Medicaid Home and Community-Based Services Programs: 2010 Data Update
Medicaid HCBS Participants and Expenditures
Participants in Medicaid Home Health and Personal Care State Plan Services and § 1915(c) Waivers. In 2010, almost 3.2 million individuals received services through the three main Medicaid HCBS programs (Table 1A). Of those participants, 807,659 individuals received home health services through the mandatory state plan benefit, 951,853 individuals received personal care services through the optional state plan benefit, and 1,403,736 individuals were served through § 1915(c) waivers (Figure 3). All states and DC offered the mandatory home health services state plan benefit in their Medicaid programs (Table 1B), while 32 states actively offered the optional personal care services state plan benefit, with Kansas as the latest state to elect this option in 2007 (Table 1C). (Delaware and Rhode Island had approval from the Centers for Medicare and Medicaid Services (CMS) to offer personal care state plan services but did not report any participants in their programs.) Forty-seven states and DC operated multiple § 1915(c) waivers in 2010 (Table 1D).
Participation in the three main HCBS programs increased by two percent between 2009 and 2010, representing the lowest growth rate since 2007 (Table 1A). Between 2000 and 2010, the total number of individuals receiving Medicaid HCBS grew steadily each year by an average of four percent, with the exception of the 2005-2006 period, when there was a decline of one percent (Table 1A and Figure 4).
Over the 2000 to 2010 reporting period there was, however, great inter-state variation in average Medicaid HCBS participant annual growth rates with large increases in Pennsylvania (15%), Nevada, and North Carolina (both 13%) (Table 1A). In Pennsylvania, growth was led by increased enrollment in home health state plan services and § 1915(c) waivers (34% and 12%, respectively) whereas in Nevada the growth was led by increased enrollment in state plan personal care and home health services (34% and 28%, respectively). In North Carolina, historical annual growth was led by increased enrollment in state plan personal care and home health services (20% and 19%, respectively) (Tables 1B, 1C, and 1D).
Among the states studied in this report, Arkansas and New Hampshire were the only states with decreases in HCBS enrollment between 2000 and 2010 (-1% each) (Table 1A). Although both Arkansas and New Hampshire reported increases in § 1915(c) waiver participants from 2000 to 2010, both had declines in their home health and personal care state plan services enrollment over this period. New Hampshire reported a decline of eight percent in its state plan personal care participation rate from 2000 to 2010 while Arkansas reported a four percent decline in its state plan home health services participation (Tables 1B, 1C, and 1D).
Although most states had an increase in total HCBS enrollment between 2009 and 2010, thirteen states reported a decline during this period. The three states with the highest rate of total HCBS enrollment decline from 2009 to 2010 were Florida (11%), Hawaii (19%), and Nevada (11%) (Table 1A). State plan home health services enrollment declined in 23 states (Table 1B), and 9 states had a decline in state plan personal care services enrollment (Table 1C). Ten states had a decline in § 1915(c) waiver participants (Table 1D). Figure 5 illustrates the variation in total Medicaid HCBS program participation among the states.
Hawaii’s decline in total Medicaid HCBS program participation is largely due to the state’s ongoing efforts to transition HCBS waiver services for all beneficiary populations other than people with intellectual and developmental disabilities (I/DD) to its § 1115 managed care waiver. In Florida and Nevada, the declines in total HCBS program participation were driven by reductions in home health and personal care state plan services participation.
Expenditures in Medicaid Home Health and Personal Care State Plan Services and § 1915(c) Waivers. In 2010, total Medicaid spending on HCBS across the three main programs was $52.7 billion (Table 2A). The large majority of Medicaid spending on non-institutional long-term care services was for § 1915(c) waivers). In 2010, Medicaid spending on § 1915(c) waivers was $36.8 billion, compared to $10.2 billion on personal care state plan services and $5.7 billion on home health state plan services (Tables 2B, 2C, 2D and Figure 6).
Between 2000 and 2010, total annual Medicaid spending on HCBS in the three main programs increased by more than $33 billion (171%) with an average annual increase of 11 percent (Figure 7). Between 2009 and 2010, the 6 percent increase in total HCBS spending was the lowest in the 11-year study period and less than the growth rate (7%) for total acute and long-term care Medicaid expenditures in the same period; this change corresponds with a decline in total Medicaid spending growth.1 Although there was a general trend of annual percentage increases in Medicaid HCBS expenditures, six states (California, Delaware, Louisiana, Missouri, Oklahoma, and Tennessee) reported an annual decline in expenditures between 2009 and 2010 (Table 2A). In California (7%) and Missouri (6%), the decline was led by a fall in spending on personal care state plan services (Table 2C). The slight decline (-1%) in HCBS expenditures in the other four states was due to a decrease in their § 1915(c) waiver spending in 2010 (Table 2D).
Medicaid HCBS expenditures as a proportion of total Medicaid LTSS expenditures increased between 2009 and 2010 as they have done every year since 2000.2
National total Medicaid HCBS expenditure data mask state-to-state variations in spending across the three major programs. First, while national per person spending on Medicaid HCBS averaged $16,673 in 2010, state spending ranged from $7,844 in Texas to $34,506 in New York (Figure 8, Table 3A). Second, differences exist in spending across the three major Medicaid HCBS programs. National per person expenditures ranged from $7,077 for home health state plan services participants to $26,218 for § 1915(c) waiver participants in 2010 (Table 3B, 3C, 3D and Figure 9). This difference was likely due to the types and extent of services provided in the three main HCBS programs. The lower national per user spending on home health state plan services participants likely reflects shorter periods of per participant service utilization compared to either § 1915(c) waivers or the personal care services state plan option. Third, there was also significant per person expenditure variation among § 1915(c) waivers targeted to different populations (Table 4).
