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

Medicaid Home Health and Personal Care Services State Plan Benefits

Unlike waivers, states are not permitted to maintain waiting lists or geographically limit the services provided through Medicaid home health and personal care state plan benefits. State plan services must be available to all beneficiaries as medically necessary. However, federal Medicaid rules allow states to use certain cost-containment strategies for state plan benefits. To understand how states controlled spending for home health and personal care services state plan benefits in 2014, all state Medicaid programs were asked about approved provider types, services provided within the scope of each benefit, the use of any expenditure or service caps, and the availability of self-direction within the programs. The following summary of the 2014 survey findings shows how states use cost control policies to limit access to Medicaid home health and personal care state plan services.  (Although Rhode Island and Delaware did not report participants or expenditures for personal care state plan services in 2014, their policy survey responses are included.)

Providers and Services

To obtain a more comprehensive picture of the three main Medicaid HCBS programs, states were asked about the types of approved providers for state plan HCBS and the scope of benefits provided (no Tables shown). In addition to licensed home health agencies, 16 states (31%) allowed hospice agencies to provide home health state plan services, while Centers for Independent Living and independent providers were allowed to provide personal care state plan services in 13 states (38%) and 20 states (59%), respectively.

In addition to skilled nursing services, therapy services, and home health aide services for assistance with ADLs, 14 states (27%) provided assistance with instrumental ADLs (e.g., medication management, meal preparation) as part of their home health state plan benefit. In addition, although therapy services are optional within the home health services state plan benefit, almost all states provide some form of therapy, such as physical, occupational, or speech. Even though case management is not required under the home health state plan benefit, four states (8%) provided this service.

Among states with personal care state plan services, 31 states (91%) provided assistance with instrumental ADLs, while 14 states (41%) provided some sort of transportation services. Case management was offered in 6 states (18%) within the personal care services state plan option.

Cost Controls

More than half of all states (59%, or 30 states) utilized either expenditure or service limits or both in their home health services state plan programs in 2014, while 62 percent of states with the optional personal care services state plan benefit used cost control limits. Among states offering the optional personal care services state plan benefit, 19 states used service limits while only two states used cost control limits. Among the 30 states with cost controls in their home health services state plan benefit, only Connecticut had a combination of expenditure and service limits; the rest had only one of these limits in place. Service limitations were the most popular form of cost control for home health state plan services, with 26 states (87% of cost control states) using such limits (Table 12).

Self-Direction

In 2014, only nine states allowed self-direction within their home health services state plan programs. In contrast, 71 percent of states (24 states) with the personal care services state plan option allowed self-direction (Table 12).

Provider Reimbursement

The average reimbursement rate that states provided to home health agencies was $92.69 per home health visit in 2014, compared to $91.45 in 2013. In states that paid registered nurses or home health aides directly or mandated their reimbursement rates, the average rate per visit was $87.46 and $54.14, respectively, a slight increase from 2013 (Table 15). For the personal care services state plan option, the average rate paid to provider agencies was $18.73 per hour in 2014, a slight increase from $18.20 per hour in 2013. In states where personal care services providers were paid directly by the state or where reimbursement rates were determined by the state, the average reimbursement rate was $13.02 per hour in 2014 (Table 15). (Note: reimbursement rates for services provided under § 1915(c) waivers are not included in the policy survey.) Medicaid provider reimbursement rates are often set by state legislatures as part of the budget process.