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Using Medicaid Waiver Funding for Nutrition Services Including Home Delivered Meals

Background

This article describes how Older American Act (OAA) Nutrition Programs can use the Medicaid Waiver program to offer nutrition services to their growing number of frail homebound older adults. Josefina Carbonell, Assistant Secretary, Administration on Aging, recently stated, “the President has proposed a $1.75B program over 5 years to encourage States to transition people from nursing homes or other long-term care institutions back into the community (1). In the year 2000, approximately 35 million people were over 65 years of age and this number will double to about 70 million by the year 2030. Although many older adults remain independent and actively involved in their communities, many are frail with multiple chronic conditions and need more long-term care services allowed by the Medicaid waiver to prevent and/or delay nursing home placement. As the number of older adults continues to grow, so will their need for assistance to remain functionally able (2). It is clear, that AoA has recognized this growing need and is taking steps to address the matter. OAA Nutrition Programs provide services that assist frail homebound older adults to remain in their homes and maintain quality of life. The Medicaid Waiver program is one way that may help OAA Nutrition Programs increase the number of services they provide.

How is the Medicaid Waiver different from Medicaid?

The Medicaid waiver allows States to provide an array of home and community services including home-delivered meals, nutrition counseling and nutrition risk reduction to older adults. In most States, the Medicaid program is the primary funding source for nursing facilities.

The Medicaid Program

Medicaid is a State-Federal partnership that pays for health and long-term care services to low-income persons who are aged, blind, disabled, members of families with dependent children, or meet certain other criteria for need (3). The Medicaid program varies considerably from State to State, as well as within each State over time. Within broad national guidelines that the Federal government provides, each State establishes its own eligibility standards, determines the type, amount, duration, and scope of services, sets the rate of payment for services and administers its own program. The Medicaid program is administered by the Centers for Medicare & Medicaid Services (CMS), which was formerly the Health Care Financing Administration (HCFA).

The Medicaid Waiver Program

In 1981, the federal government established the Home- and Community-Based Care Service (HCBS) waiver program under Section 1915(c) of the Social Security Act. This allows States to provide community-based services by waiving certain Medicaid statutes and regulations. HCBS Waiver services enable individuals who are at risk of being placed in long-term care facilities to be cared for in their homes, preserving their independence and ties to family and friends. The HCBS waivers are State-specific and each State has the flexibility to develop and implement their own benefits package of HCBS for persons who would otherwise be in a hospital or nursing facility (4).

Prior to the HCBS waiver program, Medicaid long-term care benefits were limited to hospitals, nursing facilities and intermediate care facilities. There are now approximately 264 home and community-based services waiver programs operating throughout the country. All States except Arizona have at least one program. Arizona operates an equivalent of an HCBS waiver program under section 1115 demonstration waiver authority (4).

Federal law allows States to request waivers of certain Federal Medicaid requirements. The law allows for two kinds of Medicaid waivers, Section 1115 research and demonstration waivers and Section 1915 program waivers. The two types of waivers most frequently used by the Aging Network fall under Sections 1915(b) and 1915(c) of the Social Security Act. These waivers allow States to provide services to Medicaid beneficiaries using innovative approaches and are frequently used by States to promote home-and community-based services, or to use managed care in their Medicaid programs (5).

Section 1915(b) ensures Medicaid beneficiaries have a choice of providers that allows States to waive Medicaid's "freedom-of-choice" requirement. With this type of waiver, States may require beneficiaries to enroll in managed care plans, create specialty care delivery systems, such as managed behavioral care, create programs that are not available statewide, or provide enhanced services for beneficiaries. For States to be approved, the waiver request cannot negatively affect beneficiary access to services or quality of care and must be cost effective. These waivers initially are granted for two years (6).

What are the main services provided under the Medicaid Waiver Program?

Each State, as a provider, chooses the services they wish to offer Medicaid waiver beneficiaries. No specific services are required in an HCBS waiver program. Similarly, there is no limit on the number of services that can be offered under a single waiver program. The Social Security Act lists seven core services, which may be provided in HCBS waiver programs. These services include:

•  Case management,

•  Homemaker/home health aide services,

•  Personal care services,

•  Adult day health,

•  Habilitation, and

•  Respite care.

What nutrition services and other services are provided under the Medicaid Waiver?

Nutrition services, including home-delivered meals, nutrition counseling and nutrition risk reduction may also be provided, but are subject to CMS approval. Approximately 38 States provide nutrition services according to a recent CMS summary report. For example, Arkansas , Iowa , Maryland and Oregon provide home delivered meals. Iowa and Maryland provide medical nutrition therapy (nutrition care planning, nutrition assessment and dietetic instruction) and Florida provides home delivered meals, dietitian services, nutrition assessment and nutrition risk reduction. Other services that may be provided under the waiver are also subject to CMS approval. They include non-medical transportation, in-home support services, special communication services, minor home modifications, risk reduction and adult day care (7).

