Medicaid Home and Community-Based Services Enrollment and Spending
Issue Brief
AZ delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable to separately report unduplicated home health enrollment data. Instead, AZ’s home health state plan enrollment is included in its Section 1115 waiver enrollment. In FY 2018, Arizona reported that all 52,400 of its Section 1115 waiver enrollees received home health services.
HI delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable to separately report unduplicated home health enrollment data. Instead, HI’s home health state plan enrollment is included in its Section 1115 waiver enrollment. In FY 2018, Hawaii reported that 2,500 of its 8,500 Section 1115 waiver enrollees received home health services.
NE reports home health state plan enrollment only for fee-for-service enrollees.
TX reports home health state plan enrollment only for fee-for-service enrollees.
KS delivers personal care state plan services through a Section 1115 capitated managed care waiver and is unable to separately report unduplicated personal care enrollment data. Instead, KS’s personal care state plan enrollment is included in its Section 1115 waiver enrollment.
NM delivers personal care state plan services through a Section 1115 capitated managed care waiver and is unable to separately report unduplicated personal care enrollment data. Instead, NM’s personal care state plan enrollment is included in its Section 1115 waiver enrollment.
NY is unable to report Section 1115 waiver managed LTSS enrollment by community vs. institutional setting. In 2015 (the most recent year for which NY data are available), 49,930 people received long-term institutional or HCBS in NY’s Section 1115 waiver.
Among the 34 states offering the personal care state plan option, 20 allow self-direction. The 15 states reporting self-directed enrollment data are AK, AR, CA, FL, ID, MA, MI, MO, MT, NJ, OK, TX, UT, VT and WA. The five states that allow self-directed personal care state plan services but do not report enrollment are ME, MN, NV, NH and NY.
For additional information on states’ self-direction policies, see KFF, Key State Policy Choices About Medicaid Home and Community-Based Services (Feb. 2020), https://www.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services.
Three of 51 states allow individuals to self-direct home health state plan services. CA and NE allow self-direction but are unable to report enrollment.
AZ delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable to separately report home health spending data. Instead, AZ’s home health state plan spending is included in its Section 1115 waiver spending. Total home health state plan spending was $70 million in AZ in FY 2018.
HI delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable to separately report home health spending data. Instead, HI’s home health state plan spending is included in its Section 1115 waiver spending. Total home health state plan spending was $4 million in HI in FY 2018.
NE reports home health state plan spending only for fee-for-service enrollees.
TX reports home health state plan spending only for fee-for-service enrollees.
KS delivers personal care state plan services through a Section 1115 capitated managed care waiver and is unable to separately report personal care spending data. Instead, KS’s personal care state plan spending is included in its Section 1115 waiver spending.
NM delivers personal care state plan services through a Section 1115 capitated managed care waiver and is unable to separately report personal care spending data. Instead, NM’s personal care state plan spending is included in its Section 1115 waiver spending.
NY is unable to report Section 1115 waiver managed LTSS spending by community vs. institutional setting. In 2015 (the most recent year for which NY data is available), total institutional and HCBS Section 1115 waiver spending was $146,589,000.
Section 1915 (c) waiver participants were enrolled about 300 days a year on average in 2016, the most recent year data are available. KFF analysis based on CMS 372 reports for Section 1915 (c) waivers in 2016.
The FY 2018 survey asked states to update prior years’ (FY 2016 and FY 2017) spending and enrollment data if necessary; therefore, all trend analyses reflected in this report includes the most recently reported FY 2017 data.
Section 1115 waiver enrollment is not presented by target population because, unlike Section 1915 (c) waivers, Section 1115 waivers can include multiple populations, and states only report total Section 1115 waiver enrollment in our survey.
48 states offer Section 1915 (c) waivers targeted to people with I/DD. The other three states (AZ, RI, and VT) serve their entire I/DD waiver populations under Section 1115. In addition, two states (NY and TN) serve some people with I/DD under Section 1115 and others under Section 1915 (c).
42 states offer Section 1915 (c) waivers targeted to seniors and/or adults with physical disabilities. The other nine states (AZ, DE, HI, NJ, NM, RI, TN, TX, and VT) serve all senior and adult with physical disabilities waiver populations under Section 1115. In addition, three states (CA, NY, and WA) serve some seniors and adults with physical disabilities under Section 1115 and others under Section 1915 (c).
11 states offer Section 1915 (c) waivers targeted to people with mental health disabilities. Another two states (DE and RI) serve people with mental health disabilities under Section 1115. In addition, WA serves some people with mental health disabilities under Section 1115 and others under Section 1915 (c).
21 states offer Section 1915 (c) waivers targeted to people with TBI/SCI. Another four states (DE, RI, VT, and WA) serve people with TBI/SCI under Section 1115.
18 states offer Section 1915 (c) waivers targeted to children who are medically fragile or technology dependent. Another two states (HI and RI) serve children who are medically fragile or technology dependent under Section 1115.
Five states offer Section 1915 (c) waivers targeted to people with HIV/AIDS. Another three states (DE, HI, and RI) serve people with HIV/AIDS under Section 1115.
Four states (CA, DE, ID, and MS) serve people with I/DD under Section 1915 (i).
Four states (IA, IN, OH and TX) serve people with mental health disabilities under Section 1915 (i).
Three states (CT, DC, and NV) serve seniors and/or people with physical disabilities under Section 1915 (i). DC did not report spending data.
Reporting states include CT and NV; DC did not report.
CA, DE, ID, and MS. ID per enrollee spending includes only the program for adults with I/DD because the state was unable to report spending data for the program for children with I/DD.
IA, IN, OH, and TX.
KFF, Explaining Texas v. U.S.: A Guide to the 5th Circuit Appeal in the Case Challenging the ACA (Jan. 2020), https://www.kff.org/health-reform/issue-brief/explaining-texas-v-u-s-a-guide-to-the-case-challenging-the-aca/
KFF, Potential Impact of Texas v. U.S. Decision on Key Provisions of the Affordable Care Act (Jan. 2020), https://www.kff.org/health-reform/fact-sheet/potential-impact-of-texas-v-u-s-decision-on-key-provisions-of-the-affordable-care-act/.
See also KFF, State Variation in Medicaid Per Enrollee Spending for Seniors and People with Disabilities (May 2017), https://www.kff.org/medicaid/issue-brief/state-variation-in-medicaid-per-enrollee-spending-for-seniors-and-people-with-disabilities/.
KFF, Medicaid Financing: The Basics (March 2019), https://www.kff.org/medicaid/issuebrief/medicaid-financing-the-basics/.
KFF, Why It Matters: Tennessee’s Medicaid Waiver Block Grant Proposal (Dec. 2019), https://www.kff.org/medicaid/issue-brief/why-it-matters-tennessees-medicaid-block-grant-waiver-proposal/.
KFF, How Will Medicare-for-all Proposals Affect Medicaid? (Sept. 2019), https://www.kff.org/medicaid/issue-brief/how-will-medicare-for-all-proposals-affect-medicaid/.
U.S. Census Bureau, Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Report Number P25-1143, at 5 (March 2015), https://www.census.gov/library/publications/2015/demo/p25-1143.html.
U.S. Census Bureau, Older People Projected to Outnumber Children for First Time in U.S. History, Release Number CB18-41 (March 13, 2018), https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html.
Id.; U.S. Census Bureau, An Aging Nation: Projected Number of Children and Older Adults (last revised Oct. 9, 2019), https://www.census.gov/library/visualizations/2018/comm/historic-first.html.