Georgia Medicaid HCBS State Plan Option (Section 1915(i)): A Complete Guide to the Federal Sub-Institutional HCBS Authority and Georgia's Non-Adoption

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By Brevy Care Team · Last verified May 12, 2026

A complete guide to the federal HCBS State Plan option under Section 1915(i) of the Social Security Act, established by Section 6086 of the Deficit Reduction Act of 2005 and significantly amended by Section 2402(a) of the Patient Protection and Affordable Care Act, how Section 1915(i) allows states to offer home and community-based services as a State Plan benefit without requiring institutional level of care, how Section 1915(i) requires statewide availability without waiting lists and allows targeting to specific populations including individuals with serious mental illness, intellectual/developmental disabilities, brain injury, and older adults, how the CMS Final Rule at 42 CFR 441.650-.745 establishes needs-based eligibility, person-centered planning, conflict-free case management, and quality assurance, why Georgia has not adopted Section 1915(i) and instead operates HCBS through Section 1915(c) waivers, and what implications Georgia's non-adoption has for families seeking sub-institutional HCBS. :::

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Key takeaways

• Section 1915(i) of the Social Security Act establishes the HCBS State Plan option, allowing states to offer home and community-based services as a State Plan benefit rather than as a Section 1915(c) HCBS waiver. Section 1915(i) was added by Section 6086 of the Deficit Reduction Act of 2005 (P.L. 109-171) and significantly amended by Section 2402(a) of the Patient Protection and Affordable Care Act (P.L. 111-148).
• The most distinctive feature of Section 1915(i) is that beneficiaries are NOT required to meet institutional level of care criteria. Section 1915(i) can serve individuals with sub-institutional needs, allowing preventive HCBS that may delay or avoid institutional placement.
• Section 1915(i) must be available statewide and cannot have waiting lists. However, states may control costs through eligibility criteria (needs-based criteria and financial eligibility) that effectively limit the eligible population.
• Section 1915(i) allows states to target services to specific populations, including individuals with serious mental illness, intellectual/developmental disabilities, brain injury, older adults, individuals with substance use disorder, and others. Targeting authority was added by Section 2402(a) of the ACA.
• Unlike Section 1915(k) Community First Choice (which has an enhanced FMAP), Section 1915(i) does NOT provide enhanced FMAP. Services are reimbursed at the state's standard FMAP.
• Federal regulations at 42 CFR 441.650-.745 establish detailed Section 1915(i) requirements including needs-based eligibility, covered services, person-centered planning, conflict-free case management, quality assurance, and HCBS settings rule compliance.
• Section 1915(i) is particularly well-suited for mental health rehabilitation services. Many states have used Section 1915(i) primarily for individuals with serious mental illness, providing psychosocial rehabilitation, supported employment, supported housing, and other community-based mental health services.
• Several states have adopted Section 1915(i) as of 2024.
• Georgia has NOT adopted Section 1915(i). Georgia's HCBS framework operates primarily through five Section 1915(c) HCBS waivers (CCSP, SOURCE, ICWP, NOW, COMP).
• If Georgia were to adopt Section 1915(i), it could provide sub-institutional HCBS to populations such as individuals with serious mental illness, brain injury, intellectual/developmental disabilities with less intensive support needs, or older adults with early-stage cognitive impairment. :::

What is Section 1915(i) and why does it matter

Section 1915(i) of the Social Security Act, codified at 42 USC 1396n(i), establishes the HCBS State Plan option. Section 1915(i) was added by Section 6086 of the Deficit Reduction Act of 2005 (P.L. 109-171) and significantly amended by Section 2402(a) of the Patient Protection and Affordable Care Act (P.L. 111-148). Section 1915(i) allows states to offer home and community-based services as a State Plan benefit rather than as a Section 1915(c) HCBS waiver.

The most distinctive feature of Section 1915(i) is that beneficiaries are NOT required to meet institutional level of care criteria. This is a critical difference from Section 1915(c) waivers and Section 1915(k) Community First Choice (CFC), both of which require institutional level of care. Section 1915(i) can serve individuals with sub-institutional needs, allowing preventive HCBS that may delay or avoid the deterioration that would require institutional level of care.

Other key features of Section 1915(i) include statewide availability requirement, no waiting lists (as a State Plan benefit), targeting authority for specific populations (added by Section 2402(a) of the ACA), broad service flexibility, and conflict-free case management standards.

A number of states have adopted Section 1915(i). Georgia has NOT adopted Section 1915(i). Georgia's HCBS framework operates primarily through five Section 1915(c) HCBS waivers (CCSP, SOURCE, ICWP, NOW, COMP).

Understanding the Section 1915(i) framework is important for Georgia families even though Georgia has not adopted Section 1915(i), because (1) understanding the policy alternatives helps inform engagement with state policy discussions about HCBS reform, (2) Georgia families may move to or from Section 1915(i) states and need to understand how the HCBS system differs across states, and (3) federal Section 1915(i) policy may influence Georgia's future approach to HCBS, particularly for mental health, brain injury, and other sub-institutional populations.

Federal statutory foundation

Section 1915(i) of the Social Security Act

Section 1915(i) of the Social Security Act establishes the HCBS State Plan option. Key provisions include:

Section 1915(i)(1) - Authority and statewideness

Section 1915(i)(1) authorizes states to elect to provide HCBS as a State Plan benefit and requires the services to be available statewide.

