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Options for Designing Service Coverage: General Considerations 59circumstances such as (a) out-of-home respitecare, and (b) room and board of a live-in caregiver.Federal financial participation is available forroom and board provided as part of respite carefurnished in a facility that is approved by the stateand not a private residence. Respite care is availableas a service under HCBS waivers, but not asa distinct service under the state plan. 5The expectation is that individuals will use theirown income and resources (e.g., Federal SupplementalSecurity Income [SSI] benefits and earningsfrom employment) to meet room and boardexpenses. This exclusion can complicate developmentof strategies to support individuals in thehome and community. In contrast, room andboard expenses are Medicaid-reimbursable in aninstitutional setting where individuals receive asignificantly reduced SSI payment ($30/month) asa personal needs allowance.Obligations of Other Public Programs. Medicaidis deemed a payer of last resort. This means that ifanother public program is obliged to provide aservice to an individual, a state generally may notreplace this funding with Medicaid dollars. Forexample, if two public programs such as Medicareand Medicaid cover the same service and an individualis eligible for the service in both programs,Medicare must pay first for the service. Medicaidcan only pay once Medicare benefits are exhausted.State Policy Goals and ObjectivesFederal policies provide a framework withinwhich states can weigh their options in decidingwhether to offer a service under their Medicaidplan or through an HCBS waiver program. But astate makes its particular coverage choices in lightof its own policy goals and objectives. Five majorfactors need highlighting in this connection.State Budget Impact. States must balance theirbudgets on a regular basis—every year for moststates. This can make a state wary of offering servicesunder its statewide Medicaid plan, becauseFederal law prohibits rationing the amount ofservices furnished to individuals or limiting thenumber of persons who receive the service underthat plan (as noted in the section on Federal policyconsiderations above).Thus, states are understandably careful that thecosts of offering a service under the state plan notsignificantly exceed available resources, becausethey are uncertain both about how many individualsmight qualify and about how much it mightcost to serve each person. One reason many stateshave turned to HCBS waiver programs to expandavailability of non-institutional long-term careservices is that the amount they will spend in thewaiver context is predictable. This is because astate that offers services under an HCBS waiverprogram is obligated to serve no more than thenumber of beneficiaries the state itself establishes.Inclusiveness. While state officials and policymakersmust be concerned about expenditures, itis often equally important to them that services beavailable to all who require them. This is an argumentagainst providing services through waiversand can lead states to cover a particular serviceunder the state plan in order to ensure universalaccess. As discussed below, when deciding whetherto cover a service under the state plan or a waiverprogram or both, states need to carefully considerhow services provided in different programs cancomplement each other in providing people withdisabilities the right service mix and amount.Target Populations. Because services offeredunder a Medicaid state plan must be provided toall eligible individuals on a comparable basis, itcan be difficult to vary services or service deliveryapproaches based on the needs of individualswho have particular impairments and specializedneeds. In addition, it is sometimes easier for astate to craft a package of services and supports tomeet the needs of specific groups than to seek aone-size-fits-all state plan coverage design.These considerations frequently lead a state toselect an HCBS waiver program as a vehicle foroffering services to defined groups of individuals,because the service package can be fine-tuned tomeet their distinct needs.Maintaining a Unified Service Delivery System.While Medicaid is the major funding source forhome and community services, it is frequently not