What this article does not discuss is that “optional” services probably cannot be legally eliminated, once offered by a state. States moving to eliminate such optional services are sued and the courts rule that the optional services may not legally be eliminated based on the “integration mandate” in the Americans with Disabilities Act. This requires state services to be provided in the “most integrated setting” available. If eliminating optional home and community-based services in the community means that Medicaid clients will need to move to a nursing home in order to receive services the integration mandate is violated, because nursing homes are considered institutions. Most likely the court will block the cut, regardless of the costs to the state. Many states seeking to reduce their Medicaid costs by eliminating optional services in the community have been blocked by the courts under this theory – most notably and recently in California and Washington States.
