1115 Waiver

is a research and demonstration waiver that allows states to test new ways of delivering Medicaid services. States use this waiver to pilot innovative programs, expand eligibility, or provide services not typically covered under traditional Medicaid.

1915(c) Waiver

is the most common Medicaid Waiver program that allows states to offer Home and Community-Based Services (HCBS) to individuals who might otherwise require institutional care. Services can include personal care, respite care, and habilitation.

ADHC

(Adult Day Health Care): A program that provides daytime services, such as medical care and social activities, to individuals who need supervision. Medicaid Waivers often cover ADHC as part of long-term care services.

ADLs

(Activities Daily Living): Basic tasks related to personal care, including eating, dressing, bathing, toileting, and mobility. Eligibility for many Medicaid Waiver services is determined based on the level of assistance an individual needs with ADLs.

AFC

(Adult Foster Care): A residential option where adults with disabilities or the elderly receive care in a family-like setting. An adult foster care provider typically lives in the home and offers 24-hour care and supervision. This service is an alternative to institutional care and is available through many HCBS Waivers.

Assistive Technology

Devices or equipment that help individuals perform tasks they would otherwise have difficulty doing. This can include things like mobility aids (e.g., wheelchairs, walkers), communication devices, or home automation systems. Under HCBS Waivers, assistive technology is provided to increase individuals’ independence.

Behavioral Support Services

Services designed to help individuals with behavioral challenges manage their emotions, develop coping strategies, and improve their overall well-being. Behavioral support can include therapy, counseling, or behavior modification plans, and is an essential component of HCBS for individuals with developmental or intellectual disabilities.

CAP

(Cost Allocation Plan): A plan used by states to allocate costs across various Medicaid services, including those covered under Waivers. Understanding CAP is essential for proper billing and reimbursement.

Case Management

A service provided under many Medicaid Waivers to help individuals navigate their care options. A case manager works with individuals and their families to develop, implement, and coordinate care plans.

CFC Option

(Community First Choice Option): A Medicaid program option that allows states to offer home and community-based attendant services and supports to individuals who are eligible for institutional care. The goal is to help individuals live independently by providing services such as personal care and help with activities of daily living (ADLs).

CMI

(Case Mix Index): A method of classifying patient types based on their diagnosis, which helps determine reimbursement rates for services delivered. Providers need to understand how CMI impacts billing.

CMS-372 Report

An annual report required by the Centers for Medicare & Medicaid Services (CMS) to monitor the financial and operational performance of Medicaid Waiver programs. This report is crucial for compliance.

Community Integration

Programs and services aimed at helping individuals engage in their communities through social, recreational, or employment activities. Community integration services support individuals in accessing community resources, participating in group activities, and improving their social skills.

Companion Services

Non-medical care, supervision, and socialization provided to individuals who are elderly or have disabilities. Companion services may involve helping with light household tasks, engaging in conversation, or accompanying individuals to appointments or social activities.

Consumer Direction

Also known as Self-Direction: is a model that allows individuals receiving HCBS services to have more control over their care. In a consumer-directed program, the individual can hire, train, and supervise their caregivers, manage their service budgets, and make decisions about how their care is delivered.

Day Habilitation

A service that provides individuals with disabilities opportunities for personal development during the day. Day habilitation programs focus on improving life skills, promoting social interaction, and encouraging community involvement. These programs are typically provided outside the home and help individuals become more active and independent.

DME

(Durable Medical Equipment): Equipment that provides therapeutic benefits to individuals with medical conditions or physical disabilities. Examples include wheelchairs, hospital beds, and oxygen equipment.

EBD

(Elderly, Blind, and Disabled Waiver): A waiver designed to provide in-home care services for individuals who are elderly, blind, or disabled, allowing them to avoid nursing home placement.

Environmental Modifications

Also known as Home Modifications Changes made to an individual’s home to improve accessibility and promote independence. These can include installing ramps, widening doorways, or adding grab bars in bathrooms. HCBS Waivers often cover the cost of these modifications to help individuals with mobility challenges remain in their homes.

EVV

(Electronic Visit Verification): A system that electronically verifies the time and location of in-home service delivery for Medicaid Waiver beneficiaries. EVV helps prevent fraud and ensures accurate billing.

FFS

(Fee-for-Service): A payment model under which providers are paid for each specific service they deliver, as opposed to receiving a fixed amount for all services provided.

Financial Eligibility

Income and asset limits individuals must meet to qualify for Medicaid Waiver services. These limits vary by state and specific waiver programs.

Functional Eligibility

A set of criteria used to determine if an individual qualifies for Medicaid Waiver services based on their physical or cognitive abilities. This often involves an assessment of the individual’s ability to perform activities of daily living (ADLs), such as bathing, dressing, or eating.

Habilitation Services

Services that help individuals with disabilities acquire, maintain, or improve skills necessary for everyday life. This may include teaching life skills such as managing finances, cooking, or social interaction.

HCA

(Home Care Agency): An agency that provides in-home care services, such as personal care assistance, under Medicaid Waivers. HCAs play a critical role in enabling individuals to remain in their homes.

HCBS

(Home and Community-Based Services): are provided in an individual’s home or community rather than in an institutional setting like a nursing home. HCBS Waivers allow individuals with disabilities, chronic conditions, or those who are aging to remain in their homes while receiving the care they need.