Section 1915(i)(1)(D) - Targeting

Section 1915(i)(1)(D), added by Section 2402(a) of the ACA, allows states to target Section 1915(i) services to specific populations defined by the state, subject to CMS approval. Targeting categories may include older adults, individuals with mental health conditions, individuals with intellectual/developmental disabilities, individuals with brain injury, and other populations.

Section 1915(i)(1)(F) - Needs-based eligibility

Section 1915(i)(1)(F) requires states to establish needs-based eligibility criteria for Section 1915(i) that are below institutional level of care criteria.

Section 1915(i)(2) - Covered services

Section 1915(i)(2) establishes the covered services under Section 1915(i), including a broad list of HCBS such as case management, homemaker services, home health aide services, personal care services, adult day health services, habilitation services, respite care, psychosocial rehabilitation services, clinic services for individuals with chronic mental illness, and other services requested by the state and approved by CMS.

Section 1915(i)(3) - Person-centered planning

Section 1915(i)(3) requires person-centered service planning for Section 1915(i) services.

Section 1915(i)(4) - Self-direction

Section 1915(i)(4) allows states to offer self-direction options for Section 1915(i) services.

Section 1915(i)(5) - Conflict of interest

Section 1915(i)(5) requires conflict of interest standards for case management under Section 1915(i).

Section 6086 of the Deficit Reduction Act of 2005

Section 6086 of the DRA 2005 (P.L. 109-171), enacted in 2006, added Section 1915(i) to the Social Security Act. The original Section 1915(i) was significantly more restrictive than the current version, with income limits, no ability to target populations, and other restrictions. Despite these restrictions, the original Section 1915(i) represented an important new federal authority for HCBS State Plan benefits, complementing the existing Section 1915(c) waiver authority.

Section 2402(a) of the Affordable Care Act

Section 2402(a) of the Patient Protection and Affordable Care Act (P.L. 111-148), enacted in 2010, significantly amended Section 1915(i). The ACA changes included:

1. Allowing states to target Section 1915(i) services to specific populations
2. Removing the original income limit
3. Allowing states to offer services to individuals with income up to the institutional eligibility limit
4. Adding conflict of interest standards for case management
5. Expanding the range of services that may be covered
6. Other technical amendments

The ACA changes made Section 1915(i) significantly more attractive to states. After the ACA, state adoption of Section 1915(i) increased substantially, with most adoptions occurring after 2010.

Section 1915(i) versus other Section 1915 authorities

Section 1915(i) is one of several Section 1915 authorities for HCBS, each with different requirements and trade-offs:

States may use multiple Section 1915 authorities for different populations or services. For example, a state might use Section 1915(c) waivers for individuals with developmental disabilities requiring intensive support, Section 1915(i) for individuals with serious mental illness or sub-institutional needs, and Section 1915(k) for individuals requiring institutional level of care who need attendant services.

Federal regulatory framework

42 CFR 441.650-.745

CMS issued a Final Rule for 1915(i) State Plan HCBS, establishing the regulatory framework at 42 CFR 441.650-.745. The Final Rule also harmonized regulations for Section 1915(c) waivers, Section 1915(i) State Plan HCBS, and Section 1915(k) Community First Choice on matters including person-centered planning and the HCBS settings rule.

Key provisions of 42 CFR 441.650-.745 include:

42 CFR 441.650 - General provisions

42 CFR 441.650 establishes the general framework for Section 1915(i), including the State Plan option, federal authority, and effective dates.

42 CFR 441.656 - Needs-based eligibility criteria

42 CFR 441.656 establishes that states must develop needs-based eligibility criteria for Section 1915(i) that are below institutional level of care criteria. This ensures that Section 1915(i) serves a sub-institutional population.

States have significant flexibility in defining needs-based criteria, which may include functional limitations in activities of daily living or instrumental activities of daily living, clinical criteria such as diagnoses and symptom severity, risk factors that indicate likely deterioration without HCBS, or other criteria appropriate to the targeted population.

42 CFR 441.658 - Needs-based criteria for institutional level of care

42 CFR 441.658 requires states to establish needs-based criteria for institutional level of care that are more stringent than the Section 1915(i) needs-based criteria. This ensures the proper hierarchical relationship between Section 1915(i) (sub-institutional) and Section 1915(c) waivers (institutional level of care).

42 CFR 441.700 - Covered services

42 CFR 441.700 establishes the covered services under Section 1915(i). The covered services list is broad and includes case management, homemaker services, home health aide services, personal care services, adult day health services, habilitation services (residential and day), respite care, day treatment or other partial hospitalization services, psychosocial rehabilitation services, clinic services for individuals with chronic mental illness, and other services requested by the state and approved by CMS.

42 CFR 441.715 - Person-centered planning

42 CFR 441.715 requires Section 1915(i) services to be furnished according to a person-centered service plan that reflects the beneficiary's preferences, goals, and needs.

42 CFR 441.720 - Service plan

42 CFR 441.720 establishes specific requirements for the service plan, including content, development process, and review schedule. The service plan must be developed through a person-centered process led by the beneficiary, include the beneficiary's family or representative as appropriate, identify needed services and supports, identify risks and include risk mitigation strategies, and be reviewed and revised at least annually or when circumstances change.

