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Assurance 5 - Financial Accountability

A state Medicaid Agency pays only for services that are approved and provided, the cost of which does not exceed the cost of a nursing facility or institutional care on a per person or aggregate basis (as determined by the state).

What are the requirements of this HCBS waiver assurance?

Financial Integrity
A state must have methods to ensure that the payments made to provider agencies, vendors and workers are accurate and are for services that were actually provided.

Provider Rates and Bills
As part of its HCBS waiver application, a state must describe the reimbursement method that will be used to determine payments to providers. States must follow these reimbursement methods when they pay providers.

States must describe the process by which providers will be paid.

Unallowable Costs
Medicaid cannot pay for room and board costs (that is, housing, meals), except in certain circumstances. These costs are allowed only if a person is receiving institutional respite or when the person needs a live-in caregiver.

Cost Neutrality
The cost of services provided under the HCBS waiver cannot exceed the cost of services provided in a nursing home or in an institution for persons with intellectual disabilities. This is usually referred to as "cost neutrality”. 

Medicaid is a state/federal program. If the state does not comply with these requirements, it will not receive the federal portion of the Medicaid payments.


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