What are Home and Community Based Services (HCBS)?
HCBS provides 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 population groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses. Home and Community Based services are provided through a Medicaid waiver or Medicaid state plan service.
HCBS Settings Rule
In 2014, the Centers for Medicare and Medicaid Services (CMS) at the Department of Health and Human Services issued the Home and Community Based Services (HCBS) Settings Rule. This rule requires that every state ensure that services delivered to seniors and people with disabilities living in the community – outside of institutions – meet minimum standards for integration, access to community life, choice, autonomy and other important consumer protections. The HCBS Settings Rule was created to expand the availability of community-based services that maximize autonomy and choice for individuals with disabilities, and to address the problem of institutional-like settings receiving scarce HCBS dollars.
What Does the HCBS Settings Rule Require?
The HCBS requirements are designed to ensure that people with disabilities living in the community have access to the same kind of choice and control over their own lives as those not receiving Medicaid HCBS funding. The rule applies to all settings (i.e. place where seniors and people with disabilities live, work or spend time) that receive HCBS funding, and requires that the setting:
is integrated in the greater community.
supports the individual’s full access to the greater community, including opportunities to seek employment, work in competitive integrated settings, engage in community life, control personal resources and receive services in the community.
is selected by the individual from among different setting options, including non-disability specific options and an option for a private unit in a residential setting.
ensures an individual’s rights to privacy, dignity, respect, and freedom from coercion and restraint.
optimizes individual initiative, autonomy and independence in making life choices, including in daily activities, physical environment, and personal associations.
optimizes individual initiative, autonomy and independence in making life choices, including in daily activities, physical environment, and personal associations.
Why is this important?
Maryland, like other states, relies on funding from Medicaid to pay for part of the cost of providing services to people with intellectual and developmental disabilities in community-based settings. The Maryland Developmental Disabilities Administration (DDA) has three Medicaid waivers which are approved by CMS, and which help pay for Home and Community Based Services. For Medicaid funding to be used, community-based settings must meet the requirements of the HCBS New Settings Rule. People who live in settings that have the effect of isolating people with disabilities from the broader community cannot receive HCBS funded services in that setting.
What is an Institution/Setting that Isolates?
According to guidance from CMS issued on March 22, 2019 in the form of FAQs, the regulations describe three categories of residential or non-residential settings that are presumed to have the qualities of an institution:
Settings that are located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment;
Settings that are in a building located on the grounds of, or immediately adjacent to, a public institution; and
Any other settings that have the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving Medicaid HCBS. CMS intends to take the following factors into account in determining whether a setting may have the effect of isolating individuals receiving Medicaid HCBS from the broader community of individuals not receiving HCBS:
- Due to the design or model of service provision in the setting, individuals have limited, if any, opportunities* for interaction in and with the broader community, including with
individuals not receiving Medicaid-funded HCBS; - The setting restricts beneficiary choice to receive services or to engage in activities outside of the setting; or
- The setting is physically located separate and apart from the broader community and does not facilitate beneficiary opportunity to access the broader community and participate in community services, consistent with a beneficiary’s person-centered service plan.