OBBBA Impacts Home & Community-Based Services in Ohio
What You Need to Know in Ohio: The OBBBA's Transformative Impact on Ohio's Home and Community-Based Service Waivers for Individuals with Intellectual and Developmental Disabilities
The newly enacted “One Big Beautiful Bill Act” (OBBBA) is poised to bring significant, albeit nuanced, changes to Home and Community Based Service (HCBS) Waivers in Ohio, particularly for individuals with intellectual disabilities. The most crucial takeaway is that while existing HCBS waivers for those meeting institutional levels of care are largely protected, the OBBBA opens an entirely new door for states like Ohio: the option to expand HCBS eligibility to individuals whose care needs fall below the traditional institutional threshold. This could potentially transform access to vital community-based support for many more Ohioans, though the ultimate implementation will depend on state-level decisions regarding this newly available flexibility.
Here’s a breakdown of the key impacts:
No “Slashing” of Existing Waivers
Despite some initial concerns, the OBBBA does not slash existing HCBS waiver funding or eliminate waivers for people who currently have them, nor does it change the federal matching rate for states (FMAP). [See Section 71121(a)]
Deep Cuts to Medicaid (Primarily Other Groups)
The law does include deep cuts to Medicaid, but these are primarily targeted at recipients other than those who access HCBS waivers for institutional care level disabilities, such as low-income adults without such needs. These cuts are to be largely achieved through eligibility restrictions, work requirements, cost-sharing for new expansion populations, and changes to provider taxes and state-directed payments, rather than direct cuts to the FMAP for traditional or existing HCBS for individuals with disabilities.
Option for States to Form New “Non-Institutional Level of Care” Waivers
A significant change is that the OBBBA allows states to create new kinds of HCBS waivers for individuals who do not meet an “institutional level of care” [see Subchapter E, Section 71121(a) Expanding HCBS Coverage Under Section 1915(c) Waivers for more information]. Previously, Medicaid only covered HCBS for people whose care needs were significant enough to qualify for living in a nursing home or intermediate care facility. This new provision gives states the option to provide HCBS to individuals with needs that fall below that institutional level, meaning they need support but not to the extent of requiring institutionalization. However, many states already face waitlists so may be unable to expand enrollment.
Ohio’s Choice
It’s crucial to note that waiver expansion is an option for states, not a requirement. Ohio, like other states, will have to decide whether to pursue these new “non-institutional level” waivers. Services under such waivers are costly, so some states may choose not to expand.
“While HCBS waivers for individuals with institutional care needs are largely protected, the OBBBA does include deep Medicaid cuts primarily targeting other recipient groups.”
Protection for Existing Waiver Recipients
If Ohio chooses to open a new non-institutional level waiver category, the law requires the state to demonstrate that adding more people to HCBS will not increase the average waiting list time for those who already qualify for institutional care (i.e., those with the highest needs for whom waivers are currently intended). This is meant to protect individuals with intellectual and developmental disabilities who are already eligible for waivers from seeing their wait times increase.
Transparency Requirements
H.R. 1 Section 71121 of the OBBBA mandates that states be more transparent with their waiver data. They must report annually on:
- The costs (as such term is defined by the Secretary) of services furnished to individuals, broken down by type (e.g., personal care, therapies).
- With respect to each type of home or community-based service provided under the waiver, the length of time that such individuals have received such service. (e.g. how long people actually receive each type of service).
- How those costs compare to institutional care.
- The number of individuals who have received home or community-based services under the waiver during the preceding year.”
In summary for Ohio IIDD Providers
For individuals with intellectual disabilities currently receiving HCBS waivers in Ohio because they meet an institutional level of care, the OBBBA does not directly remove these services. However, it presents an opportunity for Ohio to expand HCBS to individuals with intellectual and developmental disabilities who have care needs but do not currently meet the strict “institutional level of care” criteria. Whether Ohio will implement these new non-institutional waivers, and how, remains to be seen and will depend on state-level decisions and resource allocation. Ohio has not announced any plan to end existing waivers as of July 2025.
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Disclaimer: The information provided is for educational purposes only. Nothing contained herein constitutes financial, legal, tax, or other advice. Consult your tax and legal professional for details on your situation.
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Missy is a member of Brady Ware’s nonprofit services team and co-leader of the firm’s Long-Term Care team focused on IIDD providers. With nearly two decades of CPA experience and a background in consumer finance, she provides tax, audit, review, and compilation services, as well as business consulting. Missy’s commitment to delivering top-notch accounting services and strategic consulting has positioned her as a trusted professional in the nonprofit sector.