Medicaid and COVID19: How to use Home & Community-Based Services waivers


Many of the 1.8 million older adults who live in Ohio will require long-term care as they age. The Administration of Community Living estimates 70 percent of those older than age 65 will require some type of long-term care as they age, and about 20 percent will need care for five years or more. Nursing homes and other institutional settings were once the standard model for this type of care. Over the past several decades, long-term care has shifted out of institutions and into the community. Reductions in the number of nursing facility beds that are supported by public programs, and an increase in the availability of home and community-based services, enables more people to remain in their homes and age in place, even if they cannot live completely independently. This shift toward home and community-based services has been positive for many older adults, especially as the majority of older adults say it is important to them to be able to remain in their neighborhood as they age.

Seventy percent of those older than age 65 will require some type of long-term care as they age.

Long-term care services provided in the home can be medical or non-medical and can be directed toward the individual or towards an individual’s living environment. Home-based services may be provided by the staff of a for-profit agency, a nonprofit agency, a managed care organization, an independent caregiver, volunteer or a government office. Home care includes home health care, homemaker services and aging supportive services. Older adults with complex health issues, reduced mobility, or limited financial resources often rely on nonprofessional caregivers, their friends and family, to provide support that allows them to remain in their homes. These caregivers often monitor the social conditions that allow for a vulnerable person to remain in a home and community-based setting. Caregivers often manage housing, food access, health services, transportation and household finances, all of which are social determinants that impact health. These caregiving relationships may be formalized into set schedules or be more informal, providing assistance as needed.

Home care includes home health care, homemaker services and aging supportive services.

The impact of COVID-19

As the spread of COVID-19 continues and physical distancing is practiced by many, nonprofessional caregivers may need to keep their distance from care recipients. Similarly, with mass layoffs and high unemployment throughout the state, family members who had been able to financially contribute to the care of an older adult may no longer be in a situation to do so. The scale of economic insecurity faced by older adults is often overlooked, and while low-income seniors have historically relied on Social Security and Supplemental Security Income for economic stability, these payments are fixed, come once a month and leave many ill-prepared for unexpected circumstances. Older adults who had previously been able to rely on familial caregiving and financial support, may suddenly find themselves in need of additional non-familial supports to maintain their independent living arrangements. For older people with sufficient resources the memo is clear, stay home, stock up on food and supplies and avoid group activities. However, this guidance fails to address the challenges of millions of low-income older adults who lack access to healthy food and social services. Creating pathways to receive these services and provide family caregivers and their care recipients with financial support to continue care will help ensure older adults continue to be safe and healthy in their homes.

Older adults who had previously been able to rely on familial caregiving and financial support, may suddenly find themselves in need of additional non-familial supports to maintain their independent living arrangements.

The role of Medicaid

From its inception in 1965, Medicaid guaranteed access to a “nursing facility level of care” for program participants. This means states that have Medicaid programs must be able to provide services that enable recipients to achieve “activities of daily living” such as dressing, eating and general hygiene. While this is a guaranteed benefit, not all services require an institutional setting and, in fact, the provision of these services outside of institutions was the basis of the landmark Olmstead v. L.C. case in 1999. Home & Community-Based Services (HCBS) waivers, also called 1915(c) waivers, allow states to offer HCBS in their Medicaid programs in lieu of institutional settings. Not only are these waivers often preferred by individuals in need of long-term care, but have also been shown to be cost-effective in managing Medicaid programs.

As an amendment to 1915(c) waivers, states can use “Appendix K” as a response to emergencies like COVID-19. This amendment, which we are hearing is being pursued by the Ohio Department of Medicaid, can modify or expand eligibility or services, increase cost limits and permit non-traditional service provisions like virtual engagement. Since Ohio has several waivers covering both the elderly and developmentally disabled populations, the state may have to submit multiple amendments depending on the waiver in question.