42 CFR 441.725 - Quality assurance

42 CFR 441.725 requires Section 1915(i) programs to include quality assurance, including discovery (identifying issues), remediation (addressing identified issues), and continuous improvement (preventing future issues).

42 CFR 441.530 - HCBS settings rule

42 CFR 441.530 (the HCBS settings rule) applies to Section 1915(i) services. The HCBS settings rule requires HCBS settings to be integrated in the community, support full access to the greater community, ensure the individual receives services in the community to the same degree as individuals not receiving Medicaid HCBS, optimize but not regiment individual initiative and autonomy, and facilitate individual choice.

42 CFR 441.745 - Conflict of interest standards

42 CFR 441.745 establishes conflict of interest standards for case management under Section 1915(i). Specifically, providers of case management cannot also be providers of direct services (with limited exceptions for rural areas and other circumstances where conflict-free case management would be impractical).

The conflict of interest standards represent an important beneficiary protection. They prevent the case manager-provider conflict that can occur when the same entity assesses needs, plans services, and provides services. Without conflict-free case management, providers may have incentive to recommend services they provide rather than services that best meet the beneficiary's needs.

Why Section 1915(i) is unique

Sub-institutional eligibility

The most distinctive feature of Section 1915(i) is the sub-institutional eligibility criteria. This means Section 1915(i) can serve individuals who have HCBS needs but do not yet require institutional level of care. This is a significant departure from Section 1915(c) waivers and Section 1915(k) CFC, both of which require institutional level of care.

Sub-institutional eligibility allows states to provide preventive HCBS that may help individuals avoid the deterioration that would require institutional level of care. For example, a state might use Section 1915(i) to provide mental health rehabilitation services for individuals with serious mental illness, early intervention services for individuals with brain injury, day services for individuals with intellectual/developmental disabilities with less intensive support needs, recovery supports for individuals with substance use disorder, or care management for older adults with chronic conditions.

Targeting

Section 1915(i) allows states to target services to specific populations. Targeting authority was added by Section 2402(a) of the ACA and enables states to address the specific needs of populations such as individuals with serious mental illness, individuals with intellectual/developmental disabilities, individuals with brain injury (acquired or traumatic), older adults, individuals with substance use disorder, children with serious emotional disturbance, and other populations defined by the state.

Targeting allows states to design Section 1915(i) programs around the specific needs and service mixes appropriate for each population. Different populations may need different services, different intensity levels, and different provider types.

State Plan benefit structure

As a State Plan benefit, Section 1915(i) must be available statewide and cannot have waiting lists. This provides universal entitlement for eligible beneficiaries within the targeted population.

However, states may control Section 1915(i) costs through eligibility criteria. For example, a state can set needs-based eligibility criteria that effectively limit the eligible population, and can set financial eligibility criteria that limit access to lower-income individuals. The eligibility-based cost control is different from the slot-based cost control of Section 1915(c) waivers but can achieve similar results in terms of overall program costs.

Service flexibility

Section 1915(i) allows broad service flexibility, including services that may not be available under Section 1915(c) waivers. This includes mental health rehabilitation services, recovery supports, day services, and other community-based services. The service flexibility makes Section 1915(i) particularly well-suited for populations whose service needs do not fit well under traditional Section 1915(c) waiver frameworks.

Conflict-free case management

Section 1915(i) has unique conflict of interest standards that prevent the case manager-provider conflict. This protects beneficiaries by ensuring that the case manager who assesses needs and plans services is not also the entity that provides services (in most circumstances). Conflict-free case management is increasingly recognized as a best practice for HCBS, and Section 1915(i) was an early federal authority requiring it.

State adoption of Section 1915(i)

A number of states have adopted Section 1915(i) authority for various purposes, with some states operating multiple programs targeting different populations. States that have adopted Section 1915(i) include:

Arkansas

Arkansas operates Section 1915(i) programs for individuals with serious mental illness and other populations. Arkansas was an early adopter of Section 1915(i), implementing the original 2006 version and updating after the 2010 ACA amendments.

Colorado

Colorado operates Section 1915(i) programs for older adults and individuals with mental health conditions. Colorado's Section 1915(i) is integrated with the state's broader LTSS framework.

Connecticut

Connecticut operates Section 1915(i) programs for older adults and individuals with disabilities. Connecticut also operates Community First Choice under Section 1915(k).

Delaware

Delaware operates a Section 1915(i) program for individuals with serious mental illness, providing community-based rehabilitation services.

District of Columbia

DC operates a Section 1915(i) program for individuals with serious mental illness, providing community-based rehabilitation services.

Idaho

Idaho operates Section 1915(i) programs for older adults and individuals with disabilities.

Indiana

Indiana operates a Section 1915(i) program for individuals with serious mental illness through its Adult Mental Health Habilitation Services program.

Iowa

Iowa operates Section 1915(i) programs for individuals with intellectual/developmental disabilities and individuals with brain injury.

Kansas

Kansas operates a Section 1915(i) program for individuals with serious mental illness.

Louisiana

Louisiana operates a Section 1915(i) program for individuals with intellectual/developmental disabilities.

