Forum Session

State Progress in Implementation of Home- and Community-Based Service Programs Enacted by the ACA
September 27, 2013


Carol V. O'Shaughnessy, MA


The Patient Protection and Affordable Care Act of 2010 (ACA) enacted the most significant opportunities for state expansion of Medicaid-financed home- and community-based services (HCBS) since 1981, when Congress enacted the Medicaid section 1915(c) waiver program. The ACA programs are intended to spur state Medicaid agencies to improve their long-term services and support infrastructures and provide greater access to HCBS for people with disabilities. Four of the programs—the Balancing Incentive Program (BIP), the Community First Choice (CFC) state plan option, the health home state plan option, and the Money Follows the Person Rebalancing (MFP) demonstration program—offer states enhanced federal Medicaid matching funds as long as they meet federal requirements. The ACA expanded the scope of services and eligibility under a fifth program, the section 1915(i) HCBS state plan option, established under prior law. (See table for selected characteristics of the ACA HCBS programs and the section 1915(c) waiver program.) State interest in implementing these new programs has been fairly robust partially due to the enhanced match, perhaps because most states are experiencing a period of budget constraints. Even so, some states have reported concerns about both their ability to contribute their share of matching funds and the pressures on limited state staff to implement the various programs. Most states have implemented MFP programs; for the remaining programs, some states have received Centers for Medicare & Medicaid Services (CMS) approval to implement, are in the planning stages, or in some cases are not moving forward. The complexity of administering a large array of optional HCBS programs, each carrying different eligibility and service requirements, as well as mandatory competing state responsibilities in other Medicaid program areas, may be affecting state uptake to date.

This Forum session explored the ACA expansions from federal and state perspectives. Questions included:

  • What has been states’ capacity to implement the programs, both in terms of dedication of staff to manage the programs and ability to contribute their share of Medicaid matching funds?
  • What strategies are states using to decide which of the various ACA HCBS programs to implement?
  • How are states prioritizing implementation of the HCBS programs, especially in view of competing priorities, such as implementation of the broader Medicaid eligibility expansions and state health insurance exchanges enacted by the ACA?
  • For states that have implemented the new programs, how are the programs aligned with other Medicaid HCBS programs offered by the state? With state efforts to establish Medicaid managed LTSS systems?
  • What has been the effect of the various programs’ enhanced federal matching funds for HCBS? Will states be able to continue the programs once enhanced matching funds sunset?


Suzanne (Suzie) R. Bosstick, MA (bio)
Deputy Director
Disabled and Elderly Health Programs Group
Center for Medicaid and CHIP Services
Centers for Medicare & Medicaid Services

Kristi R. Plotner, LCSW (bio)
Director, Office of Policy, Planning & Development
Office of the Governor, Division of Medicaid
State of Mississippi

Dawn Lambert (bio)
Director, Money Follows the Person (MFP) Demonstration
Department of Social Services Medical Care Administration
State of Connecticut

Related Materials

For this meeting, Forum staff prepared a table showing selected characteristics of the ACA HCBS programs and the section 1915(c) waiver program.

See also "Key Issues in State Implementation of the New and Expanded Home and Community-Based Services Options Available Under the Affordable Care Act" (Kaiser Family Foundation, Issue Brief, September 2013).

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