in the state, it was uncertain whether third-party reimbursement
would be available to these individuals for the level of mental
health services needed to function safely in the community.
To allow for continuation of Medicaid coverage for this
population, therefore, OMPP applied for a behavioral and primary health care coordination (BPHC) service under the 1915(i)
state plan option, which is a care management benefit targeted
to adults age 19 or older with a qualifying mental health condition and income up to 300 percent of FPL.
The goal of the 1915(i) service was to provide a pathway to
full Medicaid coverage and the specific mental health services
that would be required by the eligible individuals. This result
was achieved through the optional eligibility group provisions
and the income disregards for medically needy individuals outlined in Section 1902 of the SSA.
5 Due to the 1915(i) program
changes under the ACA, Indiana was able to maintain access to
critical mental health services for more than 4,500 individuals.
In the period between the January 2007 effective date of 1915(i)
as set forth by the DRA and the revisions introduced by the ACA
in 2010, only five states had incorporated HCBS into their state
plans. By August 2014, 12 states were participating in the 1915(i)
state plan option and four more states were planning to participate in federal fiscal year 2014. The growing popularity of the
1915(i) state plan option can be attributed to its flexibility, which
allows states to do the following:
■ ■ Provide a vehicle for full Medicaid coverage to medically needy individuals who would not otherwise qualify for
■ ■ Add HCBS and/or expand coverage of individuals who meet
institutional levels of care without having to amend current
1915(c) waivers; and
■ ■ Meet the HCBS needs of Medicaid enrollees who have a
degree of physical and intellectual disability that does not
qualify them for institutional levels of care.
A key consideration in the implementation of a 1915(i) service package is that the delivery of HCBS through the state plan
may assist in managing eligible individuals’ chronic conditions,
and may lead to savings by delaying or avoiding more costly care
in a hospital or other institutional setting. As a result, both the
program cost and potential offsets in other service categories
should be presented in discussions of the financial implications
of providing the 1915(i) state plan option.
The following resources were instrumental in the writing of this
article, and are also very good references for additional information related to the 1915(i) state plan option:
■ ■ Centers for Medicare and Medicaid Services (January 16,
2014). “Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment
Reassignment, and Home and Community-Based Setting
Requirements for Community First Choice and Home and
Community-Based Services (HCBS) Waivers; Final Rule.”
Federal Register. See http://www.gpo.gov/fdsys/pkg/FR-
■ ■ U.S. Government Accountability Office Report to Congressional Requesters (June 2012). “Medicaid: States’ Plans to Pursue
New and Revised Options for Home- and Community-Based
Services.” See http://www.gao.gov/assets/600/591560.pdf.
■ ■ Letter from Centers for Medicare and Medicaid Services to
State Medicaid Directors (August 6, 2010). “Re: Improving
Access to Home and Community-Based Services.” See http://
■ ■ Letter from Center for Medicaid and State Operations to State
Medicaid Directors (April 4, 2008). “Guidance on Implementation of Section 6086 of Deficit Reduction Act of 2005.” See
■ ■ O’Keeffe, J., Saucier, P., et al. (October 29, 2010). “
Understanding Medicaid Home and Community Services: A Primer, 2010
Edition.” See http://aspe.hhs.gov/daltcp/reports/2010/prim-
ROBERT M. DAMLER, MAAA, FSA, and Marlene T. Howard,
MAAA, FSA, are consulting actuaries with the Indianapolis office
of Milliman. Their expertise with the Medicaid industry primarily
involves consulting to state agencies.
1 Kaiser Family Foundation (August 28, 2014). Status of State Action of the
Medicaid Expansion Decision. State Health Facts. Retrieved October 27, 2014,
2 According to the Kaiser Family Foundation, 12 states were participating in
the 1915(i) state plan option and four more states were planning to participate in
fiscal year 2014, as of August 2014. See http://kff.org/medicaid/state-indicator/
3 In an April 4, 2008, letter from CMS to state Medicaid directors, the
service offerings were limited to any or all of the following: “case management
services, homemaker/home health aide services, personal care services, adult
day health services, habilitation services, and respite care. In addition, the
following services may be provided for individuals with chronic mental
illness: day treatment or other partial hospitalization services, psychosocial
rehabilitation services, and clinic services (whether or not furnished
in a facility).”
4 Indiana Family and Social Services Administration. Behavioral and Primary
Healthcare Coordination (BPHC) 1915(i) Home and Community Based Service
(HCBS). Retrieved October 27, 2014, from http://www.in.gov/fssa/files/BPHC_
5 More information related to the BPHC program is available on the Indiana
Medicaid website at http://www.in.gov/fssa/ddrs/4862.htm.
The goal of the 1915(i) service was
to provide a pathway to full Medicaid
coverage and the specific mental
health services that would be required
by the eligible individuals.