HCFA

(Home Care Facilities Association): This term refers to the regulatory body or association that oversees home care facilities in certain states. The exact responsibilities and naming conventions of these bodies may differ state by state.

IDD

(Intellectual and Developmental Disabilities): A term used to describe a range of developmental and intellectual impairments. IDD Waivers offer tailored services to individuals with these disabilities to support independent living.

IHSS

(In-Home Supportive Services): Services designed to help individuals with daily living activities, such as bathing, dressing, and meal preparation, provided in the individual's home through Medicaid Waivers.

Incident Report

A formal report filed when something unusual happens during the delivery of Medicaid Waiver services, such as an injury or violation of the care plan. These reports are essential for compliance and quality assurance.

ISP

(Individualized Service Plan): A personalized care plan developed to outline the specific services and supports an individual will receive under a Medicaid Waiver. The plan is tailored to meet the individual's goals and preferences.

LOC

(Level of Care): An assessment used to determine the intensity of care an individual requires, often used to determine eligibility for Medicaid Waivers that cover institutional care alternatives.

LTSS

(Long-Term Services and Supports): Services that help individuals with long-term care needs, often involving assistance with daily living activities such as mobility, personal hygiene, and medication management. LTSS can be provided in-home or in facilities.

MLTSS

(Managed Long-Term Services and Supports) it is a delivery model where states contract with managed care organizations to provide long-term services and supports (LTSS). These services help individuals who need assistance with daily activities such as eating, bathing, and dressing.

Natural Supports

Refers to non-paid assistance provided by family members, friends, neighbors, or community organizations that help individuals remain in their homes or communities. HCBS programs often work in tandem with natural supports to provide comprehensive care.

PACE

(Program of All-Inclusive Care for the Elderly): A program that provides comprehensive medical and social services to frail, elderly individuals to allow them to remain in the community rather than moving to a nursing home. PACE programs combine both Medicare and Medicaid services.

PASRR

(Preadmission Screening and Resident Review): A federally mandated process in some states to screen individuals for mental illness or intellectual disabilities before they are admitted to a nursing home, ensuring that Waiver services are properly coordinated.

PCP

(Primary Care Provider): The healthcare professional who provides first contact and continuous care for an individual under Medicaid. They are often central in coordinating Waiver services.

PERS

(Personal Emergency Response Systems): An electronic device that allows individuals to call for help in an emergency. PERS is often provided to individuals who live alone or are at risk of falls or medical emergencies. This service helps ensure that individuals can get help quickly, even if they cannot physically reach a phone.

Person-Centered Care

An approach to healthcare where the individual’s preferences, goals, and needs are prioritized. Under Medicaid Waivers, person-centered care ensures that care plans are flexible and tailored to each individual’s unique situation.

POS

(Place of Service): A code used in billing to indicate the location where services were provided, such as in-home care, a doctor’s office, or a hospital. Proper coding is crucial for accurate reimbursement.

QA

(Quality Assurance): A set of processes designed to ensure that Medicaid Waiver services are delivered according to established standards. Providers must maintain QA protocols to remain compliant.

RA

(Remittance Advice): A document sent by Medicaid to providers explaining the payment or denial of claims submitted. It provides details on adjustments, denials, and payments.

Respite Care

A service that provides temporary relief to family caregivers by arranging short-term professional care for individuals with disabilities, chronic conditions, or the elderly. Respite care can be provided at home or in a facility.

Self-Advocacy

Encouraging and supporting individuals to speak up for their rights and make decisions about their own care. In HCBS Waiver programs, self-advocacy is an important part of person-centered planning, where individuals are empowered to take control of their care and life decisions.

SEP

(Single Entry Point): A centralized point of access for individuals seeking to enroll in Medicaid Waiver services, where they can learn about eligibility, services offered, and how to apply.

Skilled Nursing Services

Medical care provided by licensed nurses (RNs or LPNs) in the home. Skilled nursing includes services such as wound care, administering injections, and monitoring chronic conditions. These services are a critical part of HCBS Waivers for individuals who require ongoing medical oversight but do not need to be in a hospital or nursing facility.

Supported Living

A type of service that helps individuals with disabilities live independently in their own homes or in shared housing. This may include assistance with personal care, budgeting, cooking, or engaging in community activities. Supported living services focus on helping individuals develop and maintain their independence.

TBI

(Traumatic Brain Injury Waiver): A specific Medicaid Waiver program that provides care and rehabilitation services to individuals who have suffered traumatic brain injuries.

UB-04

A standard claim form used by Medicaid providers to bill for institutional services. Understanding how to fill out the UB-04 correctly is essential for smooth reimbursement.

Waiver Renewal

Many states operate Medicaid Waiver programs on a time-limited basis, requiring renewal every 3-5 years. Waiver renewals may involve changes in eligibility criteria, services, or funding levels.

Waiver Slot

A waiver slot refers to a space or "opening" available for a participant to enroll in a Medicaid Waiver program. Because funding is often limited, waiver programs may have a waiting list, and slots are offered as funding becomes available.

Waiver Waiting List

Some states have waiting lists for individuals applying to Medicaid Waiver programs due to funding limits. The waiting list prioritizes applicants based on their level of need or the availability of services.