medicaid Services (CMS). Unlike
disabilities, individuals aged 65 and older, or individuals
Medicaid state plan benefit coverage, Medicaid waiver
with mental illness. As a result, states typically have more
benefit coverage is time-limited for the duration of the
than one approved Section 1915(c) waiver, with each
waiver (e.g., three or five years) and must be renewed by
waiver program offering a specialized package of HCBS to
the state subject to CMS approval.
a specific population. A CMS final rule published in 2014

gives states the option to combine target groups within one
Section 1915(c) Home and Community-Based Services
waiver program. Prior to this change, a Section 1915(c)
(HCBS) Waiver authority authorizes the Secretary of HHS
waiver could serve only one of the following three target
to waive certain requirements of Medicaid law, thereby
groups: (1) older adults, individuals with disabilities, or
allowing states to cover a broad range of HCBS (including
both; (2) individuals with intellectual disabilities,
services not available under the Medicaid state plan) for
developmental disabilities, or both; or (3) individuals with
certain persons with long-term care needs. Specifically,
mental illness. Eligible waiver participants must meet
under SSA Section 1915(c) states may waive rules
regarding “statewideness” and “comparability” of
certain financial requirements (including income and
services.
resource requirements) and state-defined level-of-care
States may also apply certain income-counting rules to
criteria that demonstrate the need for LTSS. That is,
persons in HCBS waivers that allow an individual to be
individuals must have a level of need for LTSS that would
eligible for Medicaid who might not otherwise qualify. For
otherwise be covered under a Medicaid institutional benefit,
FY2014, Medicaid expenditures for Section 1915(c) HCBS
such as nursing facility care, Intermediate Care Facility for
waivers were $41.5 billion.
people with Intellectual Disability (ICF/ID), or hospital
Section 1915(c) Waivers
care.
Section 1915(c) waivers are designed to expand
Waiting List Requirements
opportunities for states to provide home and community-
There are no statutory or regulatory requirements that
based care to additional groups of persons with long-term
define or describe waiting lists for Medicaid Section
services and supports (LTSS) needs while containing
1915(c) waiver programs. Under the Section1915(c) waiver
Medicaid costs. Under this authority, states with approved
authority, states may cap the number of individuals served
applications may provide home and community-based care
in a waiver program by setting a numerical limit (no less
to persons who, without these services, would require
than 200) on the number of individuals participating in the
Medicaid-covered institutional care. Section 1915(c)
waiver. Such limitations must be specified in the state’s
waivers permit states to cover services beyond the medical
application for a Section 1915(c) waiver, which is subject to
and medically related benefits that have been the principal
CMS approval. Because state Medicaid programs often
focus of the Medicaid program. Under this authority, states
have greater demand for HCBS than the number of
can cover a wide variety of nonmedical, social, and
available waiver “slots” for a given program, limiting the
supportive services that allow individuals to live
number of individuals receiving HCBS is one way for states
independently in the community.
to contain costs. As a result, many states maintain waiting
lists (sometimes referred to as interest lists, planning lists,
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link to page 2 Waiting Lists in Medicaid Section 1915(c) Waivers
and registries) when their program slots are filled or when
the University of California, San Francisco, from a Section
state legislatures do not fully fund the maximum number of
1915(c) Waiver Policy Survey that collected data for 2015.
waiver slots under the CMS-approved waiver program.
These data were published by KCMU in an October 2016
According to CMS technical guidance for the Section
report. Table 1 provides data on Section 1915(c) waiver
1915(c) waiver:
program waiting lists across all states and the District of
Columbia (DC) by waiver target population group.
The state’s limit on the number of individuals who
participate in a waiver may result in a waiting list
In summary, 47 states and DC had at least one Section
for waiver services (e.g., entrance to the waiver of
1915(c) waiver program in 2015, for a total of 293
otherwise eligible applicants must be deferred until
programs. Thirty-five states reported having waiting lists;
capacity becomes available as a result of turnover
12 states and DC reported no such lists. Among the 35
or the appropriation of additional funding by the
states with waiting lists, there were an estimated 640,841
legislature). Entrance to the waiver may not be
wait-listed individuals across 131 Section 1915(c) waiver
deferred when there is unused waiver capacity
programs. The average wait time across all programs was
(except when a state has established a point-in-time
just over two years (27 months); however, the average
length of time an individual may spend on a waiting list
limit, reserved capacity or made entrance subject to
varies by target population and ranged from 4 months for
a phase-in schedule). If it is necessary to defer the
HIV/AIDS waivers to 43 months for individuals with
entrance of individuals to the waiver, the state must
Intellectual/Developmental Disabilities (I/DD) waivers.
have policies that govern the selection of
individuals for entrance to the waiver when
capacity becomes available. These policies should
Of waiver programs with wait lists, 70% prioritized certain
clients. In addition, two-thirds of waiver programs with
be based on objective criteria and applied
wait lists screened individuals for Medicaid eligibility
consistently in all geographic areas served by the
(67%). Thus, since not all waiver programs with wait lists
waiver.
screened individuals, the total number of persons on wait
lists may be an overestimate of the number of individuals
State Use of Waiting Lists
who are eligible for Section 1915(c) waiver services. The
The most recent data for Medicaid Section 1915(c) waiver
majority of waiver programs with wait lists (92%) provided
program waiting lists is from analyses by the Kaiser
non-waiver services to Medicaid-eligible individuals who
Commission on Medicaid and the Uninsured (KCMU) and
are also on the wait list for a waiver slot.
Table 1. Data on Waiting Lists for Medicaid Section 1915(c) Waiver Programs, by Target Population
(Data for 2015)
Aged/
Children Disabled
Aged
TBI/
HIV/
Mental

I/DD
Disabled
(<18)
Only
Only
SCI
AIDS
Health
Total
Number of Waiver Programs
103
54
51
24
18
27
11
5
293
Number of Program Waiting Lists
56
19
23
12
4
15
1
1
131
Number of Persons on Waiting
428,151
117,693
51,606
11,744
27,731
3,823
65
28
640,841
Lists
Average Waiting Period (months)
43
18
25
17
25
16
4
5
27
Number (%) of Waiting Lists that
34
14
18
7
3
10
1
1
10
Screen for Eligibility
(61%)
(74%)
(78%)
(58%)
(75%)
(67%)
(100%)
(100%)
(67%)
Number (%) of Waiting Lists that
39
16
12
8
3
12
1
1
12
Prioritize Clients
(70%)
(84%)
(52%)
(67%)
(75%)
(67%)
(100%)
(100%)
(67%)
Number (%) of Waiting Lists that
52
18
20
11
4
13
1
1
13
Provide Non-Waiver Services
(93%)
(95%)
(87%)
(92%)
(100%)
(87%)
(100%)
(100%)
(87%)
Source: Terrance Ng, Charlene Harrington, MaryBeth Musumeci, et al. Medicaid Home and Community-Based Services Programs: 2013
Data Update, KCMU, October 2016, see Tables 5, 13, and 14, pp. 45-46.
Notes: I/DD = Intellectual/Developmental Disability; Aged/Disabled = Individuals with physical disabilities/Individuals Aged 65+; Children (< 18)
= children under age 18 who are medical y fragile or technology-dependent; Disabled Only = Individuals with physical disabilities; Aged Only =
Individuals aged 65+; TBI/SCI = Traumatic Brain Injury/Spinal Cord Injury; HIV/AIDS = Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome; and Mental Health = Individuals with mental or behavioral health conditions.

Kirsten J. Colello, Specialist in Health and Aging Policy

IF10620
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Waiting Lists in Medicaid Section 1915(c) Waivers

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