Medicaid Home and Community-Based Services Enrollment and Spending

Medicaid continues to be the primary payer for home and community-based services (HCBS) that help seniors and people with cognitive, physical, and mental health disabilities and chronic illnesses with self-care and household activities. Medicaid fills a gap by covering HCBS that are often otherwise unavailable and/or unaffordable through other payers or out-of-pocket and provides substantial federal funding to help states meet their Americans with Disabilities Act community integration obligations. This issue brief presents Medicaid HCBS enrollment and spending data from the Kaiser Family Foundation’s 17th annual state survey. The Appendix Tables contain detailed state-level data. Key findings include the following:

  • About 4.6 million enrollees received Medicaid HCBS with joint federal and state HCBS spending totaling $82.7 billion in 2017.
  • Nearly all Medicaid HCBS enrollment (86%) and spending (93%) went to services that are provided at state option. Home health state plan services are the only mandatory HCBS.
  • Services provided through waivers account for the majority of HCBS enrollment (52%) and spending (69%). Unlike state plan authorities, waivers allow states to cap enrollment but also enable states to expand HCBS financial eligibility.
  • Medicaid HCBS spending per enrollee averaged just over $17,800 nationally, with substantial variation among states. State variation in per enrollee spending reflects different choices about optional HCBS authorities, benefit package contents, and scope of covered services. National per enrollee spending varied among the different HCBS state plan and waiver program authorities, reflecting differences in breadth, intensity, and longevity of service use.
  • Per enrollee spending by Section 1915 (c) waiver target population ranged from nearly $5,000 for people with HIV/AIDS to nearly $43,000 for people with traumatic brain or spinal cord injuries and over $44,000 for people with intellectual or developmental disabilities.

The optional nature of most HCBS covered populations and services puts them at risk if Medicaid financing were to change from the current structure of a federal guarantee to states with no pre-set limits to capped federal funding under a block grant or per capita cap, as recently proposed in President Trump’s FY 2020 budget.

Issue Brief