How Many People Use Medicaid Long-Term Services and Supports and How Much Does Medicaid Spend on Those People?

Overview of Methods: KFF included all people with at least one month of Medicaid enrollment who were using the following types of LTSS: institutional care (care provided in a nursing facility or intermediate care facility) and HCBS (home health, personal care, 1915(c) waiver, 1115 waiver, and “other” HCBS). Several summary level indicators categorize people who used specific types of LTSS as using only institutional care, only HCBS, or both types of care. KFF categorized claims using the type-of-service code from the first line claim, which was applied to the header claim in a merged dataset. More details are below.

Institutional LTSS: KFF defined enrollees who used institutional LTSS if they had a claim for care provided at either a nursing facility or intermediate care facility (see table below).

Home and Community-Based Services: KFF used eligibility information and claims files to identify people who used HCBS.

1. Enrollees who had at least one month of 1915(c) enrollment (WVR_1915C_MOS > 0) were identified as using 1915(c) waiver services.
2. For people who did not have any enrollment in a 1915(c) waiver, KFF used the claims to determine whether they were using HCBS, including home health, personal care, or other HCBS (see table below).
3. If enrollees used home health, personal care, or other HCBS; and were enrolled in an 1115 waiver (WVR_TYPE_CD equal to 01 or 29), and lived in a state that provided HCBS through an 1115 waiver, they were identified as using 1115 waiver services. From 2018-2020, the following states provided HCBS through an 1115 waiver: AZ, AR, CA, DE, HI, KS, MD, MN, NJ, NM, NY, RI, TN, TX, VT, and WA.
4. For enrollees who used HCBS but were not enrolled in a 1915(c) or 1115 waiver as described above, KFF categorized the types of services they were using as home health, personal care, or other HCBS. Enrollees could use multiple types of HCBS in those categories. KFF compared the T-MSIS data to older HCBS surveys from 2018 and 2020 and identified discrepancies which suggest that the “other HCBS” group likely includes some people using HCBS through a 1915 state plan authority and some people using HCBS through a waiver in states that did not populate 1915(c) information on the eligibility file.

• • KFF counted only the enrollees with the top 50% of home health claims in each state as people who used home health to exclude people who used short-term home health. The cut-off point reflects the distribution of home health claim counts per enrollee in each state and was selected to calibrate counts such that the number of people using LTSS in each state was similar to the number identified in the older KFF surveys. The specific claim count cut-off varied by state and year. In 2020, the claim counts for the top 50% of people who used home health services in each state ranged from 1 claim in Utah to 28 claims in Massachusetts.
  • Similarly, KFF counted only enrollees with the top 75% of personal care claims as people who used personal care in each state. The claim count cut-off varies by state and year. In 2020, the claim counts for the top 75% of people who used personal care services in each state ranged from 2 claims in Illinois and Delaware to 126 claims in Massachusetts.

Key Limitations: For HCBS, where there are few established benchmarks on the number of people using services, KFF calibrated the selection criteria such that state-level counts were similar to the results from KFF’s HCBS survey. For most states, the approach yielded reasonable results but in several cases, there were significant discrepancies between the survey data and the T-MSIS output. Examples include Maine (where the 1915(c) enrollees appear to be showing up as people who used state plan services), Rhode Island (which has low counts of people using HCBS in all categories), and Wisconsin (where the 1915(c) enrollees are showing up as people who used other HCBS).