Improve Equity in Services in Medicaid Waivers for People with Significant Disabilities

Goal: Individuals with disabilities and older Texans should receive equitable services—regardless of the specific Medicaid waiver program that funds their care.

Problem: The administration of every Medicaid waiver program is different—each has its own financial eligibility criteria, service assessment instruments, service descriptions, rate methodology and annual expenditure cap. As a result, the needs of some individuals with significant disabilities (children, young adults, older Texans) cannot be met because of the service limitations or monetary caps of the waiver for which they are eligible.

Recommendation: The Disability Policy Consortium supports reforming the community long term care system to make the services provided through and the administration of its Medicaid waiver programs more equitable based on the significance of the person’s need, rather than labels based on diagnosis, disability and/or age. Specifics follow.

Background: Texas currently has multiple Medicaid waivers for people with disabilities and older Texans that allow them to live in the community with support services.¹

Some of the waivers are based on a person’s age, some are based on when the disability was acquired and some are based on a person’s specific medical diagnosis/condition/disability. Some of the waivers cover the whole state while others only are available in designated areas in the state.

Each of the waivers has their own financial eligibility criteria, service assessment instruments, service descriptions,rate methodology and how much any one individual can expend per year (service plan cap). Some of these Medicaid waivers are administered by the Health and Human Services Commission (HHSC) and some by Department of Aging and Disability Services (DADS).

There are some individuals with significant disabilities (children, young adults, older Texans) whose support needs cannot be met because the waiver they are eligible for does not have the specific service they need and/ or the monetary cap of that waiver is insufficient to adequately meet their support needs. For example, individuals with brain injury cannot access needed cognitive therapies. Individuals in Community Living Assistance and Support Services (CLASS) or Community Based Alternatives (CBA) cannot access residential assistance that is available only in Home and Community-based Services (HCS). These individuals are in jeopardy of being inappropriately institutionalized. Individuals in HCS cannot access many of the specialized services available in the CLASS waiver.

Additionally, there is a wide range of wages paid to direct care workers in the various long term service and supports programs, ranging from minimum wage to just over $19 per hour (using Consumer Directed Services (CDS) in the HCS waiver). These variances create difficulties for the agency in administering the programs and difficulties for providers trying to operate different service programs and some providers have problems trying to hire attendants at all because those attendants can be paid more working in other programs.

Specific Recommendations:

• HHSC/DADS should submit a funding request to allow people with significant disabilities eligible for any of the multiple waiver services to receive an equitable range of support services;
• HHSC/DADS should take administrative/legislative steps to make the range of services offered and the rates for the services more equitable and efficient to administer.
• HHSC/DADS should be directed to review where and the how best the multiple Medicaid waivers should be delivered and administered.

Justification: The current system is based on historic ways of delivering support services to people with disabilities and older Texans. Beginning to reform the community long term care system based on the significance of the person’s need, rather than labels based on disability and/or age, will allow Texas to better meet the tsunami of demand that the aging of our population and the improvement in medical technology will bring about. It will be more cost effective and equitable to the diverse disability and aging populations.

¹The community living options in Medicaid waiver programs are:

• Community Based Alternatives (CBA): provides services to people 21 or older who are eligible to live in a nursing facility. Services include nursing services, attendant services, medical supplies, therapies, home modifications, emergency response services, and adaptive aids.
• Community Living Assistance and Support Services (CLASS): provides services to people of any age who have a diagnosis of a related condition. Services include case management, nursing services, physical therapy, respite care, functional life skills training, and psychological services. CLASS is not available in every county.
• Deaf-Blind with Multiple Disabilities Program (DBMD): provides services to people 18 or older who have deaf-blindness and at least one other disability. Services are designed to increase independence and communication skills, and include adaptive aids, behavior communication services, case management, environmental accessibility, habilitation, intervener, orientation and mobility, occupational, physical and speech therapies, housekeeping, and nursing services.
• Medically Dependent Children Program (MDCP): provides services to children under 21 who have medically complex needs. These services include respite, minor home modifications, and adaptive aids.
• Home and Community-based Services (HCS) Program: provides services to people with a diagnosis of mental retardation or a related condition with an IQ of 75 or below. Services include case management, adaptive aids, minor home modifications, therapies, nursing, residential assistance, respite, day habilitation, and supported employment.