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Medicaid Home and Community-Based Services Enrollment and Spending

Issue Brief
  1. See, e.g., Kaiser Family Foundation, Medicaid Beneficiaries Who Need Home and Community-Based Services: Supporting Independent Living and Community Integration (March 2014), https://www.kff.org/medicaid/report/medicaid-beneficiaries-who-need-home-and-community-based-services-supporting-independent-living-and-community-integration/.

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  2. See generally Kaiser Family Foundation, Streamlining Medicaid Home and Community-Based Services: Key Policy Questions (March 2016), https://www.kff.org/medicaid/issue-brief/streamlining-medicaid-home-and-community-based-services-key-policy-questions/; Kaiser Family Foundation, Medicaid Long-Term Services and Supports: An Overview of Funding Authorities (Sept. 2013), https://www.kff.org/medicaid/fact-sheet/medicaid-long-term-services-and-supports-an-overview-of-funding-authorities/.

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  3. In Olmstead, the Supreme Court held that the unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act. Kaiser Family Foundation, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision (June 2014), https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.

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  4. For additional background and current state policies relating to each of these authorities, see Kaiser Family Foundation, Key State Policy Choices About Medicaid Home and Community-Based Services (April 2019), https://www.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services.

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  5. Enrollment in Section 1115 HCBS waivers includes those for which the state does not have an accompanying Section 1915 (c) waiver.

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  6. Although 51 states provide home health state plan benefits, total home health state plan enrollment excludes three states (AZ, DE, and HI). These states deliver home health state plan services through Section 1115 capitated managed care waivers and were unable to separately report home health enrollment data. Instead, their state plan home health enrollment is included in their Section 1115 waiver enrollment.

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  7. Total personal care state plan enrollment includes 32 of 35 states with CMS approval to elect this option. The other three states (DE, KS, and NM) deliver personal care state plan services through Section 1115 capitated managed care waivers and were unable to separately report personal care enrollment data. Instead, their state plan personal care enrollment is included in their Section 1115 waiver enrollment.

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  8. Total Section 1915 (i) enrollment includes 11 of 16 states electing this option. The other six states (CO, FL, MD, OH, OR, and WI) were unable to report Section 1915 (i) enrollment data.

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  9. Total Section 1115 waiver enrollment includes 10 of 11 states using this authority. The other state (NY) is unable to report HCBS waiver enrollment separate from institutional waiver enrollment. 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.

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  10. Total CFC enrollment includes 7 of 8 states electing this option. One state (NY) was unable to report CFC enrollment data.

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  11. States can manage enrollment for Section 1915 (i) state plan services by restricting functional eligibility criteria for future beneficiaries if enrollment will exceed the state’s initial estimate.

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  12. Forty-eight states offer a total of 276 Section 1915 (c) waivers targeted to different populations in 2017.

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  13. Additional Medicaid HCBS enrollees are subject to mandatory or optional enrollment in capitated managed care through other managed care authorities, which are not included in our survey. Our survey is limited to authorities that authorize HCBS (Section 1115 allows states to authorize both HCBS and managed care.) Other Medicaid managed care authorities include the Section 1932 state plan option and Section 1915 (a) and Section 1915 (b) waivers.

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  14. KS’s Section 1115 waiver authorizing capitated managed care operates concurrently with its Section 1915 (c) waivers for people with I/DD (KS-0224), children with autism (KS-0476), people with physical disabilities (KS-0304), medically fragile/technology dependent children (KS-4165), people with TBI (KS-4164), children with serious emotional disturbance (KS-0320), and frail seniors (KS-0303). CMS Special Terms and Conditions for KanCare, #11-W-00283/7 at ¶ 42 (p. 41) (approval period Jan. 2019-Dec. 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ks/ks-kancare-ca.pdf.

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  15. The letter accompanying CMS’s October 2018 approval of NC’s Section 1115 waiver notes that “[t]he state requested to transition its 1915 (c) Home and community Based services (HCBS) waivers for Innovation Waiver Services [for children and adults with I/DD] (NC-0423.R02.00) and Traumatic Brain Injury services (NC-1326.R00.00) into the demonstration. CMS determined the state could effectively operate its HCBS waivers under the 1915 (c) authorities concurrently with 1115 authority requiring Medicaid beneficiaries, except those excluded or exempted, to enroll into a managed care plan to receive state plan and HCBS waiver services.” Letter from CMS Administrator Seema Verma to NC Deputy Secretary for Medical Assistance Dave Richard, at 3 (Oct. 19, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/nc-medicaid-reform-ca.pdf.

