State Variation in Medicaid LTSS Policy Choices and Implications for Upcoming Policy Debates

Issue Brief
  1. 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/.

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  2. Id.

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  3. To align with available data sources, this report uses states’ ACA expansion status as of 2018 (33 expansion states and 18 non-expansion states). Medicaid expansion coverage became effective January 1, 2014 in all states that have adopted the expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), Louisiana (7/1/2016), Virginia (1/1/2019), Maine (1/10/2019 with coverage retroactive to 7/2/2018), Idaho (1/1/2020), Utah (1/1/2020), Nebraska (10/1/2020), Oklahoma (planned for 7/1/2021), and Missouri (planned for 7/1/2021). For purposes of this analysis, Idaho, Utah, Nebraska, Oklahoma, and Missouri are considered non-expansion states because they implemented expansion after 2018.

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  4. Mathematica, Medicaid Long-Term Services and Supports Annual Expenditures Report: Federal Fiscal Years 2017 and 2018 (Jan. 2021), https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltssexpenditures-2017-2018.pdf.

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  5. KFF, People with Disabilities Are At Risk of Losing Medicaid Coverage Without the ACA Expansion (Nov. 2020), https://www.kff.org/medicaid/issue-brief/people-with-disabilities-are-at-risk-of-losing-medicaid-coverage-without-the-aca-expansion/.

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  6. To align with available data sources, this report uses states’ ACA expansion status as of 2018 (33 expansion states and 18 non-expansion states). Medicaid expansion coverage became effective January 1, 2014 in all states that have adopted the expansion except for the following: Michigan (4/1/2014), New Hampshire (8/15/2014), Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), Montana (1/1/2016), Louisiana (7/1/2016), Virginia (1/1/2019), Maine (1/10/2019 with coverage retroactive to 7/2/2018), Idaho (1/1/2020), Utah (1/1/2020), Nebraska (10/1/2020), Oklahoma (planned for 7/1/2021), and Missouri (planned for 7/1/2021). For purposes of this analysis, Idaho, Utah, Nebraska, Oklahoma, and Missouri are considered non-expansion states because they implemented expansion after 2018.

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  7. Aside from the Medicaid expansion, the ACA introduced other reforms that simplify and modernize Medicaid eligibility and enrollment processes. All states must adopt these reforms for poverty-related coverage pathways, and states can choose whether to apply them to age and disability-related pathways. 42 C.F.R. § 435.916; KFF, Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings From a 50-State Survey (June 2019), https://www.kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey-issue-brief/.

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  8. The overall shift in spending from institutional services to HCBS reflects decades long rebalancing efforts by states and the federal government to meet beneficiary preferences for community living and community integration obligations under the Americans with Disabilities Act and the Supreme Court’s Olmstead decision and provide services in the most cost effective setting.

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  9. The MFP program operates in 29 Medicaid expansion states and 15 non-expansion states, and as of December 2019, 101,540 individuals have transitioned from an institution into the community since MFP began. Mathematica, Money Follows the Person: State Transitions as of December 31, 2019 (Sept. 2020), https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/mfp-2019-transitions-brief.pdf.

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  10. Notably, spending data for five states (CA, IL, NC, NY and VA) are excluded, as a large share of services are provided by managed care organizations for which data are unavailable. Mathematica, Medicaid Long-Term Services and Supports Annual Expenditures Report: Federal Fiscal Years 2017 and 2018 (Jan. 2021), https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltssexpenditures-2017-2018.pdf.

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  11. The BIP offered states temporary enhanced federal matching funds for Medicaid HCBS in exchange for making certain structural changes to their LTSS delivery systems. Participation in BIP was limited to states that, as of 2009, were devoting less than half of their total Medicaid LTSS spending to HCBS; 14 expansion states and four non-expansion participated. This total excludes three states (IN, LA, and NE) who initially participated in BIP but terminated their programs before completion. KFF, Medicaid Balancing Incentive Program: A Survey of Participating States (June 2015), https://www.kff.org/medicaid/report/medicaid-balancing-incentive-program-a-survey-of-participating-states/.

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  12. Self-direction typically allows individuals to select and dismiss their direct care workers and determine workers schedules. Most states also allow individuals to set worker payment rates and/or allocate their service budgets.

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  13. California is expanding financial eligibility for the optional aged, blind, disabled population from 100% to 138% FPL and adding a new income disregard in the amount of the Medicare Part B premium. New Hampshire plans to expand its Medicaid buy-in program for working people with disabilities to include seniors up to 250% FPL. Louisiana is expanding HCBS waiver coverage for children with significant disabilities without regard to household income and assets. KFF, State Medicaid Programs Respond to Meet COVID-19 Challenges: Results from a 50-State Medicaid Budget Survey For State Fiscal Years 2000 and 2001 (Oct. 2020), https://www.kff.org/medicaid/report/state-medicaid-programs-respond-to-meet-covid-19-challenges/.

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