Medicaid Home and Community-Based Services Enrollment and Spending

Medicaid fills in gaps in the overall health care system by serving as the primary source of coverage for long-term services and supports (LTSS), including home and community-based services (HCBS), as these services are typically unavailable and/or unaffordable through private insurance or Medicare.  HCBS help seniors and people with disabilities and chronic illnesses live independently outside institutions by assisting with daily needs. This issue brief presents the latest (FY 2018) Medicaid HCBS enrollment and spending data from KFF’s 18th annual 50-state survey. Appendix Tables contain detailed state-level data. Key findings include the following:

• Most HCBS enrollees receive services provided at state option. Over 2.5 million individuals receive HCBS through an optional Section 1915 (c) or Section 1115 waiver, and nearly 1.2 million receive optional personal care state plan services, while 600,000 receive home health state plan services, the sole required benefit. Fewer individuals receive HCBS through the relatively newer state plan options including Section 1915 (i) and Community First Choice.
• Joint federal and state Medicaid HCBS spending totaled $92 billion in FY 2018, with nearly all spending for optional services.
• National per enrollee spending varies among the HCBS authorities, ranging from under $8,000 for Section 1915 (i) state plan services to nearly $30,000 for Section 1915 (c) waivers.
• Per enrollee spending by Section 1915 (c) waiver target population is highest for people with intellectual/developmental disabilities ($46,000). Per enrollee spending is relatively lower for seniors/adults with physical disabilities ($16,000).  

State Medicaid programs will face increased pressure to meet the health and LTSS needs of a growing elderly population in the coming years, and their ability to do so could be affected by an economic downturn that could leave states with limited resources and require reductions in services offered at state option. In addition, if the ACA ultimately is struck down in Texas v. Azar, states would lose authority to offer some HCBS as well as some flexibility to design benefit packages. The 2020 elections also could have important implications for Medicaid and HCBS as policymakers may consider a range of proposals, from those that could cap federal Medicaid financing program-wide as in the President’s FY 2020 budget to proposals advocated by some Democrats to create a single, federal, universal health insurance program known as Medicare-for-all.