Maryland

Maryland operates a Section 1915(i) program for individuals with serious mental illness. Maryland also operates Community First Choice under Section 1915(k).

Mississippi

Mississippi operates a Section 1915(i) program for individuals with serious mental illness through its Intensive Community-Based Services program.

Montana

Montana operates a Section 1915(i) program for older adults. Montana also operates Community First Choice under Section 1915(k).

Nevada

Nevada operates a Section 1915(i) program for individuals with serious mental illness.

Oregon

Oregon operates Section 1915(i) programs for various populations. Oregon also operates Community First Choice under Section 1915(k).

Texas

Texas operates a Section 1915(i) program for youth with serious emotional disturbance through its Youth Empowerment Services (YES) Waiver. Texas also operates Community First Choice under Section 1915(k).

Wisconsin

Wisconsin operates Section 1915(i) programs for various populations including individuals with serious mental illness and older adults.

The adoption pattern shows that many states have used Section 1915(i) primarily for mental health populations, with some states extending to other populations such as individuals with brain injury, intellectual/developmental disabilities, and older adults. The mental health focus reflects the particularly good fit between Section 1915(i) (which allows for psychosocial rehabilitation, supported employment, and other recovery services) and the service needs of individuals with serious mental illness.

Why states adopt Section 1915(i)

States adopt Section 1915(i) for several reasons:

Sub-institutional preventive HCBS

Section 1915(i) allows states to provide HCBS to individuals who do not yet require institutional level of care, supporting preventive interventions that may delay or avoid institutional placement. This is the primary policy rationale for Section 1915(i).

Mental health rehabilitation

Section 1915(i) is particularly well-suited for mental health rehabilitation services. Many states have used Section 1915(i) to fund psychosocial rehabilitation, supported employment, supported housing, peer support services, and other community-based mental health services that may not fit well under Section 1915(c) waivers (which require institutional level of care that is more typical of nursing facility populations than mental health populations).

Brain injury services

Section 1915(i) provides flexibility for brain injury services, including cognitive rehabilitation, behavioral health services, community integration services, and other supports for individuals with traumatic or acquired brain injury.

Targeting flexibility

The targeting authority allows states to focus on specific populations with the greatest need for HCBS. This makes Section 1915(i) particularly useful for narrowly-defined populations whose needs do not fit well under broader Section 1915(c) waivers.

Statewide availability

The statewideness requirement ensures that services are available throughout the state, eliminating geographic disparities. This is particularly important for specialized populations (e.g., individuals with brain injury) where rural service capacity may be limited.

Conflict-free case management

The conflict of interest standards protect beneficiaries from case management abuses and align with broader federal trends toward conflict-free case management.

Person-centered planning

Section 1915(i) requires person-centered planning, supporting beneficiary-driven care plans.

Why states do not adopt Section 1915(i)

States may decline to adopt Section 1915(i) for several reasons:

No enhanced FMAP

Unlike Section 1915(k) CFC, Section 1915(i) does not provide enhanced FMAP. The lack of financial incentive is a key deterrent compared to CFC. States contemplating an HCBS State Plan benefit may prefer CFC because of the enhanced FMAP, but CFC requires institutional level of care while Section 1915(i) does not. The choice between Section 1915(i) and CFC depends on whether the state wants to serve sub-institutional or institutional populations.

State share of costs

The state share of Section 1915(i) services represents new state spending, particularly for sub-institutional populations who may not currently receive HCBS. For states facing budget pressures, the new spending requirement may be a deterrent.

Statewide availability commitment

The requirement for statewide availability without waiting lists is a significant commitment, particularly for states with limited HCBS provider capacity in rural areas.

Existing waiver infrastructure

States with well-developed Section 1915(c) waiver infrastructure may prefer to continue with waivers rather than adopt Section 1915(i). However, Section 1915(c) waivers cannot serve sub-institutional populations, so states wanting to serve sub-institutional populations face a choice between Section 1915(i) and other authorities (such as Section 1115 demonstrations).

Implementation complexity

Section 1915(i) implementation requires substantial state Medicaid agency capacity, including developing eligibility processes, service definitions, payment methodology, quality assurance, and conflict-free case management structures.

Conflict of interest implementation

The conflict of interest standards require structural separation of case management and direct services, which can be challenging in states where existing providers operate integrated case management and direct service programs. Some states have struggled to implement conflict-free case management because of the need to restructure existing provider relationships.

Georgia's HCBS framework

Georgia has not adopted Section 1915(i). Georgia's HCBS framework operates primarily through Section 1915(c) HCBS waivers, plus limited State Plan services:

Five Section 1915(c) HCBS waivers

Georgia operates five Section 1915(c) HCBS waivers:

1. Community Care Services Program (CCSP): Serves older adults and adults with disabilities
2. Service Options Using Resources in a Community Environment (SOURCE): Similar to CCSP with enhanced case management
3. Independent Care Waiver Program (ICWP): Serves adults aged 21 to 64 with severe physical disabilities
4. New Options Waiver (NOW): Serves individuals with developmental disabilities with less intensive support needs
5. Comprehensive Supports Waiver Program (COMP): Serves individuals with developmental disabilities with more intensive support needs

As Section 1915(c) waivers, all five programs operate under waiver authority with enrollment limits and waiting lists, which differs from the State Plan benefit structure of Section 1915(i).

