1915(c) HCBS waiver Appendix K modifications

In an emergency, Section 1915(c) home- and community-based services (HCBS) waivers may be modified with the submission of Appendix K. Among other things, Appendix K may be used to:

• establish a hotline;
• increase the number of individuals served under a waiver;
• create an emergency person-centered plan;
• expand provider qualifications or the pool of providers who can deliver services;
• institute or expand opportunities for self-direction; or
• permit payment to HCBS providers when a beneficiary has a short-term hospital or institutional stay.

States may also temporarily increase individual eligibility cost limits; modify service, scope or coverage requirements; exceed service limitations; add services to the waiver; provide services in out-of-state settings; or permit payment for services rendered by family caregivers or other legally responsible individuals (CMS 2020a).

A completed Appendix K must be submitted to CMS for each affected waiver; the appendix may be approved retroactively. Appendix K may not be used to make changes that are not permitted in statute, including payment for room and board in non-institutional settings (CMS 2020a).[1]

COVID-related Appendix K modifications

In response to COVID-19, states are using Appendix K to make temporary changes affecting eligibility; covered services; provider settings and qualifications, such as allowing family members and legal guardians to provide personal care services; payment, including increasing provider rates and making retainer payments to certain providers; and oversight requirements.

As of May 26, 2020, 43 states and the District of Columbia states had received Appendix K approvals for 221 Section 1915(c) waivers with effective dates ranging from a few months up to one year. Generally, states have requested use of Appendix K for multiple HCBS waivers. Most states have received Appendix K approval for HCBS waivers targeting certain populations such as beneficiaries with intellectual and developmental disabilities, adults and children with physical disabilities, or beneficiaries over age 65.

States are making various changes to HCBS waiver eligibility. Temporary modifications made to waiver eligibility include increasing cost limits for entry into the waiver, and modifying additional targeting criteria. Most states are seeking to temporarily modify processes for level-of-care evaluations or reevaluations and extending reassessment and reevaluation due dates. States are also modifying covered benefits due to COVID-19.

TABLE 1. COVID-related Section 1915(c) Appendix K Modifications Related to Eligibility

Notes: This table reflects states with COVID-19-related Section 1915(c) Appendix K approvals as of May 26, 2020. Depending on a state’s delivery system, states may also use Section 1115 authority to make modifications to Section 1915(c) waivers. States that provide HCBS through Section 1115 authority may also use Appendix K. Increase Factor C is the unduplicated number of participants.

* Denotes that the state only requested modifications for select waivers.

Source: MACPAC analysis of Section 1915(c) COVID-19 Appendix Ks.

States are adding or modifying current benefits due to COVID-19. Most states are allowing certain services to occur electronically to allow for the continuation of services in the home, and conducting evaluations, assessments, and person-centered planning meetings virtually. Many states have sought to temporarily exceed service limitations or requirements related to the amount or duration of services, or prior authorization requirements. Other changes include adding home delivered meals or modifying service providers for home delivered meals to allow for additional providers, including non-traditional providers (e.g., UberEats).

TABLE 2. COVID-related Section 1915(c) Appendix K Modifications for Covered Services, Service Delivery, and Planning

Notes: This table reflects states with COVID-19-related Section 1915(c) Appendix K approvals as of May 26, 2020. Depending on a state’s delivery system, states may also use Section 1115 authority to make modifications to Section 1915(c) waivers. States that provide HCBS through Section 1115 authority may also use Appendix K.

  * Denotes that the state only requested modifications for select waivers.

Source: MACPAC analysis of Section 1915(c) COVID-19 Appendix Ks.

Many states are increasing the pool of HCBS providers by allowing family members, and in some states, legally-responsible caregivers, including parents and spouses, to receive payment for certain services, if it was not already permitted in the state’s waiver. In addition, states are temporarily expanding settings where services may be provided. This allows facilities such as adult day health providers to offer personal care services (HMA 2020). Some states have also sought authority to temporarily allow case management entities to provide direct services. States are waiving both federal and state regulations related to HCBS provider settings. To minimize the spread of infection, some states are not allowing individuals to visit waiver participants and others have modified state licensure requirements for certain provider types. Other changes include temporary modifications to provider qualifications, including extending or waiving certain training requirements.

TABLE 3. COVID-related Section 1915(c) Appendix K Modifications for Provider Settings and Qualifications

Notes: This table reflects states with COVID-19-related Section 1915(c) Appendix K approvals as of May 26, 2020. Depending on a state’s delivery system, states may also use Section 1115 authority to make modifications to Section 1915(c) waivers. States that provide HCBS through Section 1115 authority may also use Appendix K.

* Denotes that the state only requested modifications for select waivers.

Source: MACPAC analysis of Section 1915(c) COVID-19 Appendix Ks.

Many states have modified their payment policies to enhance payment to HCBS providers, and modified oversight requirements. Roughly half of states have used Appendix K to require a temporary increase in provider rates; however, it is unclear how many states have implemented such increases. States are also using Appendix K to temporarily provide retainer payments to HCBS providers.

Appendix K may be used to temporarily modify incident reporting requirements, medication management, or other participant safeguards to ensure individual health and welfare and to account for emergency circumstances. Most states have made temporary modifications to such requirements; for example, Maryland, North Dakota, Utah, and Washington have changed timeliness requirements for provider incident reporting.

TABLE 4. COVID-related Section 1915(c) Appendix K Modifications for Payment and Oversight

Notes: This table reflects states with COVID-19-related Section 1915(c) Appendix K approvals as of May 26, 2020. Depending on a state’s delivery system, states may also use Section 1115 authority to make modifications to Section 1915(c) waivers. States that provide HCBS through Section 1115 authority may also use Appendix K.

*  Denotes that the state only requested modifications for select waivers.

Source: MACPAC analysis of Section 1915(c) COVID-19 Appendix Ks.

For the most up to date information on approved state Section 1915(c) Appendix K modifications, see CMS’s Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers webpage.

[1] States that provide HCBS through Section 1115 demonstration authority may use Appendix K to make similar modifications to their demonstrations. Several states have received approval to make Appendix K updates to existing Section 1115 demonstrations in response to COVID-19. For the most up to date information on approved state Section 1115 Appendix K modifications, see CMS’s Coronavirus Disease 2019 (COVID-19): Section 1115 Demonstrations.