the growth of home and community - based services ( hcbs ) under medicaid can be traced to the early 1980s when it was found that : a disproportionate percentage of medicaid resources were being used for institutional long - term care ( davidson , 1980 ; grannemann and pauly , 1983 ; holahan , 1975 ; spiegel and podair , 1975 ) .
several studies documented that at least one - third of persons residing in nursing facilities that were medicaid funded would have been capable of living at home or in community residential settings if additional supportive services were available ( fox and clauser , 1980 ; kraus , et al . , 1978 ; pegels , 1980 ; weissert , 1986 ) .
institutional bias  in the medicaid benefit and eligibility structure ( grannemann and pauly , 1983 ; holahan , 1975 ; leonard , brust , and choi , 1989 ; weissert and scanlon , 1985 ) .
residents in both nursing facilities and intermediate care facilities for the mentally retarded frequently reported an unsatisfactory quality of life ( de silva and faflak , 1976 ; gardner , 1977 ; lakin and hall , 1990 ; scheerenberger , 1976 ) .
a number of court cases resulted in court orders to deinstitutionalize persons with developmental disabilities .
the hcbs waiver program was established by section 2176 of the omnibus budget reconciliation act of 1981 and was incorporated into the social security act ( the act ) at section 1915(c ) . under the hcbs waiver program
, states can elect to furnish under medicaid , as an alternative to institutional care , a broad array of services ( excluding room and board ) that are not otherwise covered under the medicaid program .
passage of this statute represented a first step towards recognizing that many individuals at risk of institutionalization can be supported in their homes and communities , thereby preserving their independence and bonds to family and friends , at a cost not higher than institutional care ( health care financing administration , 1996 ) .
the act lists seven specific services that may be provided under the hcbs waiver program .
although not specified in the act , other services may be provided at the request of the state if approved by hcfa .
for example , these services may include transportation , in - home support services , meal services , special communication services , minor home modifications , and adult day care ( health care financing administration , 1996 ) . hcbs waiver services may be provided to individuals who are elderly and disabled , physically disabled , developmentally disabled or mentally retarded , or mentally ill .
hcbs waiver services may also be targeted to individuals with a specific illness or condition , such as children who are technology - dependent or individuals with aids ( health care financing administration , 1996 ) . in the absence of the hcbs waiver
these individuals would require the level of care offered in a hospital , nursing facility , or intermediate care facility for the mentally retarded .
states have a great deal of flexibility in designing their own unique hcbs waiver program(s ) .
this enables a state to identify a specific population and target services to that population to meet the population 's unique needs .
as previously noted , the hcbs waiver program gives states the flexibility to develop and implement creative alternatives to institutional care for individuals who are medicaid eligible .
this flexibility is advantageous to the states as it allows states to tailor their programs to the specific needs of the populations they wish to serve .
for example , under the hcbs waiver a state may : provide services in the home or community as a cost - effective alternative to institutional care .
target services to a specific group by waiving section 1902(a)(10)(b ) of the act which relates to the comparability requirement .
limit services to a specific geographic area by waiving section 1902(a)(1 ) of the act which relates to the statewideness requirement .
request an exception to the deeming rules under the social security administration 's supplemental security income program , thereby the eligibility determination for an individual in the community on an hcbs waiver is made using institutional versus community deeming rules .
the medicaid hcbs waivers are an important tool for states to meet the requirements of the americans with disabilities act ( ada ) as defined by the u.s .
is properly regarded as discrimination based on disability  in violation of the provisions of the ada .
the court affirmed the policy that the ada supports access to community living for persons with disabilities by obliging states to administer their services , programs , and activities  in the most integrated setting appropriate to the needs of the qualified individuals with disabilities .  in addition , the court found that institutionalization severely limits a person 's ability to interact with family and friends , to work , and to make a life for himself or herself . to help states
comply with the court 's ruling , hcfa and the department of health and human services ' office for civil rights have begun working with states and the disability community toward the goals of promoting hcbs and honoring individual choice in service provision .
estimated total medicaid expenditures for the hcbs waiver program for 1998 were over $ 9 billion for an estimated 606,953 participants ( harrington et al . , 1999 ) .
states continue to renew existing hcbs waivers , as well as request new hcbs waivers .
( arizona provides similar services under the authority of a section 1115 demonstration waiver rather than a section 1915(c ) waiver [ harrington et al . , 1999 ] . )
 the history and current status of the medicaid home and community - based services waiver program are presented . 
 the article discusses the states ' role in developing and implementing creative alternatives to institutional care for individuals who are medicaid eligible . 
 also described are services that may be provided under the waiver program and populations served . 
Background
Advantages of HCBS Waivers
Current Status