In Minnesota , the Medicaid Waiver program is approved to provide case management, homemaker, respite, adult day care, home delivered meals, foster care, residential care, and assisted living to older adults. In Wyoming , their Medicaid program is approved to provide case management, personal care, respite, adult day health, transportation, and home delivered meals to older adults and individuals with disabilities.

CMS has summary reports that describe waiver program services and their approval status for Regular Waivers and Model Waivers without Analysis ( 3/12/03 ):

Regular Waiver Report http://cms.hhs.gov/medicaid/1915c/regular.pdf

Model Waiver Report http://cms.hhs.gov/medicaid/1915c/model.pdf

How can nutrition risk be reduced using case management and nutrition services?

An array of intensive services is necessary to help Medicaid Waiver eligible older adults remain in their homes. Case management is one such service that provides older adults with the support for their medical, physical, emotional and social needs. Through case management, the needs of each individual are assessed, a plan of services to meet those needs are developed, the delivery of services are arranged and monitored, and the effectiveness and need for continuation of services are evaluated. Case managers work with clients to ensure that a care plan matches their needs, values, and preferences. Case managers can help older adults take advantage of nutrition services, such as, home-delivered meals, nutrition education, diet modification, adaptive eating devices and nutrition counseling. Case management can also play a critical role in the care of an older person's nutritional status. Case managers can be an early warning system for identifying older individuals at nutritional risk by serving as a critical link to a dietitian/nutritionist who can provide a more comprehensive nutrition assessment and select appropriate interventions to help reduce nutritional risk.

For example, in Oregon , State Medicaid case managers must confirm eligibility and authorize meals for clients and approve invoicing of those meals. In Florid a , case managers make a referral for nutrition services (i.e. home delivered meals, nutrition counseling, nutrition risk reduction). At United Home Care, a home health agency in Miami-Dade county, case managers refer older individuals at nutritional risk to the agency's dietitian. The dietitian then conducts a thorough nutrition assessment (anthropometrics, 24-hour recall, medication management, etc) and develops appropriate outcomes/goals to help reduce nutrition risk.

In Maryland , participants are enrolled through the Area Agency on Aging (AAA). The AAA receives an initial assessment by the local health department and a plan of care is developed. The plan of care is submitted to the Department of Aging (DAAS) for approval. In Iowa , the Case Management Team reviews the case and makes a referral for services. In Arkansas , the client completes an application and is assessed for medical need by the DAAS Registered Nurse. The county Department Health Services (DHS) office determines financial eligibility. The plan of care is approved by the physician and assigned to a provider for services.

What type of provider is eligible to offer services under Medicaid Waiver?

Prior to applying for Medicaid waiver services, it is recommended that your program contact its local SUA and AAA for eligibility criteria. The following are examples of local service providers that may be eligible to offer certain Waiver services, if they meet waiver requirements: licensed assisted living programs, home health agencies, residential service agencies, nursing facilities, meal delivery services, local health departments, respite care providers, local departments of social services, personal care providers, congregate housing providers, building contractors, personal emergency response vendors, medical equipment vendors, and certain types of licensed professionals (e.g. dietitians/nutritionists). Three States, Arkansas , Iowa , and Maryland require that a dietitian who provides nutrition counseling under the Medicaid Waiver program be licensed by the State.

In Iowa , the provider of nutrition counseling services must be from one of the following areas: community action agency, home health agency, hospital enrolled in Medicare, licensed dietitian approved by the Area Agency on Aging, or licensed nursing facility. The provider of home delivered meals and nutrition supplements must be: an Area Agency on Aging, community action agency, home care agency, home health aide provider certified to participate in Medicaid, a hospital enrolled with Medicare, a medical equipment and supply dealer certified to participate in the Medicaid program, a licensed nursing facility, or a licensed and inspected restaurant.

Service agencies in Arkansas must apply to the State Division of Aging and Adult Services to be a Medicaid provider. A certified provider of home delivered meals does not have to provide Title III services. However, the provider's kitchen must be approved by the Department of Health and meals must provide 1/3 of the RDA and be approved by a dietitian. The provider must also comply with all federal, State, county, and local laws and regulations concerning the procurement, preparation, handling, and transportation of food, have available all necessary licenses, permits, and food handlers' card as required by law, and if applicable, assure that their intermediate source of delivery meets or exceeds federal, State and local requirements.

I have heard about “choice.” What does that mean in the Medicaid Waiver Program?

The Medicaid provisions refer to the “freedom of choice” principle, which indicates that individuals can select the provider(s) of the services for which they are eligible. This principle applies to all Medicaid-funded services, including services furnished through HCBS waiver programs. It is important that individuals be offered a choice of qualified providers so that they are able to obtain the support and care they need according to their preferences.