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  16. 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, two states (CA and NY) serve some seniors and adults with physical disabilities under Section 1115 and others under Section 1915 (c).

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  17. 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.

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  18. The other three states (AZ, RI, VT) serve their entire I/DD waiver populations under Section 1115. In addition, two states (NY and TN) service some people with I/DD under Section 1115 and others under Section 1915 (c).

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  19. Another two states (DE and RI) serve people with mental health disabilities under Section 1115.

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  20. Another three states (DE, RI, and VT) serve people with TBI/SCI under Section 1115.

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  21. Another two states (HI and RI) serve children who are medically fragile or technology dependent under Section 1115.

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  22. Another three states (DE, HI, and RI) serve people with HIV/AIDS under Section 1115.

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  23. CA, DE, ID, and MS.

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  24. Reporting states include IA, IN, and TX. Non-reporting states include FL, OR, and WI.

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  25. Reporting states include CT, DC, NV. Non-reporting states include CO, MD, OH.

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  26. Four states (KS, KY, ME, and VA) have waivers allowing self-direction but did not report enrollment. Among the 44 states reporting self-direction enrollment, not all did so for all waivers allowing self-direction.

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  27. The 12 states reporting self-direction enrollment for state plan personal care services are AK, CA, ID, MA, MO, MT, NJ, NV, OR, UT, VT, and WI. The 23 states not reporting self-direction enrollment for state plan personal care services are AR, CO, DE, DC, FL, KS, LA, ME, MD, MI, MN, NE, NH, NM, NY, NC, ND, OK, RI, SD, TX, WA, and WV.

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  28. As with enrollment, total home health state plan spending excludes three (of 51) states (AZ, DE, HI) and total personal care state plan spending excludes three (of 35) states (DE, KS, NM) that are unable to separately report this spending and instead include it in their Section 1115 waiver spending. Six (of 16) states were unable to report Section 1915 (i) spending (CO, FL, MD, OH, OR, WI). One (of 8) state (NY) was unable to report CFC spending. Total Section 1115 waiver spending excludes 1 (of 11) states (NY), which is unable report HCBS waiver enrollment separate from institutional waiver enrollment. In 2015 (the most recent year for which NY data is available), total institutional and HCBS Section 1115 waiver spending in NY was $146,589,000.

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  29. The other three states (AZ, RI, VT) serve people with I/DD, along with other populations, through Section 1115 waivers and do not report Section 1115 waiver enrollment by population. In addition, two states (NY and TN) serve some people with I/DD through Section 1115 and others through Section 1915 (c).

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  30. 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, two states (CA and NY) serve some seniors and adults with physical disabilities under Section 1115 and others under Section 1915 (c).

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  31. Another three states (DE, RI, and VT) serve people with TBI/SCI under Section 1115.

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  32. Another two states (DE and RI) serve people with mental health disabilities under Section 1115.

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  33. Another two states (HI and RI) serve children who are medically fragile or technology dependent under Section 1115.

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  34. Another three states (DE, HI, and RI) serve people with HIV/AIDS under Section 1115.

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  35. CA, DE, ID, and MS.

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  36. Reporting states include IA, IN, and TX. Non-reporting states include FL, OR, and WI.

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  37. Reporting states include CT and NV. Non-reporting states include CO, DC, MD, OH.

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  38. Reporting states include IA, IN, and TX. Non-reporting states include FL, OR, and WI.

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  39. Reporting states include CT and NV. Non-reporting states include CO, DC, MD, OH.

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  40. CA, DE, ID, and MS.

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  41. Kaiser Family Foundation, Medicaid Financing: The Basics (March 2019), https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.

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  42. Kaiser Family Foundation, No Easy Choices: 5 Options to Respond to Per Capita Caps (June 2017), https://www.kff.org/medicaid/issue-brief/no-easy-choices-5-options-to-respond-to-per-capita-caps/.

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