State Plan mental health services

Georgia provides some mental health services under the State Plan, including outpatient services, psychiatric rehabilitation services, and other community-based mental health services. These services are administered by the Department of Behavioral Health and Developmental Disabilities (DBHDD) in coordination with DCH. State Plan mental health services in Georgia provide a foundation for individuals with mental health conditions, but the service array and intensity are typically more limited than what a Section 1915(i) program could provide.

Brain injury services

Georgia has limited Medicaid-funded brain injury services for individuals who do not meet ICWP institutional level of care criteria. Some State Plan rehabilitation services are available, but comprehensive community-based brain injury services are not generally available.

Section 1915(b) managed care

Georgia operates Georgia Families managed care under Section 1915(b) for the parent and caretaker relative and children populations. Behavioral health services for Georgia Families enrollees are typically covered through the CMO benefit packages, although certain specialty mental health services may be carved out.

Why Georgia has not adopted Section 1915(i)

Georgia has not adopted Section 1915(i). Several factors have contributed to this:

1. No enhanced FMAP: Without enhanced FMAP, Section 1915(i) does not have the financial incentive of Section 1915(k) CFC. Georgia has also not adopted CFC, but Section 1915(i)'s lack of enhanced FMAP is a particular factor.

2. State share of costs: Section 1915(i) services represent new state spending, particularly for sub-institutional populations who may not currently receive HCBS.

3. Statewide availability commitment: The requirement for statewide availability without waiting lists is a significant commitment.

4. Existing waiver infrastructure: Georgia has invested in CCSP, SOURCE, ICWP, NOW, and COMP infrastructure.

5. Conflict of interest implementation: The conflict of interest standards require structural separation that may be challenging for existing Georgia providers, particularly community mental health providers who currently operate integrated case management and direct service programs.

6. Other Medicaid priorities: Recent Georgia Medicaid reform efforts have focused on Pathways to Coverage, postpartum coverage extension, and other initiatives.

What Section 1915(i) adoption would mean for Georgia

If Georgia were to adopt Section 1915(i), the implications for Georgia families would depend on the populations and services targeted. Common Section 1915(i) implementations include:

Mental health rehabilitation

A Section 1915(i) program for individuals with serious mental illness could provide psychosocial rehabilitation, supported employment, supported housing, peer support services, and other community-based mental health services. This could support recovery and community integration for Georgia residents with serious mental illness, potentially reducing hospitalizations and improving quality of life.

Brain injury services

A Section 1915(i) program for individuals with brain injury could provide cognitive rehabilitation, behavioral health services, community integration services, and other supports. This could fill an important gap for Georgia residents with brain injury who do not meet ICWP institutional level of care criteria.

Sub-institutional HCBS for older adults

A Section 1915(i) program for older adults with sub-institutional needs could provide preventive HCBS including care coordination, adult day services, respite for family caregivers, and other supports. This could help older Georgians remain in the community and delay the need for institutional care.

Sub-institutional HCBS for individuals with intellectual/developmental disabilities

A Section 1915(i) program for individuals with intellectual/developmental disabilities with less intensive support needs could provide supported employment, day services, and other community-based supports. This could provide services to Georgians who are on the NOW waiting list or whose support needs do not meet NOW criteria.

Substance use disorder recovery supports

A Section 1915(i) program for individuals with substance use disorder could provide recovery coaching, peer support services, supported employment, supported housing, and other community-based recovery supports.

Worked examples

Example 1: Sarah, 35, Atlanta, mental illness sub-institutional

Sarah is 35 years old with serious mental illness (schizophrenia). She lives in Atlanta with her parents. She receives outpatient mental health services through the State Plan, including medication management with her psychiatrist and weekly therapy sessions. She has occasional hospitalizations for psychiatric crises (most recently 2 months ago, for a 9-day inpatient stay). She is not currently institutionalized but has needs for community-based rehabilitation services to support her recovery.

Under Georgia's current framework, Sarah's outpatient mental health services are covered under the State Plan, but more intensive community-based rehabilitation services may be limited or not available. Specifically, Sarah does not currently have access to psychosocial rehabilitation, supported employment, supported housing, or comprehensive peer support services.

Under a hypothetical Section 1915(i) implementation in Georgia for individuals with serious mental illness, Sarah could receive psychosocial rehabilitation (helping her develop skills for community living and employment), supported employment (helping her obtain and maintain employment with accommodations), supported housing (helping her transition to her own apartment with supports), peer support services (peers in recovery providing support and mentorship), and other community-based mental health services as a State Plan benefit. These services could support her recovery and community integration, potentially reducing the need for hospitalizations and supporting her transition to independent living.

This example illustrates the primary use case for Section 1915(i): community-based mental health rehabilitation services that may not fit well under Section 1915(c) waivers (which require institutional level of care).

Example 2: Henry, 50, Macon, brain injury rehabilitation

Henry is 50 years old. He sustained a traumatic brain injury in a motor vehicle accident 3 years ago. He has cognitive impairments (memory deficits, executive function difficulties) and some physical limitations but does not require nursing facility level of care. He lives with his wife and receives outpatient rehabilitation services on a limited basis.