The definition or concept of “choice” differs among States. For example, recipients may choose a service provider (if more than one is available in the service area) in Arkansas , Iowa , and Maryland . In Iowa , most home delivered meal providers do not provide a choice of menus except when frozen meals are used and then a choice is provided. In Florida , some lead case management agencies have list of meal providers that each client can choose from. Some of the meal providers offer one selection per day (some hot, some frozen), while other service providers offer a menu with different selections available (most are frozen). The lead agency is trained to document by narrative notation that the client was given choice of meal providers (a list of available providers).

Costs of Nutrition Services to the Medicaid Waiver Program and Service Definitions

Several States provided information on home delivered meal charges to Medicaid waiver as described in the following chart.

State Unit on Aging

Nutrition Service

Cost/meal

Alabama

Frozen meals

Shelf-stable meals twice/year to at-risk clients

$3.70

$3.00

Arkansas

“Elder Choice” meals

Weekend meals are frozen, weekday meals are hot where possible and frozen if hot is not available.

$4.97

Iowa

Home delivered meals

$7.19 (max)

Maryland

Home delivered meals

Dietitians

$5.00 (max)

$55.00 /hour

Nebraska

Home delivered meals

$3.95

Oklahoma

Home delivered meals

$4.39

Oregon

Home delivered meals

$5.24

Utah

Home delivered meals

$7.20 (max)

Examples of service definitions for home-delivered meals and nutrition counseling from states are provided below:

Maryland

Home delivered meals (Unit of service: One meal delivered to the participant's home)

  • The meal may be hot, cold, frozen or shelf stable as recommended by the care team or the dietitian and each meal must be nutritionally adequate based on the RDA/DRI.
  • Up to two meals per day may be provided.
  • Reimbursement is for cost associated with food, food preparation and delivery.
  • The service is not available for those in assisted living facilities.

Nutrition Counseling (Unit of service: one hour or less of service rendered one-on-one by a qualified provider for a participant in the participant's home or the provider's office)

Services include the provision of nutrition care plan interventions specified as necessary to ensure the participants' health and safety and prevent institutionalization or hospitalization.

Iowa

Home delivered meal (Unit of service: one meal)

  • Such meal or liquid supplement must provide at least 1/3 RDA
  • A maximum of 14 meals is allowed per week.

Nutrition Counseling (Unit of service: 15 minutes)

  • The service may be provided if a nutritional problem or condition is of such a degree of severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted.

Arkansas

Home delivered meal (Unit of service: One daily nutritious meal served to eligible clients who are homebound. Home delivered meals are limited to a maximum of thirty-one units per month and four emergency meals per State fiscal year.)

  • Hot home delivered meals provide one meal per day of nutritional content equal to one-third of the RDA as recommended for an adult male 55 years or older and comply with the Dietary Guidelines for Americans .
  • Frozen home delivered meals have the same requirements as hot with a few more rules. The goal of the frozen meals is to supplement not replace the hot meals.
  • Frozen meals are for those who reside in remote areas where daily hot meals are not available or choose to receive a frozen meal rather than a hot meal or are at nutritional risk and are certified to receive a meal for use on weekends or holidays when the hot meal provider is not in operation.
  • Clients must have adequate and appropriate storage and be able to perform the simple tasks associated with storing and heating a frozen meal or have made other appropriate arrangement approved by DAAS.
  • A maximum of seven frozen meals may be delivered at one time.

What steps are involved in getting Medicaid Waiver services approved?

Waivers are approved for several years, and then may be renewed. Today, every State has received and implemented at least one Medicaid program waiver, often to provide home- and community-based services as an alternative to nursing home care, or to require certain Medicaid beneficiaries to enroll in managed care plans.

For a 1915(b) waiver, the State Agency submits the application to CMS and the program is considered approved unless it is acted upon within 90 days. Within this time frame, CMS can approve, disapprove, or stop the 90-day clock on the process if additional information about the program is needed. The 1915(b) waiver programs are approved for 2-year periods, and can be renewed on an ongoing basis if the State applies (5).

To receive approval to implement the 1915(c) HCBS waiver programs, State Medicaid agencies must assure CMS that on an average per capita basis the cost of providing home- and community-based services will not exceed the cost of care for the identical population in an institution. State Medicaid agencies must also specify the amount, duration, and scope of each service they provide, which must be sufficient to achieve its purposes. States may not place limits on services or arbitrarily deny or reduce coverage of required services solely because of diagnosis, type of illness, or condition. Generally, a State plan must be in effect throughout an entire State (i.e., the amount, duration, and scope of coverage must be the same Statewide) (3). The State Medicaid agency must also document that there are safeguards in place to protect the health and welfare of beneficiaries. HCBS waiver programs are initially approved for 3 years and may be renewed every 5 years (6).

