Waiver Redesign FAQ

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

From 2022 to 2024, the Iowa Department of Health and Human Services (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. Iowa HHS learned that current waiver waitlists are not timely, efficient or needs based. Services don’t line up 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.  

Iowa HHS proposes merging the 6 diagnosis-based, disability-specific waivers to 2 age-based waivers with wider eligibility while keeping the Elderly waiver.

 Having age-based waivers would focus on the person and their needs across the lifespan instead of the person’s diagnosis.  

Iowa HHS plans to make gradual and careful changes so they would not happen all at once. To get ready, Iowa HHS is putting systems and processes in place to run the new waivers and to help providers stay enrolled throughout the transition. Iowa HHS will form and carry out a plan to enroll members in the new waivers and will give Iowans updates to help you understand and plan for this transition. 

Iowa HHS published an updated timeline which shows that some changes are already underway, such as changes to assessments, the launch of Certified Community Behavioral Health Clinics, and a Behavioral Health redesign.  

In 2025, Iowa HHS will focus on these priorities:  

• Rolling out a Uniform Assessment, so everyone has the same assessment.
• Improving waitlist policies and processes.
• Aligning fee schedules across the 7 existing waivers.
• Enhancing consumer-directed programs (ICDAC/CCO).
• Standardizing services across waivers.
• Strengthening provider capacity and network adequacy.
• Building a quality management system. 

Check the HOME page and FAQs for updates on these priorities.  

1. CBS are many different types of services that help Iowans who are aging, have disabilities, or have behavioral health needs so they can stay healthy and independent in their homes and communities. They can include services funded by Medicaid home and community-based services, Iowa’s Mental Health and Disability Services 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 programs that give Iowans more choices about how and where they receive long-term care services. These services are for people with disabilities and older Iowans who need services to help them stay in their homes and communities rather than move to a nursing home. These services can include things like personal care assistance, therapy, and help with daily tasks. CMS authorizes HCBS waivers under Section 1915(c) of the Social Security Act.   

Iowa HHS would update service definitions, provider qualifications, and performance measures for Prevocational, Day Habilitation and Supported Employment to align with the proposed waivers as needed. 

You will still have the option to self-direct services through CCO and you will not lose access to your Independent Support Broker (ISB). However, working with ISBs will be optional for Iowans who self-direct their services. 

No, there will still be waitlists in the future. Iowans currently on a waitlist would stay on the waitlist during the move to redesigned waivers. Iowa HHS is working to improve the waitlist system by creating screening tools to understand everyone’s needs when they join a waitlist. Iowa HHS has a system to help prioritize people with the highest needs so they can get quicker access to waivers.  Iowa HHS is also looking into ways to offer some support to people on waitlists waiting for services.   

Yes, the new waiver waitlists would still have a system that gives priority to people with the highest needs, so they can get waiver services faster.   

No. If you are on a waiver now, you would stay on a waiver. You would keep services and work toward your person-centered goals.  

Under the new waivers, groups that currently don’t have waiver waitlists may be placed on one. However, the waitlists will have a system to prioritize people with the highest needs, so they can get services faster. 

Existing services will still be available. Some service titles and definitions may change based on feedback Iowa HHS has heard from Iowans. Iowa HHS will also make changes to remove repeating or overlapping aspects across current services. These waiver services need Iowa Legislative funding and CMS must approve the waiver applications before these service changes can go into place. 

In the proposed list of new services, Iowa HHS has renamed some services and expanded the definitions for other services. Almost all services would still be available. If a service is no longer available, Iowa HHS and case managers will work with members to find another service to meet any needs. 

Many of the proposed changes will not take away any services from the waivers unless they are also available through the Medicaid state plan. This means that each person would still get the services they currently receive through a combination of the proposed new waivers and the Medicaid state plan. 

Iowa HHS is working on a simple process for providers to enroll in the proposed new waivers, and may make some changes to required provider qualifications, with the goal of reducing burden on providers while making sure they can deliver high quality services. Iowa HHS is partnering with a group of providers to understand needed changes and work on solutions.  

Yes, people moving from the Children and Youth waiver to the Adult and Disability waiver would have a spot on the Adult and Disability waiver when they turn 21.   

People would move straight from the Children and Youth waiver to the Adult and Disability waiver when they turn 21. Six months before a person’s 21st birthday, the case manager would let them know that they are aging out of the Children and Youth waiver and start planning for the move to the Adult and Disability waiver. The case manager would confirm that the member wants to keep getting services through the Adult and Disability waiver. If so, the case manager would change the service plan to indicate the move based on the last completed continued stay review (CSR) for the Children and Youth waiver.   

No, a member’s Level of Care (LOC) won’t be changed when they move to the Adult and Disability waiver. The LOC would carry over, based on the last Children and Youth waiver continued stay review (CSR). One year after the last CSR under the Children and Youth waiver, the person would be reassessed under the Adult and Disability waiver. 

The main parts and requirements of person-centered service plans will not change. The service planning team will use the uniform assessment to guide the process. They will review the assessment and work closely with the member to identify their strengths, needs, preferences, goals, and health risks. Both Managed Care Organization (MCO) and Fee-for-Service (FFS) plans will follow the same template for fairness and consistency.  

An assessment is a way to check what kind of help someone needs and if someone qualifies to receive services through HCBS programs. Iowa HHS has several goals related to the assessment changes including:   

1. Making the waiver assessment process simpler and more person-centered.  
2. Creating a more uniform (or standard) way to assess all people on waivers and people who are needing waiver services.  
3. Assessing everyone the same way and completing assessments separately from managed care organizations. 