Medicaid § 1915(c) Waivers. Between 2009 and 2010, the number of § 1915(c) waivers declined slightly to 284, due largely to the elimination and transition of Rhode Island’s § 1915(c) waivers to a § 1115 waiver, as described above. Hawaii transitioned its § 1915(c) waivers for non-I/DD participants into a § 1115 waiver and retained a single I/DD § 1915(c) waiver in 2010. In 2010, with the exception of Arizona, Rhode Island, and Vermont which operate their entire Medicaid long-term care programs through § 1115 waivers and therefore do not offer any § 1915(c) waivers, every state and DC had § 1915(c) waivers targeted to populations who would otherwise require institutional care. These beneficiary groups include: the aged (age 65 and over), aged or disabled, individuals with physical disabilities, individuals with I/DD, children who are medically fragile or technology-dependent, individuals with HIV/AIDS, and individuals with traumatic brain and/or spinal cord injury (TBI/SCI).
Table 4 details, by waiver type, § 1915(c) waiver enrollment, total expenditures, and per participant expenditures for the two most recent reporting years. In 2010, 1,403,736 participants were served through Medicaid § 1915(c) waivers (Tables4 and 5). The three percent increase (40,464 individuals) from 2009 to 2010 is less than the nine percent increase from 2008 to 2009 and represents the smallest increase in participation since 2004. As in previous years, the majority of § 1915(c) waiver participants (681,446, or 49%) received services through waivers that targeted the aged and aged or disabled (Figure 10). The next largest group of waiver participants (567,117) was enrolled in § 1915(c) waivers for persons with I/DD, representing 40 percent of total § 1915(c) waiver participants. Persons with physical disabilities accounted for only six percent (85,537) of total waiver participants. The waivers with the smallest enrollment were those for children who are medically fragile or technology-dependent (36,270), individuals with TBI/SCI (17,193), individuals with HIV/AIDS (12,930), and individuals with mental health disabilities (3,243). The § 1915(c) waivers with the largest annual increase in participation were those for the aged (10%), followed by those serving individuals with mental health disabilities (9%) (Table 4).
In 2010, overall expenditures for § 1915(c) waivers increased to $36.8 billion, a nine percent increase compared to 2009. This was lower than the rate of increase between 2008 and 2009 (11%) and was the lowest rate of increase since 2006. The vast majority of spending on § 1915(c) waivers was for individuals with I/DD. Although individuals enrolled in I/DD waivers accounted for just 40 percent of total waiver participants, expenditures for this population accounted for 71 percent of all § 1915(c) waiver spending (Tables 4 and 6 and Figure 10). Between 2009 and 2010, the annual rate of expenditure growth was highest for mental health waivers (18%), mainly due to the expansion of existing waivers for persons with mental health disabilities and the establishment of a new mental health waiver in Connecticut. The expenditure growth rates from 2009 to 2010 for waiver programs for children who are medically fragile or technology-dependent and for the aged were both 14 percent (Table 4).
Growth in average § 1915(c) waiver expenditures per participant increased from two percent in the 2008-2009 period to six percent in the 2009-2010 period (Table 4). This is the fastest rate of growth since 2005. Persons with I/DD had the highest spending per person served ($46,156) (Tables 4 and 7). This amount was more than four times higher than average waiver spending on both the aged and aged/disabled waiver participants. Per participant expenditures grew by eight percent for mental health and I/DD waivers, with all other waivers showing increases except for a two percent decline in per participant spending for HIV/AIDS waivers (Table 4).
HCBS and Managed Long-Term Care within § 1115 Waivers. In addition to the Medicaid home health and personal care services state plan benefits and § 1915(c) waivers, states can deliver HCBS through § 1115 demonstration waivers.3 Section 1115 of the Social Security Act allows the Secretary of the Department of Health and Human Services to waive state compliance with certain federal Medicaid requirements and authorizes the use of federal Medicaid funds in ways that are not otherwise allowable. Section 1115 waivers enable “experimental, pilot or demonstration project[s] which, in the judgment of the Secretary, [are] likely to assist in promoting the objectives [of the Medicaid program].”4 Section 1115 waivers have been used to implement a variety of initiatives related to HCBS, such as self-direction of personal care services,5 payments to spouses who provide personal care services, and managed long-term care.
Three states (Arizona, Rhode Island, and Vermont) presently use § 1115 waivers to administer statewide Medicaid capitated managed care programs that include all covered HCBS for all populations and services; these states do not offer any § 1915(c) waivers. In 2010, Arizona spent $1.0 billion on HCBS for 40,752 participants. Rhode Island spent $288.0 million on HCBS for 4,200 participants, and Vermont spent $194.3 million on HCBS for 7,643 participants.6 Vermont’s model is unique in that the state serves as the managed care entity. Other states that administer Medicaid managed care programs that include HCBS contract with private health plans to provide covered services for a capitated per member per month rate. In addition to Arizona, Rhode Island, and Vermont’s statewide programs, another five states (Delaware, Hawaii, New York, Tennessee, and Texas) use § 1115 waivers for Medicaid capitated managed care programs that include HCBS for at least some geographic areas and/or populations; these states also offer § 1915(c) waivers for other HCBS.7 Other states implement Medicaid managed long-term care programs through combination § 1915(b)/(c) waivers (Section 1915(b) waivers allow states to offer Medicaid services in a managed care model or otherwise limit a beneficiary’s choice of providers).8