What is a waiver?

Under Section 1915(c) of the Social Security Act, Medicaid law authorizes the Secretary of the U.S. Department of Health and Human Services to waive certain Medicaid statutory requirements.  These waivers enable States to cover a broad array of home and community-based services (HCBS) for targeted populations as an alternative to institutionalization.  Waiver services may be optional State Plan services which either are not covered by a particular State or which enhance the State’s coverage.  Waivers may also include services not covered through the State Plan such as respite care, environmental modifications, or family training.

The four basic types of 1915(c) HCBS waivers available for states based on the target population’s level of alternative long-term institutional care are:

• intermediate care facility-mental retardation (ICF-MR) level of care for mentally retarded and/or developmentally disabled individuals;

• chronic or rehabilitative hospital level of care for individuals who are medically fragile, chronically ill, or severely disabled;

• psychiatric hospital level of care for individuals who are severely or chronically mentally ill; and

• nursing facility level of care for individuals who are elderly, physically disabled, and/or cognitively impaired.

To be a waiver participant, an individual must be medically qualified, certified for the waiver’s institutional level of care, choose to enroll in the waiver as an alternative to institutionalization, cost Medicaid no more in the community under the waiver than he or she would have cost Medicaid in an institution, and be financially eligible based on their income and assets.