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Glossary

HCBS waiver

A state Medicaid program, approved by CMS under section 1915(c), that pays for home and community-based services for people who would otherwise qualify for an institution. Structured family caregiving and most in-home supports run under one. PACE does not; it is its own Medicare and Medicaid benefit.

Also 1915(c) waiver, home and community-based services waiver, Medicaid waiver

Medicaid as written covers institutions. Section 1915(c), added in 1981, lets a state ask CMS to waive parts of the statute so it can pay for services at home for people who meet an institutional level of care: personal care, respite, home modifications, adult day health, and the family-caregiver models that go by names such as structured family caregiving. Every state runs at least one; most run several, each aimed at a population, with its own enrollment cap, services and provider rules.

Three features of a waiver shape the work of a provider agency:

  • Eligibility is two determinations. Financial eligibility for Medicaid, made by the state’s Medicaid office on the clock in 42 CFR 435.912, and the functional determination that the person meets the level of care the waiver is tied to, made by the state or its assessor. The provider agency delivers services after both; it does not make either.
  • The service starts with a plan. Waiver rules require a person-centered service plan, and the provider’s own plan of care at the start of service is written from the assessment and the records available then.
  • The vocabulary is the state’s. Georgia’s Elderly and Disabled Waiver Program, Indiana’s PathWays for Aging, Ohio’s PASSPORT and Missouri’s Structured Family Caregiving Waiver are all 1915(c) programs, and each names its providers and its visit rules in its own manual.

PACE is often listed beside the waivers and is not one. It is a permanent benefit under sections 1894 and 1934 of the Act, with its own rules at 42 CFR Part 460; see PACE. What the two share is the nursing-facility level of care at the door, determined by the state in both cases.

Where it is defined

Vivlio for structured family caregivingDiagnosis documentation, the H&P, medications and the functional evidence, assembled before the nurse's first home visit.

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