Prior to 1981, people in need of long-term care services could only receive Medicaid funding for such services when the services were provided in an institutional setting such as a nursing home. In October 1981, the Social Security Act was amended to allow states to choose to offer Medicaid funding for long-term care services when those services are provided in the individual's home or community. This became known as the Home and Community Based (HCB) Waiver or Medicaid Waiver option.
When the HCB waiver option is selected by a state; that state is choosing to waive the institutional requirements and must decide for whom those requirements will be waived. The state can select the group or groups of people for whom they wish the requirements to be waived. Some examples of groups of people for whom these requirements may be waived are people who are elderly or disabled, people who have an intellectual disability or a related disability, or people who have a head or spinal cord injury. In addition to choosing to waive the institutional requirements and selecting the groups of individuals for whom the requirement will be waived, states are allowed to choose which goods or services will be funded through the HCB waiver. The state must choose services that are not already funded as part of the State's Medicaid Program Plan.
State Waiver Requirements
When the HCB Waiver option is chosen, the state must make several assurances to the Centers for Medicare and Medicaid Services (CMS) which is the division of the U.S. Department of Health and Human Services that is responsible for reviewing, approving and monitoring any waiver options selected by the state. The state must assure that necessary safeguards are taken to protect the health and welfare of all individuals, assure that all individuals require the level of care that would be provided in an institution and assure that the individual’s need for the specified level of care is periodically reevaluated. The state must assure that individuals are informed of any reasonable alternatives available under the waiver, assure that individuals are given the choice of either institutional or home and community-based services and assure that the expenditures under the waiver will not exceed the amount that would have been spent if the individual has chosen institutionalization.
Waivers in South Carolina
In South Carolina, the SC Department of Health and Human Services (SCDHHS) is the state agency responsible for all Medicaid funding. South Carolina has chosen to serve several different populations by utilizing the HCB waiver option. SCDHHS, through its Community Long Term Care (CLTC) Division, administers HCB Waivers to serve the elderly and disabled (Community Choices Waiver), people with HIV or AIDS (HIV/AIDS Waiver), and adults who are dependent on a life support system (Ventilator Dependent Waiver).
SC DDSN Waivers
In addition, SCDHHS partners with the South Carolina Department of Disabilities and Special Needs (SCDDSN) to offer three waivers to serve: one waiver serves people with head or spinal cord injuries (HASCI Waiver), two of the waivers serve people with an intellectual disability or related disabilities (ID/RD Waiver and CS Waiver). Both the ID/RD and CS waivers allow individuals with an intellectual disability or related disabilities to choose to receive care at home rather than in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). Although the individual may choose to receive care at home, he/she must require the degree of care that would be provided in the ICD/IID. In other words, individuals choosing this option must meet ICD/IID level of care. The purpose of the Community Supports Waiver is to serve people with an intellectual disability or related disabilities in the community, whose waiver service needs will not exceed the individual cost limit set forth in the waiver. It also offers opportunities for individuals to self-direct certain services if they choose.