Under Georgia's current framework, Henry can receive State Plan rehabilitation services (physical therapy, occupational therapy, speech therapy) up to coverage limits, but comprehensive community-based brain injury services are not generally available. He does not qualify for ICWP because his disability does not meet ICWP institutional level of care criteria.

Under a hypothetical Section 1915(i) implementation for individuals with brain injury, Henry could receive comprehensive brain injury rehabilitation services including cognitive rehabilitation (specialized cognitive therapy), behavioral health services (addressing behavioral changes after brain injury), community integration services (supporting his return to community activities), supported employment (if employment is appropriate for his recovery), and other community-based supports designed for the brain injury population.

This example illustrates Section 1915(i)'s ability to fill service gaps for specific populations whose needs do not fit traditional HCBS waivers.

Example 3: Margaret, 78, Savannah, early-stage dementia

Margaret is 78 years old with early-stage dementia (mild cognitive impairment progressing to early-stage Alzheimer's disease). She lives alone in Savannah. She has some cognitive impairment but is still able to live independently with minimal supports. She does not yet require nursing facility level of care.

Under Georgia's current framework, Margaret may not qualify for CCSP or SOURCE because she does not yet require nursing facility level of care. She can receive limited Medicaid services through the State Plan, but comprehensive HCBS are typically only available through HCBS waivers requiring institutional level of care.

Under a hypothetical Section 1915(i) implementation for older adults with cognitive impairment, Margaret could receive preventive HCBS including care coordination (helping her navigate health care and community resources), adult day services (providing structured activities and supervision), respite for family caregivers (giving her adult children breaks from caregiving), home-delivered meals, transportation assistance, and other supports. These preventive services could help Margaret remain in the community longer and delay the progression of her cognitive impairment.

Example 4: David, 25, Augusta, IDD with employment supports

David is 25 years old with intellectual/developmental disability (mild intellectual disability). He has graduated from high school and lives with his parents. He has the cognitive ability to participate in supported employment but does not require the intensive services that NOW or COMP provide. He has been on the NOW waiting list for 2 years.

Under Georgia's current framework, David is on the NOW waiting list. He can receive State Plan rehabilitation services but cannot access comprehensive day services, supported employment, or other community-based supports until he is enrolled in NOW (which may take many more years given the waiting list).

Under a hypothetical Section 1915(i) implementation for individuals with intellectual/developmental disability with less intensive support needs, David could receive supported employment (helping him obtain and maintain competitive employment in the community), day services, transportation assistance, and other community-based supports as a State Plan benefit. This would provide him with services tailored to his needs without requiring him to compete for limited NOW slots.

This example illustrates how Section 1915(i) can serve sub-institutional intellectual/developmental disability populations who do not meet the institutional level of care criteria for NOW or COMP.

Example 5: Linda, 42, Athens, substance use disorder

Linda is 42 years old with opioid use disorder. She is in recovery (12 months sober) and receives medication-assisted treatment (MAT) through her primary care provider. She has 3 children and is in the process of regaining custody after losing custody during her active addiction. She needs community-based recovery supports to maintain her recovery and prevent relapse.

Under Georgia's current framework, Linda can receive MAT and SUD treatment services through the State Plan. Community-based recovery supports may be available through SAMHSA-funded programs (such as the State Opioid Response grants) but are not generally available as Medicaid State Plan benefits.

Under a hypothetical Section 1915(i) implementation for individuals with substance use disorder, Linda could receive recovery coaching (peer recovery support specialists providing mentorship), peer support services, supported employment, supported housing, and other community-based recovery supports as a State Plan benefit. These services could support her continued recovery and family reunification.

Example 6: Robert, 65, Columbus, chronic disease management

Robert is 65 years old with multiple chronic conditions (diabetes, hypertension, congestive heart failure). He lives in Columbus with his wife. He receives State Plan services including primary care, specialist care, and pharmacy. He has had several hospitalizations in the past year for diabetes complications and heart failure exacerbations.

Under Georgia's current framework, Robert receives State Plan services but does not have access to community-based chronic disease management services beyond limited care coordination through his primary care provider. His repeated hospitalizations suggest that more intensive community-based supports could improve his outcomes.

Under a hypothetical Section 1915(i) implementation for older adults with chronic disease, Robert could receive comprehensive chronic disease management including care coordination, health education, medication management, home-delivered meals, transportation to medical appointments, and other community-based supports. These services could reduce his hospitalizations and improve his quality of life.

Frequently asked questions

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What is Section 1915(i) of the Social Security Act?

Section 1915(i) of the Social Security Act, codified at 42 USC 1396n(i), establishes the HCBS State Plan option. Section 1915(i) was added by Section 6086 of the Deficit Reduction Act of 2005 (P.L. 109-171) and significantly amended by Section 2402(a) of the Patient Protection and Affordable Care Act (P.L. 111-148). Section 1915(i) allows states to offer home and community-based services as a State Plan benefit rather than as a Section 1915(c) HCBS waiver. The most distinctive feature of Section 1915(i) is that beneficiaries are not required to meet institutional level of care criteria.

Does Georgia have a Section 1915(i) program?

No. Georgia has not adopted Section 1915(i). Georgia's HCBS framework operates primarily through five Section 1915(c) HCBS waivers (CCSP, SOURCE, ICWP, NOW, COMP), all of which operate under Section 1915(c) waiver authority.

