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14 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERmedical disabilities) accounted for the remaining3.2 percent of program participants. 47Average cost of HCB waiver servicesIn 1998, the cost of HCB waiver services was about$14,950 per participant. However, there weremarked differences in costs among HCBS waivertarget populations. The average cost of HCB waiverservices for people with developmental disabilitieswas $29,353 per participant. In contrast, HCBSwaiver programs that serve seniors and/oryounger persons with non-developmental disabilitiesincurred an average cost per participant of$5,362. 48 The differences in HCBS waiver costsamong target population groups stem from a widevariety of factors. Major factors that affect costsinclude: (a) differences in the intensity of the servicesparticular target populations require; and (b)the extent to which other state plan services canmeet the needs of the target population (and therebyreduce the costs of the additional services thatare furnished through HCBS waiver programs).Historically, the costs of supporting individualswith developmental disabilities through HCBSwaiver programs have been well above costs ofsupporting other target populations, because a relativelyhigh percentage of waiver participantswith developmental disabilities have been receivingresidential rather than in-home services.The Katie Beckett ProvisionThe Katie Beckett provision is a statute—the TaxEquity and Fiscal Responsibility Act (TEFRA)134—added to Medicaid in 1982. Katie Beckett isthe name of the child whose parents petitionedthe Federal government for her to receiveMedicaid services at home instead of in a hospital,and whose plight led the Reagan Administrationto urge Congress to enact the provision. TEFRA134 gives states the option to cover noninstitutionalizedchildren with disabilities. Prior toenactment of this provision, if a child with disabilitieslived at home, the parents’ income andresources were automatically counted (deemed)as available for medical expenses. However, if thesame child was institutionalized for 30 days ormore, only the child’s own income and resourceswere counted in the deeming calculation—substantiallyincreasing the likelihood that a childcould qualify for Medicaid. This sharp divergencein methods of counting income often forced familiesto institutionalize their children simply to getthem medical care.TEFRA 134 amended the Medicaid law to givestates the option to waive the deeming of parentalincome and resources for children under 18 yearsold who were living at home but would otherwisebe eligible for Medicaid-funded institutional care.Not counting parental income enables these childrento receive Medicaid services at home or inother community settings. Many states use thisoption, which requires states to determine that (1)the child requires the level of care provided in aninstitution; (2) it is appropriate to provide careoutside the facility; and (3) the cost of care at homeis no more than the cost of institutional care. Instates that use this option, parents may chooseeither institutional or community care for theirMedicaid eligible children.Targeted Case ManagementUntil 1986, the only practical avenue available fora state to secure Medicaid funding for freestandingcase management services (i.e., case managementservices not delivered as part of some otherservice or conducted in conjunction with thestate’s operation of its Medicaid program) wasthrough an HCBS waiver program. Coverage ofcase management services in HCBS waiver programswas nearly universal at that time.In 1986, Congress created the option for states tocover what were termed “targeted case management”services under their Medicaid plan. 49 Theexpressed statutory purpose of targeted case managementis to assist Medicaid recipients in “gainingaccess to needed medical, social, educationaland other services.” This option is unique amongservices afforded under the state plan, in thatstates are exempt from the comparability requirementto make such services available to all recipients.A state is permitted to amend its state plan tocover case management services for specifiedgroups of Medicaid recipients (hence the term targeted).It may also offer these services on a less-thanstatewidebasis (again via state plan amendment