Medicaid Home & Community-Based Services: People Served and Spending During COVID-19
Issue Brief
These spending totals may not align with other sources due to differences in state reporting or which services are included in the definition of HCBS.
Factors contributing to this trend include enrollee preferences for HCBS, the fact that states are encouraging HCBS as an alternative to typically more costly institutional care, and states’ community integration obligations under the Americans with Disabilities Act (ADA) and the Supreme Court’s Olmstead decision. In Olmstead, the Supreme Court held that the unjustified institutionalization of people with disabilities is illegal discrimination that violates the ADA.
The FY 2017 and 2018 data omit California, Illinois, New York, North Carolina, and Virginia.
The FY 2019 data omit California, Delaware, Illinois, and Virginia.
Due to the pandemic, KFF did not survey states in calendar year 2020, so this year’s survey also collected FY 2019 data to account for the missed year.
The four states that did not respond are Hawaii, District of Columbia, Minnesota, and New Mexico. In certain areas, states’ previously reported data and supplemental research by KFF helped to calculate national totals.
Section 1115 HCBS waivers are included in our survey only if the state does not have an accompanying Section 1915 (c) waiver.
However, states can limit the number of people receiving Section 1915 (i) state plan services by restricting functional eligibility criteria for future enrollees if the number of people receiving services will exceed the state’s initial estimate.
Number of people served was not reported for CFC in NY and Section 1915 (i) in AR.
These totals omit people receiving services in the following states that deliver state plan HCBS through Section 1115 capitated managed care waivers and cannot report the unduplicated number of people receiving state plan HCBS separate from the total number of people receiving Section 1115 waiver services: AZ (home health), DE (home health and personal care), HI (home health), KS (personal care), NM (personal care), RI (home health and personal care).
States report total spending for home health state plan services, which may include a small amount of spending for optional services. The home health state plan benefit must include nursing services, home health aide services, and medical supplies, equipment, and appliances. States also may choose to cover physical, occupational, and/or speech/language therapy as part of the home health state plan benefit.
Spending data was not reported for CFC in NY and Section 1915 (i) in AR and DC.
The home health and personal care state plan option totals omit spending for state plan HCBS in the following states that provide these services through Section 1115 capitated waivers and cannot report state plan HCBS spending separate from total Section 1115 waiver spending: AZ (home health), DE (home health and personal care), HI (home health), KS (personal care), NM (personal care), RI (home health and personal care).
States also may use Section 1115 HCBS waivers to target services to particular populations. We do no analyze Section 1115 waivers by target population because states may include more than one population within a single waiver; instead, we report total Section 1115 HCBS spending across all waiver populations.
47 states offer Section 1915 (c) waivers targeted to people with I/DD. The other four states (AZ, NJ, 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).
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.
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).
These data include four states (CA, DE, ID, MS) that serve people with I/DD under Section 1915 (i). ID serves both people with I/DD and children with serious emotional disturbance under Section 1915 (i). ID did not report the number of people served and spending by target population, so all data are attributed to people with I/DD.
Four states (CT-seniors only, DC, MI, NV) serve seniors and/or people with physical disabilities under Section 1915 (i).
These data include four states (IA, IN, OH, TX) that serve people with mental health disabilities under Section 1915 (i). ID also serves children with serious emotional disturbance under Section 1915 (i) but was unable to report data by target population, so all ID Section 1915 (i) data are attributed its I/DD target population. AR also serves people with behavioral health needs under Section 1915 (i) but did not report the number of people served or spending. AR SPA #18-0017 (approved Dec. 19, 2018, effective March 1, 2019), https://www.medicaid.gov/sites/default/files/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/AR/AR-18-017.pdf.