Medicaid Waiver Programs

October 16, 2017 12:50 pm Published by

Section 1915(c) of the Social Security Act authorized the Medicaid Home and Community-Based Services (HCBS) waiver program. Under this program, states can provide services in homes and/or residential communities for patients who need care. Waiver programs keep patients in their home or a community-based setting instead of having to enter institutions or long-term care facilities, like nursing homes.

Lower Cost Solutions

As 65 million baby boomers are aging into Medicare, the health care system is not fully equipped for handling the influx. Waiver programs lower medical costs and increase the number of resources that are available for patients. For the senior population, this is a huge benefit because the government allows seniors who are eligible for Medicare to also qualify for state Medicaid.

This dual eligibility allows the patient to be eligible for services, including personal care and homemaking. It also allows for a cost split between Medicare, which is funded 100% by the federal government and Medicaid, which is funded with a 50/50 split between the federal government and the states.

Managing Waiver Programs

Because many waiver programs depend on funding from the federal government, state governments are hesitant to manage the programs. Some have turned to having insurance companies manage programs under a model known as managed care. The state provides the managed care organization (MCO) with patient and authorization information and then the MCO refers the patient to an agency within their provider network. The agency provides services to their patients and the bills the MCO for those services. The MCO approves the claims and sends them to the state to send payment to the agency.

Beginning in 2019, all services will be required to be verified through electronic visit verification (EVV). Your agency needs to be prepared or risk losing payments. DCI Software is designed to improve operations for agencies working under managed care arrangements. Contact us for a software demo.

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