How does Section 1915(i) differ from Section 1915(c) HCBS waivers?

Section 1915(i) and Section 1915(c) differ in several important ways. Section 1915(i) is a State Plan benefit while Section 1915(c) is a waiver. Section 1915(i) does NOT require institutional level of care while Section 1915(c) does. Section 1915(i) must be available statewide without waiting lists while Section 1915(c) can have enrollment limits and waiting lists. Both have standard FMAP (no enhanced FMAP). Both require person-centered planning and HCBS settings rule compliance. Section 1915(i) has stronger conflict of interest standards for case management.

How does Section 1915(i) differ from Section 1915(k) Community First Choice?

Section 1915(i) and Section 1915(k) Community First Choice (CFC) are both State Plan options but differ in important ways. Section 1915(i) does NOT require institutional level of care while CFC does. Section 1915(i) does NOT provide enhanced FMAP while CFC provides an enhanced FMAP. Both require statewideness and no waiting lists. Section 1915(i) allows targeting to specific populations while CFC does not allow targeting (CFC must serve all individuals who meet eligibility criteria). CFC requires self-direction options while Section 1915(i) makes self-direction optional. CFC requires a Development and Implementation Council while Section 1915(i) does not.

How many states have adopted Section 1915(i)?

A number of states have adopted Section 1915(i) authority for various purposes, with some states operating multiple programs targeting different populations. States that have adopted Section 1915(i) include Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Idaho, Indiana, Iowa, Kansas, Louisiana, Maryland, Mississippi, Montana, Nevada, Oregon, Texas, and Wisconsin, among others.

What is the most common use of Section 1915(i)?

The most common use of Section 1915(i) is mental health rehabilitation services for individuals with serious mental illness. Many states have used Section 1915(i) to fund psychosocial rehabilitation, supported employment, supported housing, peer support services, and other community-based mental health services. The mental health focus reflects the particularly good fit between Section 1915(i) (which allows for sub-institutional eligibility) and the service needs of individuals with serious mental illness (who typically do not meet institutional level of care criteria but still need intensive HCBS).

What does "sub-institutional level of care" mean for Section 1915(i)?

Sub-institutional level of care means that the beneficiary does not require the level of care provided in an institution (nursing facility, ICF/IID, or hospital). Section 1915(i) requires states to establish needs-based eligibility criteria that are below institutional level of care criteria. This allows Section 1915(i) to serve individuals with HCBS needs who do not yet require institutional placement but who would benefit from HCBS to support continued community living.

Can Section 1915(i) target specific populations?

Yes. Section 1915(i)(1)(D), added by Section 2402(a) of the ACA, allows states to target Section 1915(i) services to specific populations defined by the state, subject to CMS approval. Common targeting categories include individuals with serious mental illness, individuals with intellectual/developmental disabilities, individuals with brain injury, older adults, individuals with substance use disorder, and children with serious emotional disturbance. Targeting allows states to design Section 1915(i) programs around the specific needs of each population.

Does Section 1915(i) have enhanced FMAP?

No. Unlike Section 1915(k) Community First Choice (which has an enhanced FMAP), Section 1915(i) does NOT provide enhanced FMAP. Services are reimbursed at the state's standard FMAP. The lack of enhanced FMAP is one reason why Section 1915(i) adoption has been slower than CFC adoption in some respects.

Does Section 1915(i) require statewide availability?

Yes. As a State Plan benefit, Section 1915(i) must be available statewide. States cannot limit Section 1915(i) to specific geographic areas. The statewideness requirement is similar to other State Plan benefits and to Section 1915(k) Community First Choice.

Can Section 1915(i) have waiting lists?

No. As a State Plan benefit, Section 1915(i) cannot have waiting lists. All eligible beneficiaries who meet the needs-based and financial eligibility criteria must be served. However, states may control Section 1915(i) costs through eligibility criteria (needs-based criteria and financial eligibility) that effectively limit the eligible population.

What services does Section 1915(i) cover?

Section 1915(i) covers a broad range of HCBS, including case management, homemaker services, home health aide services, personal care services, adult day health services, habilitation services (residential and day), respite care, day treatment or other partial hospitalization services, psychosocial rehabilitation services, clinic services for individuals with chronic mental illness, and other services requested by the state and approved by CMS. The service flexibility is one of the advantages of Section 1915(i).

What are the conflict of interest standards for Section 1915(i)?

42 CFR 441.745 establishes conflict of interest standards for case management under Section 1915(i). Specifically, providers of case management cannot also be providers of direct services (with limited exceptions for rural areas and other circumstances where conflict-free case management would be impractical). The conflict of interest standards represent an important beneficiary protection, preventing the case manager-provider conflict that can occur when the same entity assesses needs, plans services, and provides services.

What is person-centered planning under Section 1915(i)?

Under 42 CFR 441.715 and 42 CFR 441.720, Section 1915(i) services must be furnished according to a person-centered service plan. The plan must reflect the beneficiary's preferences, goals, and needs; identify risks and include strategies to address them; be developed through a person-centered planning process led by the beneficiary; include the beneficiary's family or representative as appropriate; and be reviewed and revised at least annually or when circumstances change.

How does Section 1915(i) financial eligibility work?

