Steve Gold summarized the changes to the Medicaid 1915 (i) waivers in an informational bulletin recently. The following is an edited version of that bulletin:

Nearly five years ago, Congress amended Medicaid by adding Section 1915 (i), intending to increase community-based services instead of institutional Medicaid services by permitting greater flexibility than Waivers permit. Unfortunately, only a few states took advantage of this.

In enacting the Affordable Care Act in 2010, Congress made a number of additional changes which are extremely important to the disability community. These amendments take away many excuses the States have used in the past.

On August 6, 2010, CMS wrote a "Dear State Medicaid Director" encouraging States to take advantage of the ACA 2010 amendments. Here are the changes:

1. The ACA strengthened Section 1915 (i) to remove the requirement that individuals had to meet an institutional level of care in order to qualify for home and community-based services. Unlike eligibility for Medicaid Waivers which require a person meet an institutional level of care, the 2010 amendments permit your state to provide community-based services for people who are not otherwise eligible for institutional care.
2. Another big change is that the Affordable Care Act amended this Section to permit States to provide community-based services to persons with chronic mental illnesses and/or substance use disorders. Services for this population are defined extremely broadly. This is long overdue and will help a portion of the disability community that has been shortchanged too long.
3. States now have the option to provide thee community-based services to persons whose incomes are 300% of the SSI income benefit.
4. Benefits can be targeted either to specific population groups without violating Medicaid's comparability requirements. Alternatively, States could target by functional needs. This permits States to have multiple programs, each targeted at specific populations, e.g., one for persons with physical needs and another benefit package targeted at persons with chronic mental illnesses. It permits your State to define populations' needs with great precision and specifics.
5. Services can be narrowly defined, e.g., personal care or home health aide, instead of the Waiver package of services. There goes a big excuse States have used with Waivers, i.e., they had to provide a broad range of services to everyone on the Waiver.
6. States have the option to offer consumers "self-direction." In the 8/6/10 Dear State Medicaid Director letter, it states that "CMS urges all States to afford participants the opportunity to direct some or all of their HCBS. Self-direction permits participants to plan and purchase their HCBS under their direction and control or through an authorized representative."