Home and community-based services (HCBS)

Medicaid describes HCBS as services that let beneficiaries receive care in their own homes or communities rather than in institutions or other isolated settings, for groups such as older adults and people with intellectual or developmental disabilities, physical disabilities, or mental health and substance use disorders. Medicaid.gov names four authorities a state can use: 1915(c) home and community-based waivers, 1915(i) state plan HCBS, 1915(j) self-directed personal assistance services, and 1915(k) Community First Choice.

Under a 1915(c) waiver, a participant has to need a level of care that would qualify them for an institutional setting, and the standard services include case management, homemaker, home health aide, personal care, adult day health, day and residential habilitation, and respite care. States can target a waiver by age or diagnosis, can run as many waivers as they choose, and nearly all states and DC offer services this way, with about 257 waiver programs active nationwide.

For billing, HCBS is many small programs rather than one benefit. Each state designs its own, so service definitions, codes, units and rates differ from program to program. Personal care adds a federal layer: states must require electronic visit verification for Medicaid personal care services since January 1, 2020, and for home health services since January 1, 2023. The mistake is treating the authorization as paperwork. A claim is paid against the units authorized for a specific service and period, so units billed past the authorization, outside its dates, or before a visit clears its EVV exception put the line at risk of denial or later recovery.