In 2025, Iowa HHS is gradually moving all waiver assessments to Telligen, the Core Standardized Assessment vendor. Here is the timeline for moving member assessments to Telligen:  

• January 1, 2025: Telligen is responsible for assessment for members on the Intellectual Disability (ID) Waiver. 
• April 1, 2025: Telligen is responsible for assessments for the Brain Injury (BI), HIV/AIDS, Health and Disability (HD), Physical Disability (PD), and Children’s Mental Health (CMH) Waivers.  
• May 1, 2025: Telligen is responsible for all Habilitation Services assessments.  
• July 1, 2025: Telligen is responsible for the Elderly Waiver assessments.  

Moving assessments to Telligen will not change your assessment schedule. The federal government requires HHS to do assessments every year. Members will still need to work with an assessor to complete assessments when they first start the Waiver (initial assessment), once a year (annual assessment) and whenever their condition changes.   

In January 2025, members on the ID waiver started using new assessment tools. Members on the ID waiver who are between ages 4 and 18 started using the interRAI Children and Youth Mental Health Assessment – Developmental Disabilities, and ID waiver members ages 19+ started using the interRAI Intellectual Disability Assessment. This group needed to use a new assessment tool because their old assessment tool, the Supports Intensity Scale-Adult (SIS-A) Edition 1, was discontinued on December 31, 2024.  

Moving from the SIS to interRAI tools, which are already used on Iowa’s HD, PD, BI, CMH, HIV/AIDS, and Elderly waivers, also helps make Iowa’s assessment process simpler and more consistent. Iowa HHS hasn’t made any changes to the assessment tool for Iowans on the HD, PD, BI, CMH, HIV/AIDS, and Elderly waivers. Iowa HHS is considering using the interRAI Early Years Assessment on all waivers for children under age 4 instead of the case management comprehensive assessment. 

Iowa HHS uses interRAI assessment tools for waiver assessments because they help the agency and its partners understand the strengths, needs, and preferences of each member. Using interRAI assessment tools is a person-centered and standardized way to assess all people on waivers or needing waiver services. InterRAI assessment tools have been carefully researched and tested many times and are used in many other states. Researchers and professionals from the interRAI organization developed several assessments that make up the interRAI set of tools. Each interRAI assessment in the set is designed to fit the unique needs of a specific group of people. The tools measure what they are supposed to (this is called “validity”), and the tools give similar results every time (this is called “reliability”). Taken together, the results from these tools show the everyday living (functional) and health-related (clinical) needs of older Iowans and Iowans with disabilities of all ages in a consistent way. 

 InterRAI assessment tools gather information about different areas of need, such as:  

• Community and Social Involvement  
• Strengths, Relationships, and Supports  
• Lifestyle  
• Communication and Vision  
• Thinking (cognition)  
• Health Conditions  
• Independence in Everyday Activities  
• Mood and Behavior  
• Medications  
• Supports and Services  

The time it takes to complete an assessment depends on things like having information ready before starting, who is involved in your team, your health and social conditions, and the assessor’s experience. The first assessment that happens when you first join the waiver will take longer. Some items to consider having prepared prior to the assessment include but are not limited to:  

• Medical records
• Individualize Education Plans (IEPs) or other school records 

The assessment tools are person-centered, meaning that you are in control of the assessment and how it is used to make your person-centered service plan. You share needed information and can choose to include others like family, friends, your case manager, or other support staff to help.  

An individualized budget is a set amount of money for a person receiving services through an HCBS waiver. This budget is tailored to each person’s unique needs and helps pay for the services they need to live in their community, instead of in an institution. Individualized budgeting allows the person to have more control over their care. They can decide which services they want and need, making sure the support they receive is personalized and flexible. Using individualized budgets helps make sure people with similar needs get fair and suitable budgets.  

The uniform assessment would help create a personalized plan that sets a monthly budget for services. Members would give their input on what types and amounts of services they need, based on their budget. To set up the right budget categories, Iowa HHS will review information on people’s needs, service use, and spending for all members.  

• Members would get a monthly budget based on the services they currently use.
• Existing members would be grouped into budget categories based on their current service spending.
• New members would have their budgets set based on their assessment, which measures their level of need, since they don’t have current service spending data.
• To smooth the transition in budgeting approaches and make sure no one has problems accessing services, in the first year of the redesigned waivers, budgets would stay close to what they are now.  

If you don’t feel that your budget is enough to meet your needs, you would be able to ask for a change. Iowa HHS will create a process for you to make this request.  

• Smaller caseloads: Iowa HHS set new rules for case manager to member ratios for community-based case managers (CBCMs).  Starting in January 2025, each community-based case manager will work with an average of 45 members, and no more than 50. This gives them more time to focus on each person. Since July 2024, Managed Care Organizations (MCOs) have hired over 100 new case managers to help meet this goal. These ratios do not apply to facility-based or fee-for-service case management. 
• More in-person visits: Case managers must meet with each member face-to-face at least once every three months. Now, Case Manager must meet with members on the Intellectual Disabilities (ID) Waiver at least every two months.
• Improved, more complete training: Iowa required all case managers to complete training, but there wasn’t one standard training program. As a result, case managers learned different content, which led to uneven quality in the support Medicaid members received.  To make sure all Medicaid long-term services and supports (LTSS) members get high-quality case management, Iowa HHS created two training programs:
• The Case Manager Certification Toolkit for new case managers
• The Case Manager Refresher Toolkit for yearly ongoing training 

These programs teach important skills and include short quizzes to help case managers stay engaged and understand the material. 

New case managers will complete the Certification Toolkit within six months of their hire date. All case managers