Medicaid

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Title XIX of the Social Security Act of 1965 established Medicaid, a jointly funded cooperative venture between the Federal and State governments, to provide medical assistance to children, individuals who are aged, blind, and/or disabled and people who are eligible to receive federally assisted income maintenance payments. Historically, Medicaid eligibility has been tied to eligibility for Federal cash assistance programs—primarily Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI) though a few States use more restrictive eligibility criteria. In more recent years, Medicaid has been expanded to include more children and women who may or may not have disabilities. Since 1996, changes in Federal law have given States new opportunities to expand publicly financed health insurance coverage to members of low-income working families with children, including parents. In general, Medicaid provides three types of health care coverage:

Health insurance for low-income families with children and people with disabilities;
Long-term care for older Americans and individuals with disabilities; and
Supplemental coverage for low-income Medicare beneficiaries for services not covered by Medicare (e.g., outpatient or prescriptions) and Medicare premium, deductibles and cost sharing.

The mandatory or basic services include hospitalization, physician services, skilled nursing facilities, home health care, and the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) for children under age 21. Additionally, States may offer optional services within their State Medicaid Plan. These services may include diagnostic services, prescription drugs, therapies, non-emergency transportation services, personal care, intermediate care facilities for the mentally retarded (ICF-MR) and rehabilitation services.

Within broad Federal guidelines, each State establishes a State Medicaid Plan, detailing eligibility standards; type, amount, duration, and scope of services; payment rates, quality assurance; and program administration. In some States, Plan specifics are also established in State statute; while in other States, agency administrators are responsible for determining services provided. State Medicaid Plans are submitted to the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) for approval.

Once a State Medicaid Plan is approved, each State may request matching funds from the Federal government for medical and other service expenditures. The matching funds are known as Federal Financial Participation (FFP). The Federal government’s share of expenditures, referred to as the Federal Medical Assistance Percentage (FMAP) rate, ranges from 50 to 83 percent depending on the State.

Because of the differences in State plans and FMAP rates, Medicaid programs vary considerably from State to State, as well as within each State over time. Nevertheless, every State provides basic medical and related services to individuals with brain injury and their families who qualify given their income and other resources. However, neither financial nor demographic data on the number of persons with TBI, types, or costs of services received under State Medicaid Plans is available.

In 1981 Congress passed the Omnibus Budget Reconciliation Act, which amended Section 1915(c)(4)(B) of the Social Security Act and paved the way for the creation of optional Medicaid Waivers to provide services beyond the scope of traditional Medicaid benefits and to overcome statewide comparability requirements. Waivers must be budget neutral. CMS developed a TBI Home and Community-Based Services Waiver prototype. There are three types of waivers: 1115, 1915(b), and 1915(c).

Research and Demonstration—1115 Waivers

Section 1115 Waivers, called “research and demonstration” waivers, may be used by States to enact a broad variety of initiatives. Approved waiver programs range from small-scale pilot projects that test new benefits to finance mechanisms for major restructurings of State Medicaid programs. States also use 1115 Waivers for welfare reform projects. The populations covered vary from waiver to waiver as does the scope of coverage and nature of the provider organizations.

Freedom of Choice - 1915(b) Waivers

Freedom of Choice, or 1915(b), Waivers allow States to place beneficiaries in primary care case management programs (PCCMs), which are run on a “managed” fee-for-service basis using a gatekeeper concept, or in a prepaid capitated arrangement. The latter type of arrangement can involve mandatory enrollment in health maintenance organizations (HMOs), health insuring organizations (HIOs), or prepaid health plans (PHPs). Currently, Freedom of Choice Waivers are approved for two-year periods and may be renewed.

Home and Community-Based Services (HCBS)—1915(c) Waivers

Through Home and Community-Based Services (HCBS) or 1915(c) Waivers, and with approval of CMS, States are permitted to waive one or more of the Social Security Act requirements for statewide availability, income and resource standards, comparability of services and equal provision of services. This process gives States the flexibility to target certain age groups, geographic areas, functional abilities, or diagnostic labels by selecting a mix of services that best meet the needs of the population.

To implement a 1915(c) Waiver, a State Medicaid agency must assure CMS that, on average, it will not cost more to provide home and community-based services than the cost for providing institutional care. Waivers are approved for three years, after which they may be renewed every five years.

The Social Security Act specifically lists seven services which may be provided under a HCBS or 1915(c) Waiver:

case management,
homemaker services,
home health aid services,
personal care services,
adult day health,
habilitation, and
respite care.

With permission from CMS, States may include other optional services such as supported employment, in-home modification, counseling, assistive devices, and transportation. These services must be above and beyond what is allowed under the State’s Medicaid Plan. Individuals with brain injury who are Medicaid-eligible may access these services under numerous types of HCBS or 1915(c) Waivers or the TBI Medicaid Waiver Prototype.

The first TBI Medicaid Waiver was implemented in 1991 in Kansas. Since then, a number of States have implemented or are in the process of obtaining TBI Waivers to meet the specific needs of individuals with brain injury. In addition to the standard menu of services under a 1915(c) Waiver, many States provide other services such as transportation, day treatment, behavior modification, cognitive rehabilitation, assistive technology, independent life skills training, specialized medical equipment, and environmental modifications for individuals with brain injury. As the result of the L.C. and E.W. v Olmstead Supreme Court Decision, States must plan for community alternatives to inappropriate institutional care. HCBS Waivers provide a vehicle for developing and paying for community-based services and supports that provide an alternative to institutional or nursing home level of care.

Administrators in 25 States reported having TBI Medicaid Waivers in place in 2004. In Maryland the waiver became operational in fiscal year 2003-04; and in Delaware, the waiver became operational in the spring of 2005. In some States the number of persons served using the TBI Waiver is unknown. In those States administrators reported the number of service slots in the most recently competed fiscal year for which data was available. Some States serve persons with brain injury and spinal cord injury within the same waiver making it difficult to obtain an exact count of persons with brain injury. Since it is possible for one individual to access Medicaid Waiver services during part of a year and another individual to access services the remainder of the year, the NASHIA estimate that more than 8,000 persons were served by TBI Waivers in 2004.

It is not possible to estimate an average per person cost of Medicaid Waiver services nationwide because the scope and duration of services varies widely depending on the eligibility criteria applied in each State. For example, in New Hampshire only individuals with acquired brain injuries who need 24-hour access to care are served under the State’s waiver program. Consequently, the per-person cost is significantly higher than in States where the primary TBI Medicaid Waiver service may be case management. Since Medicaid Waivers are jointly funded Federal /State programs, the Federal share of total expenditures varies from 50 to 83 percent depending on the State.

Individuals with brain injuries are also served under other Medicaid HCBS Waiver programs. For example, 31 States serve individuals with TBI under Developmental Disabilities Waivers; 26 States serve individuals under Aging and Disabled Waivers; 10 States serve individuals with brain injuries under Elderly Waivers; and 11 States serve individuals using Physical Disabilities Waivers. In the State of Georgia, 30 slots are set aside for persons with TBI in the State’s Independent Care Waiver. Montana reports that a set of services appropriate to persons with TBI are included in its Aging and Physical Disabilities Waiver. In most States neither the financial or demographic data on persons served, service type, nor cost is known.