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home and community based services (HCBS)

What are home- and community-based services (HCBS)?

Home and community based services (HCBS) include a variety of medical and social services provided to individuals with functional or cognitive limitations. People who receive HCBS are able to continue living in the community – instead of entering a nursing home or another institutional setting. HCBS programs serve the needs of distinct groups of individuals, including people with physical disabilities, intellectual and developmental disabilities (IDD), and mental illnesses.

HCBS programs can offer seniors and people with disabilities assistance with activities of daily living (ADLs) like toileting, bathing, eating, and getting in and out of bed. (These are known as personal care services.) Some HCBS programs also offer a variety of medical services, including:

  • home health care,
  • physical and occupational therapy,
  • skilled nursing care,
  • durable medical equipment services

Human services are another component of HCBS. These can include:

  • case management services (e.g. medical service coordination),
  • home meal deliveries,
  • transportation,
  • financial and legal services

HCBS are provided to beneficiaries in their homes or in community locations like adult or senior day care centers. Many states also have HCBS services specifically intended to help individuals transition from an institution (e.g. nursing home) to living in their community.

Medicaid has shifted to paying for LTSS in community-based settings over nursing home care over the past 20 years. This is largely due to enrollee preferences for living in the community and the U.S. Supreme Court’s Olmstead decision, which found that Medicaid’s “institutional bias” toward paying for nursing home care violated the Americans With Disabilities Act (ADA).

Medicaid currently pays for more HCBS care than any other insurer. (Medicaid spending on HCBS services totaled $92 billion in Fiscal Year 2018.) Some Americans also choose to finance their long-term care (including HCBS) by purchasing private long-term care insurance.

Nursing home care is a mandatory Medicaid benefit, but covering HCBS is optional and there are waiting lists for it in some states. Income limits for HCBS enrollees are higher in some states than for nursing home care – meaning enrollees are allowed slightly keep more of their income each month to pay for housing and other living expenses. (Note however that these income limits are state-specific.)

State Medicaid programs frequently have multiple HCBS waiver programs. Eligibility for each HCBS program involves both financial factors (e.g. income and assets) and non-financial factors (e.g. the intensity or ‘level’ of services required). Several studies have shown HCBS services cost Medicaid less money on a per-person basis than nursing home care.

Most states have both an HCBS waiver program for seniors and people with disabilities and separate programs targeted to the needs of individuals with intellectual and developmental disabilities (IDD). (These HCBS programs for individuals with IDD have higher per-capita and overall costs than other HCBS programs.)

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