After the ACA amendments, Section 1915(i) allows states to offer services to individuals with income up to the institutional eligibility limit. States may choose lower income limits. The financial eligibility flexibility allows states to serve a broader population than the original 2006 version of Section 1915(i), which had stricter income limits.

Does Section 1915(i) include self-direction options?

Section 1915(i)(4) allows states to offer self-direction options for Section 1915(i) services. Unlike Section 1915(k) CFC (which requires self-direction), Section 1915(i) makes self-direction optional. States may choose to include or exclude self-direction in their Section 1915(i) programs.

Why has Georgia not adopted Section 1915(i)?

Georgia has not adopted Section 1915(i) for several reasons including (1) lack of enhanced FMAP (compared to Section 1915(k) CFC); (2) state share of new spending for sub-institutional populations; (3) statewide availability commitment without waiting lists; (4) existing Section 1915(c) waiver infrastructure; (5) conflict of interest implementation challenges; and (6) other Medicaid reform priorities.

Would Section 1915(i) help Georgia residents with mental illness?

Potentially yes. A Section 1915(i) program for individuals with serious mental illness could provide psychosocial rehabilitation, supported employment, supported housing, peer support services, and other community-based mental health services. This could support recovery and community integration for Georgia residents with serious mental illness. Many other states have used Section 1915(i) for this population.

Could Georgia adopt both Section 1915(i) and Community First Choice?

Yes. Section 1915(i) and Section 1915(k) CFC are not mutually exclusive. Several states have adopted both authorities, using each for the populations and services it is best suited for. CFC serves individuals requiring institutional level of care who need attendant services. Section 1915(i) can serve sub-institutional populations or populations with specialized needs (e.g., mental health rehabilitation).

How do I find out more about Georgia's HCBS options?

For information about Georgia's HCBS options, contact (1) the Department of Community Health Medicaid Member Services at 1-866-211-0950 for general Medicaid information; (2) the Division of Aging Services Aging and Disability Resource Connection (ADRC) at 1-866-552-4464 for HCBS waiver information; (3) the Department of Behavioral Health and Developmental Disabilities at 1-855-660-4357 for mental health and developmental disability services; or (4) Brevy's other Georgia Medicaid guides for detailed information about LTSS, HCBS waivers, mental health services, and related topics.

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Contacts and resources

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Get help with Georgia Medicaid HCBS

If you need help understanding Georgia Medicaid HCBS options, the following contacts and resources are available:

• DCH Medicaid Member Services: 1-866-211-0950 (general Georgia Medicaid information)
• DAS Aging and Disability Resource Connection (ADRC): 1-866-552-4464 (Division of Aging Services entry point for HCBS waivers)
• DCH HCBS Waiver Unit: Contact through DCH main number for waiver-specific information
• DBHDD Customer Service: 1-855-660-4357 (Department of Behavioral Health and Developmental Disabilities for NOW, COMP, and mental health services)
• DFCS Customer Service: 1-877-423-4746 (Division of Family and Children Services for Medicaid applications)
• Georgia Gateway: gateway.ga.gov (online portal for Medicaid applications and renewals)
• AARP Georgia: 1-866-295-7283 (advocacy and education for older adults)
• Georgia Long-Term Care Ombudsman: 1-866-552-4464 (advocacy for long-term care residents)
• Atlanta Regional Commission Area Agency on Aging: Local area agency on aging for metro Atlanta
• Georgia Legal Services Program: 1-800-498-9469 (legal assistance for low-income individuals)
• 211 Georgia: 2-1-1 (statewide information and referral service)
• CMS Region IV: Federal Medicaid oversight in the Southeast
• National Association of State Mental Health Program Directors: National association supporting state mental health agencies
• ADvancing States: National association supporting state aging and disability agencies
• Brain Injury Association of Georgia: Advocacy and support for individuals with brain injury :::

Final notes

Section 1915(i) of the Social Security Act is a federal Medicaid authority that allows states to offer home and community-based services as a State Plan benefit, without requiring institutional level of care. Section 1915(i) is distinguished from Section 1915(c) waivers (which require institutional level of care and can have waiting lists) and Section 1915(k) Community First Choice (which requires institutional level of care but has enhanced FMAP). A number of states have adopted Section 1915(i), primarily for mental health rehabilitation services. Georgia has not adopted Section 1915(i) and instead operates HCBS through Section 1915(c) waivers. Understanding the Section 1915(i) framework helps Georgia families understand the policy alternatives for HCBS and engage with state policy discussions about HCBS reform, particularly for populations such as individuals with serious mental illness, brain injury, or sub-institutional needs.

This article is part of a comprehensive series on Georgia Medicaid published by Brevy. We are committed to providing accurate, up-to-date information for Georgia families navigating Medicaid eligibility, enrollment, benefits, and appeals.

Find personalized help navigating Georgia Medicaid HCBS options at brevy.com.

This article is for informational purposes only and does not constitute legal, financial, or medical advice. Brevy is a digital ally, not a substitute for professional legal or financial counsel. Federal and state Medicaid rules change frequently. For questions specific to your situation, consult with the Georgia Department of Community Health, the Division of Family and Children Services, the Department of Behavioral Health and Developmental Disabilities, or a qualified attorney or financial advisor.