Medicaid Home and Community-Based Services Programs: 2012 Data Update

Over the past three decades, the increase in access to community-based alternatives to institutional care has resulted in some rebalancing of national Medicaid LTSS dollars, but the size and scope of Medicaid HCBS programs vary across states. Section 1915(c) waivers account for the majority (74%) of spending on LTSS provided in community settings, and continued growth in waiver waiting list enrollment, to more than 582,000 persons nationally with waiting times of almost two and a half years, highlight the need for community-based LTSS, especially for individuals with I/DD and people who are aged or disabled.

At the same time, competing pressures in state budgets may mean that states may face uncertainties for the provision of Medicaid LTSS in the coming years, and states are continuing to utilize cost control measures within their Medicaid programs. In response to fiscal pressures and a desire to better coordinate beneficiaries’ LTSS, some states are looking to incorporate HCBS into Medicaid managed care arrangements.  States also are working to come into compliance with CMS’s rule defining the qualities of the settings in which Medicaid HCBS can be provided and assessing the impact of the new Department of Labor rules that extends Fair Labor Standards Act minimum wage and overtime pay protections to direct care workers who were previously exempt, which are expected to take effect in fall 2015.¹ The impact of all of these initiatives on HCBS access warrants further analysis. In the coming years, states will be challenged to continue to expand access to high quality, person-centered HCBS in a cost-effective manner, and it will remain important to monitor states’ adoption of state plan options and other initiatives to expand Medicaid HCBS, differences in services and spending, and the impact of cost control policies on access and quality.