SI DAL01310.207 Verifying Medicaid Under a State Home or Community Based Care Plan (TN 4 -- 11/2005)

A. Background

Sections 1902(e)(3) and 1915(c) of the Social Security Act allow States to develop medical assistance programs for certain groups of individuals to provide them with home or community based care.

In the Dallas Region, only Arkansas had previously provided Medicaid assistance to disabled children under the authority of section 1902(e)(3) of the Act. However, effective October 1, 2005, the State of Oklahoma began providing Medicaid under section 1902(e)(3) of the Act. These children are sometimes referred to as “TEFRA 134 children,” and they receive regular Medicaid benefits under the State’s Medicaid State Plan (i.e., this is not a Medicaid “waiver” but part of the State’s approved Medicaid plan). Essentially, section 1902(e)(3) permits States to provide Medicaid assistance to children living at home if it is less expensive than providing similar care in an institution.

In the Dallas Region, all five States provide Medicaid to children under approved 1915(c) home or community based waivers. In addition, there are other 1915(c) waivers that cover disabled and aged individuals. These programs are separate from the normal State Medicaid program and are commonly referred to as "home or community based waivers." Medicaid does not pay for room and board under these waivers. Such programs have been approved by the Centers for Medicare and Medicaid Services as a mechanism for States to provide home or community based services, not commonly covered under Medicaid, as an alternative to institutional care. Such home or community based programs are usually limited to a certain number of recipients that can be served at any one time.

B. Policy

  1. Disabled children who are eligible for a Medicaid State home care plan under either a section 1915(c) waiver or section 1902(e)(3) may be eligible for the $30.00 (FLA-D) reduced SSI payment and have all parental deeming waived (i.e., deemed income would not count) provided they meet all the requirements described in SI 01310.201.

  2. For individuals in institutions, FLA-D is not applicable for an individual where Medicaid pays more than 50 percent of the cost of care if the Medicaid payments are made under a section 1915(c) home or community based services waiver. In such a circumstance, FLA-A would be applicable if the individual were in a private institution.

C. Verification

1. When to Verify

For parental deeming of income development, see

SI 01310.207B.1 for instructions on when to verify Medicaid eligibility under a State home care plan under either section 1915(c) or 1902(e)(3).

For institutional situations where Medicaid is allegedly being paid under 1915(c), verify per C.2. and 3. below in all cases.

2. What to Verify

Verify that the individual is receiving Medicaid under either a 1915(c) home or community services waiver or (in Oklahoma or Arkansas) under 1902(e)(3) of the Medicaid State plan. Since room and board is not paid under either 1915(c) or 1902(e)(3), determining who pays the cost of room and board further establishes that Medicaid is being provided under 1902(e)(3) or 1915(c).

3. How to Verify

To verify Medicaid eligibility under either 1915(c) or 1902(e)(3), obtain from the individual/parent a copy of the Medicaid provider agreement form that was completed with the State agency or the institution. This document provides information on the financial arrangements, and it specifies which State agency (e.g., MHMR) is authorizing the Medicaid coverage.

In developing the parental waiver provision, the period of eligibility for the home or community based services must be established. If the documentation does not provide this information, call the Dallas SSI Team in the Regional Office (RO) to verify that the individual is eligible for Medicaid under a 1915(c) State home care waiver or under 1902(e)(3). Do not call the local State Medicaid Agency. The telephone number for the Dallas SSI Team is (214) 767-4224.

The RO staff will contact the State agency to verify Medicaid eligibility and obtain specific coverage periods. This information will be provided to the DO and should be recorded on a Report of Contact.

D. Section 1915(c) Waivers

The following is a list by State of section 1915(c) home or community based waivers currently in existence in the Dallas Region under which an SSI recipient/claimant may qualify.

1. Arkansas

  • Mentally Retarded/Developmentally Disabled (waiver #188.90.R2)

  • Aged (waiver #0195.90.R2)

  • Alternatives for Adults with Physical Disabilities (waiver #0312.90)</