FAQ - Waiver Redesign

Hope and Opportunity in Many Environments (HOME) is a project in Iowa that is working to improve and ensure that everyone has access to high-quality behavioral health, disability and aging services in their communities. The goal is to enhance services to make it easier for people to access the help they need and remain in their communities with their loved ones.  

In late 2022, Iowa HHS did research and gathered feedback from Iowans to learn about challenges with the current community-based services system, including home and community-based services (HCBS) waivers. HHS learned that current waiver waitlists are not timely, efficient or needs based. Services do not align with Iowans’ needs, and services and supports are hard to navigate and access. Feedback from Iowans showed opportunities for the waiver system to be more efficient, easier to understand and better at connecting Iowans to the services and supports they need throughout their lives. 

1. Changing from 7 disability-specific waivers to 2 age-based waivers with wider eligibility. Iowa HHS proposes having one waiver for Children and Youth (up to age 20) and one waiver for Adults & Aging individuals (ages 21 and over) to focus on the person and their needs across the lifespan rather than the person’s diagnosis or living situation. More people will be eligible in the future. For example, Iowa HHS also proposes adding people with developmental disabilities as an eligible group for both new waivers. 
2. Offering more comprehensive service packages with formal and informal supports that meet the needs of Iowans throughout their lives. Changes will keep existing services that Iowans need and broadly use, add a few services to meet Iowans’ current unmet needs, and simplify administration. Doing so will promote consistency and fairness across the two proposed waivers. 
3. Developing “tiered” budgets that allocate resources for eligible people based on their needs. This individualized approach will help ensure that waiver-enrolled Iowans receive the number of services that they need in a way that is efficient, cost-effective and equitable for all Iowans on waivers. 

In addition to redesigning HCBS waivers, Iowa HHS is working on other Medicaid-related changes to address challenges and improve the community-based services (CBS) system. This includes improvements to processes for assessment, waitlists and service navigation. Changes also involve establishing case management ratios and training and improving quality management. 

Iowa HHS plans to implement gradual and careful changes so transitions will not happen all at once. Changes to improve service definitions are already underway, while the change from seven waivers to two waivers will roll out over the next several years. Iowa HHS estimates that CMS might approve the waivers to start as early as July 2025. Iowa HHS will put systems and processes in place in preparation for the new waivers and support providers to remain enrolled throughout the transition. Iowa HHS will create and implement a plan to enroll members in the new waivers. Throughout, Iowa HHS will give Iowans regular updates to help them understand and plan for this transition.  

1. CBS are a broad set of services that support people who are aging, have disabilities, or have behavioral health needs either in their homes or in the community, as opposed to those in a facility or institutional setting. CBS can include both Medicaid-funded HCBS services and services funded through Iowa’s Recommend changing this to reflect new branding, Behavioral Health and Disability Services (BHDS), Department of Aging and Disability Services (ADS)  system, the Department of Aging, and other state programs. 
2. HCBS are a subset of CBS that are provided through an HCBS waiver. HCBS are Medicaid-funded supports to help people with disabilities and/or behavioral health needs as well as older Iowans to live at home and in their community. CMS authorizes HCBS waivers under Section 1915 (c) of the Social Security Act.  

Iowa will align changes that occur to Prevocational Day Habilitation and Supported Employment service definitions, provider qualifications, and performance metrics to align with the Redesigned HCBS waivers as applicable. 

An individual must be eligible for Medicaid and be financially eligible for the HCBS waivers. To be eligible for either of the two new waivers, Iowans would still need to meet two criteria: (1) they must need a level of care that would be provided at an institution, and (2) their disability must fall into one of these categories: 

1. Children & Youth: intellectual disability, brain injury, AIDS/HIV, physical disability including blindness, serious emotional disturbance, or developmental disability.  
2. Adult & Aging: intellectual disability, brain injury, AIDS/HIV, physical disability including blindness, aging, or developmental disability.  

There will be waitlists in the future. Iowans currently on a waitlist will remain on the waitlist during the transition to redesigned waivers. HHS is looking for ways to improve the waitlist system, including: a single screening tool that allows HHS to understand needs for all people as they enter a waitlists, a prioritization system so that people with highest needs have priority access to waivers, and also exploring ways to provide some supports to people on waitlists while they are waiting for services.  

Waitlists for the redesigned waivers will include a prioritization system so that people with highest needs have priority access to waivers.  

Iowans currently on waivers will remain on waivers, continue accessing their services and be able to work toward their person-centered goals. Iowa HHS will transition members to new waivers in phases, which will include an assessment of eligibility. When the new waivers begin, future waitlists would include a prioritization system to ensure that people with the highest needs can access services timely.  

Iowa HHS will share detailed communications about transitions. Iowa HHS plans to implement these changes gradually and carefully. Changes will not happen all at once. Iowa HHS will provide a plan for the transition to the new waivers, balancing a variety of considerations to maximize the outcomes for people who need waiver services, their caregivers and providers.  

Under the new waivers, population groups that currently do not face waiver waitlists may be placed on a waitlist. Future waitlists will include a prioritization system to ensure that highest-need people can access services timely. 

Existing services will remain available. Some service titles and definitions may change based on feedback received from Iowans and to eliminate duplication or overlapping components across current services. Additionally, new services will be added to address unmet needs that Iowans shared with HHS. The full list of proposed waiver services is available on the HOME site. The list needs Iowa Legislative funding and CMS approval of the waiver application. 

In the proposed list of new services, Iowa HHS has renamed some services and expanded the definitions for other services. Almost all existing services will remain available and there will be new services. The list of proposed changes with the existing services is available in the waiver redesign concept paper - Appendix C: Crosswalk Between Existing Services and Proposed Services. 

Operating two, age-based waivers would allow Iowa to offer a comprehensive service package to children that complements federally mandated services available to children under EPSDT and IDEA, as well as Medicaid school-based services like behavior counseling, nursing and special transportation. Iowa HHS is working to streamline service definitions on the Children & Youth waiver to ensure there is not duplication across these programs.  

Yes

It is our hope that you will have the option to keep the case manager you have today.

To learn more, visit the HOME page, or visit our Facebook page for more information. You may also submit a form to be added to our list of contacts to receive the HOME newsletter.  

We are glad you want to engage with us! You may always share your thoughts and questions in an email to the HOME team: iowahcbs@mathematica-mpr.com. Also, the Iowa HOME site lists current feedback opportunities. You may also submit a form to be added to our list of contacts when new opportunities are available.