Post-COVID: States Continue Medicaid HCBS Flexibilities

The pandemic transformed our world forever—and family caregivers felt the brunt of it. Taking care of family during sickness, job loss, and economic instability caused immense stress on caregivers. During the COVID-19 pandemic, states obtained federal approval to implement more flexibility with Medicaid home and community-based services (HCBS) to guarantee continued access to care. Now that the public health emergency has officially ended, many of these changes will remain in effect permanently. 

What were the temporary COVID-19 HCBS flexibilities states received?

When the COVID-19 pandemic hit, states needed to adapt their Medicaid HCBS programs offered through HCBS waivers to address growing needs. To make things easier, the federal Centers for Medicare & Medicaid Services (CMS) made some quick changes to existing programs like the 1915c waivers and 1115 demonstrations.

These temporary Appendix K authorities allowed states to:

• Pay family caregivers for providing HCBS
• Increase pay for direct care workers
• Expand access to assistive technologies
• Permit remote assessments, care planning, and monitoring
• Add telehealth and electronic service delivery options
• Allow electronic signature and document sharing
• Expand home-delivered meals
• Increase opportunities for participant-direction
• Build up caregiver support services

These flexibilities gave individuals uninterrupted access to essential HCBS during the stresses of the pandemic and helped participants avoid institutionalization. Family caregivers benefitted from additional resources and a higher pay rate; however, that changed in May 2023.

Understanding Medicaid HCBS programs 

Medicaid Home and Community-Based Services (HCBS) programs are services and supports designed to help individuals with disabilities and older adults receive the care they need while living in their homes and communities rather than in institutional settings like nursing homes or hospitals. These programs are funded by Medicaid, a joint federal and state program that provides health coverage for low-income individuals and families. HCBS programs aim to promote independence, improve quality of life, and prevent or delay the need for institutional care.

Here are some key components and features of Medicaid HCBS programs:

1. Eligibility: Eligibility for HCBS programs varies by state and may include factors such as age, income, disability, and need for long-term care services. States have flexibility in determining eligibility criteria within federal guidelines.
2. Services: HCBS programs offer a range of services to meet the specific needs of eligible individuals. Some common services include personal care assistance, home health care, adult day care, respite care for caregivers, transportation, assistive technology, and home modifications to improve accessibility.
3. Person-centered planning: HCBS programs emphasize person-centered planning, which means that individuals receiving services are actively involved in making decisions about their care. Care plans are tailored to the individual's preferences and needs, promoting a higher level of personal choice and control.
4. Waiver programs: Many HCBS programs are offered through Medicaid Home and Community-Based Services waivers. These waivers allow states to waive specific Medicaid rules to provide services that would not typically be covered under the traditional Medicaid program. Waiver programs are often designed for particular populations, such as people aged and/or disabled, people with intellectual or developmental disabilities, or people with severe mental illness.
5. Cost-sharing: While Medicaid typically covers the total cost of HCBS services for eligible individuals, some states may require beneficiaries to contribute to the cost of care based on their income and assets. These cost-sharing arrangements are often called "spend-down" or "income and asset tests."
6. Care settings: HCBS programs provide services in various community-based settings, including private homes, group homes, assisted living facilities, and adult day care centers. This allows individuals to receive care in environments that are more integrated into their communities.
7. Federal and state partnership: Medicaid is jointly funded by the federal government and individual states, and the specific details of HCBS programs can vary significantly from state to state. States have considerable flexibility in designing and implementing their HCBS programs but must adhere to federal guidelines.
8. Waiting lists: Due to limited funding and high demand for HCBS services, some states may have waiting lists for individuals seeking to enroll in these programs. Priority is often given to those with the most urgent needs.

Medicaid HCBS programs are crucial in supporting individuals with disabilities and older adults in maintaining their independence and living in their preferred community settings. States continually update and modify their programs to better meet the needs of their populations, so the specific services and eligibility criteria may change over time. If you or someone you know is interested in HCBS services, it's essential to contact your state's Medicaid office to learn about the available programs and how to apply.

What is the impact of the end of the COVID-19 public health emergency?

As of May 11, 2023, the federal public health emergency ended. This meant that the temporary Appendix K emergency authorities, which states used to modify their Medicaid HCBS programs, were no longer in effect.

Each state is now deciding which rules they want to keep permanently. They are making changes in different ways, like changing laws, requesting permission to keep specific rules, and making new regulations.

What Medicaid HCBS flexibilities are states continuing post-COVID? 

Many states plan to sustain certain Appendix K flexibilities after conducting reviews and stakeholder engagement to identify which changes had the most significant impact:

• Remote monitoring, assessments, and care planning
• Electronic signatures, document sharing, and notice distribution
• Expanded access to assistive technologies like tablets
• Added telehealth and telemedicine service options
• Increased availability of home-delivered meals
• Higher pay for family caregivers and direct care workers
• More participant self-direction opportunities

By keeping these flexibilities in place, states aim to maintain improvements in access to HCBS, reduce barriers, and support independent living.

Below is a breakdown of which Medicaid Home and Community-Based flexibilities remain:

As you can see, while some flexibilities like a higher caregiver pay rate and access to assistive technology remain, most services have ended across the country. 

How can I find out if my state is continuing COVID-19 HCBS flexibilities?

If you or a loved one benefits from Medicaid HCBS, there are six steps caregivers can take to find out if your state is preserving any emergency Appendix K flexibilities:

1. Contact your state Medicaid office directly and ask if specific flexibilities remain in effect for your particular HCBS program or waiver.
2. Review your program's most recently approved waiver documents on your state's Medicaid website and check if the flexibility is included.
3. Search your state legislature's website for any bills passed in 2023 to extend COVID-19 Medicaid HCBS flexibilities.
4. Check if your state Medicaid agency website lists policy changes and search for announcements on the continuation of flexibilities.
5. Contact your case manager or services coordinator and ask if they know which flexibilities are still allowed and if you qualify.
6. Connect with local disability advocacy groups who may have insight into state continuation plans.

The COVID-19 pandemic led states to change their Medicaid HCBS programs, improving access to services for many beneficiaries. While the public health emergency has ended, over half of states plan to sustain increased caregiver pay and other HCBS flexibilities that were temporarily allowed. 

Staying informed on Medicaid Home and Community-Based flexibilities

The flexible changes made during COVID-19 are still helping make services easier to use when more people need home care. Some changes to Medicaid home care programs during COVID were temporary. Others are now permanent. 

Knowing which changes stay helps family caregivers to help their care recipients live independently. Options like telehealth, remote help, and electronic signatures make it easier to get services. States that continue a higher family caregiver pay rate provide much-needed financial support for families. More older adults need home care now. Staying up-to-date on permanent changes helps people find the services they need.

>> Related article: Medicaid Expansion: What to Know as a Family Caregiver