At the end of the day, any effort by the Ohio Department of Medicaid should do two things: 1) ensure individuals have access to the medical services they need both related and unrelated to COVID-19 and 2) promote the physical distancing practices being promoted by the state to contain spread and “flatten the curve.” Considering what is currently available through an Appendix K amendment to Ohio’s 1915(c) waivers, we believe the Ohio Department of Medicaid should consider the following changes as compliments to its existing response efforts:

  1. Allow managed care plans to presumptively enroll individuals for all 1915(c) waivers

Expanding beyond PASSPORT’s MyCare component will ensure there is continuity of care for individuals in need of HCBS services without the need to process eligibility paperwork in a time of limited county resources for a population at significant risk.

  1. Allow family members, including those who are not directly related, to serve as paid caregivers and a live-in caregiver as a benefit

Reducing community spread is a key public health strategy of the state and, as many individuals are caring for family members already, but may be faced with the challenge of doing so with fewer resources because of the economic impact of COVID-19, this has a dual benefit of flattening the curve and stabilizing household finances.

  1. Add cell phone minutes as a benefit

This could help minimize social isolation and promote existing telephonic case management.

  1. Add grocery delivery and supplies and benefits

This would reduce the risk of unnecessary exposure, decrease pressure on emergency food assistance and provide key nutritional supports.

  1. Suspend in-person assessment requirements

This would reduce potential exposure and can maximize capacity of limited workforce.

Workforce consideration

The state has determined home health workers that provide HCBS through Medicaid waivers essential workers. This allows providers to continue to provide home health care for the extent of the governor’s Stay At Home order and beyond. The Ohio Council for Home Care & Hospice is concerned with the safety and health of staff who enter the homes of clients. A letter by the organization expressing concern about the 6,000 home care and hospice workers was sent to Governor Mike DeWine on March 16. The letter requested assistance to obtain personal protective equipment for staff as well as flexibility with Medicaid regulations, reimbursement and in-home COVID-19 testing.

Service protocols for Medicaid waiver clients can be found on the Ohio Council for Home Care & Hospice COVID-19 resource page.

Steps have been outlined to preserve the health of home health providers as they work with those who have shown symptoms of COVID-19. Service protocols for Medicaid waiver clients can be found on the Ohio Council for Home Care & Hospice COVID-19 resource page. The guidelines outline the criteria for working with clients who have a temperature greater than 100.4, who are coughing and have shortness of breath and it includes which waiver services are to be suspended until the client is symptom free for 72 hours. It also details which services should be continued.

Suspended services for waiver clients with suspected COVID-19:

  • Personal Emergency Response System installation
  • Waiver personal care and homemaking
  • Wavier nursing
  • Home Modification, Maintenance and Chore Services that require access to the inside of the home
  • In-home delivery of large Home Medical Equipment (HME)/Durable Medical Equipment (DME) such as lift chairs
  • In-home maintenance of HME/DME
  • In-home social work counseling
  • Adult day services
  • Waiver transportation

Continued services for wavier clients with suspected COVID-19:

  • Home-delivered meals
  • Existing personal emergency response services like life alerts.
  • Drop shipped HME/DME
  • Home modification, maintenance and chore services that do not require access to the inside of the home

Additional recommendations

While this piece is focused on the ways that the Appendix K amendment to Ohio’s 1915(c) waivers could help Ohio flatten the curve, there are other complementary policies both in and outside of Medicaid the state should explore.

  1. Publicize the availability of telemedicine infrastructure and virtual health care to low digital literacy populations

This reduces potential COVID-19 exposure to vulnerable populations and helps maintain standing appointments.

  1. Streamline enrollment in multiple benefit programs

While this may be difficult to achieve and coordinate in the short term, policymakers should consider ways the current eligibility systems are fragmented and how that has caused difficulties responding to an emergent need.

  1. Apply for 1135 waiver

An 1135 waiver can provide a host of benefit and workforce opportunities to Medicaid during the crisis. Many older adults, in addition to waiver services, have regular needs that range from the chronic to the acute. Many of the related services will have to be set aside as the surge of patients diagnosed with COVID-19 enter into the system. A waiver can more easily help the Ohio Department of Medicaid address challenges not only related to COVID-19, but the general care of the population.

For a full, growing list of COVID-19 policy recommendations and their status, click this link to see more on