Home and community-based services are essential in attaining independence and maintaining the quality of life for frail older adults. The Medicaid Waiver program allows States to provide home and community-based care services, including nutrition services that homebound older adults may need to prevent and/or delay nursing home placement. OAA Nutrition Programs can use the Medicaid waiver program to offer nutrition services to their growing number of homebound participants.

For a complete listing of Home and Community Based Services Waiver by State

Contributors

Simone de Olivera, RD, LD, Dietitian, United Home Care Services, 5255 NW 87 Avenue, Suite 400, Miami, FL 33178. 305-716-0756.

Jennifer Drzik, MS, RD, LD, Nutrition Program Manager, Maryland Department of Aging, 301 West Preston Street, Suite 1007, Baltimore Maryland 21201. 410-767-1090, 800-243-3425, extension 1090 jhd@mail.ooa.State.md.us

Beth Landon, LD, RD, Vice President, Community Services, CareLink Central Arkansas Area Agency on Aging, Inc., P.O. Box 5988, 706 West Fourth St., North Little Rock, AR 72119. (501) 688-7423, (800) 482-6359. blandon@care-link.org

Carlene Russell , MS , RD, FADA, Consulting Nutritionist, Iowa Department of Elder Affairs, 200 10 th Street, Suite 300 , Des Moines , IA 50309 . (515) 242-3384. carlene.russell@dea.State.ia.us

Joan Smith, Executive Director, Loaves and Fishes, Inc., 61225 SE 52 nd Ave. , Portland , OR 97206 . 503-736-6325, Fax: 503-736-6322 jsmith@lfcpdx.org

Resources

Centers for Medicare and Medicare Services: http://www.cms.hhs.gov/

Monitoring protocol for review of home and community-based services waiver programs. HCFA Regional Office Protocol for Conducting Full Reviews of State Medicaid Home and Community-Based Services Waiver Programs. Version 1.2. December 20, 2000 . Available at: http://cms.hhs.gov/medicaid/1915c/proto1-2.pdf

Promising Practices: This section provides descriptions of State programs that demonstrate effective and innovative home and community-based services. Available at: http://hcbs.org/browse.php/type_tool/135/Promising_Practices

For a complete listing of Home and Community Based Services Waiver by State

References

•  Bush Administration proposes $1.75 billion to change long-term care approach.
New report today finds need for long-term care workers will grow dramatically.

Available at: http://aging.senate.gov/index.cfm?Fuseaction=PressReleases.View&PressRelease_id=113 . Accessed 08/25/04 .

•  Administration on Aging. A Profile of Older Americans. Available at: http://www.aoa.gov/prof/Statistics/profile/profiles2002.asp Accessed 08/25/04 .

•  Understanding Medicaid Home and Community Services: A Primer. DHHS, Office of the Assistant Secretary for Planning and Evaluation. October 2000. Available at: http://aspe.hhs.gov/daltcp/reports/primer.htm http://www.keystonehumanservices.org/pdffiles/primerpt.htm Accessed 08/25/04 .

•  Home and Community-Based 1915 (c) Waivers. Centers for Medicare & Medicaid Services. Available at: http://cms.hhs.gov/medicaid/1915c/default.asp . Accessed 08/25/04 .

•  Kane R, Kane R, Kaye N, Mollica R, Riley T, Saucier P, Snow KI, Starr L.

Managed Care: Handbook for the Aging Network. Minneapolis , Minn : University of Minnesota ; 1996.

•  Home and Community-Based 1915 (b) Waivers. Centers for Medicare & Medicaid Services. Available at: http://cms.hhs.gov/medicaid/1915b/default.asp . Accessed 08/25/04 .

Compiled by Barbara Kamp, Stacey Reppas, MS, RD, Dian Weddle, PhD, RD, and staff of the National Resource Center on Nutrition, Physical Activity, and Aging Florida International University , Miami , FL.
Contact: nutritionandaging@fiu.edu

November 2004

 

This project is supported, in part, by a grant from the Administration on Aging,
Department of Health and Human Services (DHHS). Grantees undertaking projects under government
sponsorship are encouraged to express freely their findings and conclusions.
Points of view or opinions do not, therefore, reflect official DHHS policy.


Posted on: 11/12/04
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National Resource Center on Nutrition, Physical Activity & Aging
| Florida International University, OE 200, Miami, FL 33199
Phone: 305-348-1517 | Fax: 305-348-1518 | E-mail:
nutritionandaging@fiu.edu

This website is supported, in part, by a grant from the Administration on Aging, Department of Health and Human
Services (DHHS). Grantees undertaking projects under government sponsorship are encouraged to express freely their
findings and conclusions. Points of view or opinions do not, therefore, reflect official DHHS policy.