Medicaid Home and Community-Based Services Programs: 2013 Data Update

Executive Summary
  1. Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf.

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  2. Id. 

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Introduction
  1. Id. 

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  2. Olmstead v. L.C., 527 U.S. 581 (1999), available at http://www.law.cornell.edu/supct/html/98-536.ZS.html; see also Kaiser Commission on Medicaid and the Uninsured, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid:  15 Years after the Supreme Court’s Olmstead Decision (Washington, DC: Kaiser Family Foundation, 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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  3. Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf.

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  4. MFP funding expires in September 2016. For more information, see Kaiser Commission on Medicaid and the Uninsured, Money Follows the Person: A 2015 State Survey of Transitions, Services, and Costs (Washington, DC: Kaiser Family Foundation, October 2015), https://www.kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.

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Report
  1. Delaware and Rhode Island had CMS approval to offer personal care state plan services but did not report any participants in their programs.

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  2. Kaiser Commission on Medicaid and the Uninsured, Implementing the ACA: Medicaid Spending & Enrollment Growth for FY 2014 and FY 2015 (Washington, DC: Kaiser Family Foundation, October 2014), https://www.kff.org/medicaid/report-section/implementing-the-aca-medicaid-spending-enrollment-growth-issue-brief.

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  3. Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf.

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  4. For background about § 1115 waivers, see Kaiser Commission on Medicaid and the Uninsured, Five Key Questions and Answers About Section 1115 Medicaid Demonstration Waivers (Washington, DC: Kaiser Family Foundation, June 2011), https://www.kff.org/health-reform/issue-brief/five-key-questions-and-answers-about-section/.

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  5. 42 U.S.C. § 1315(a).

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  6. Self-direction of personal care services is available to states under the § 1915 (j) option, which allows states to offer self-direction provided that states offer personal care services as an optional state plan benefit or through a § 1915 (c) waiver. 42 U.S.C. § 1396n(j)(4)(A); 42 C.F.R. § 441.452(a).

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  7. Vermont’s model is unique in that the state serves as the managed care entity.

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  8. Other states implement capitated Medicaid managed LTSS programs through combination § 1915 (b)/(c) waivers. Section 1915 (b) waivers allow states to offer Medicaid services in a managed care model or otherwise limit a beneficiary’s choice of providers.

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  9. Expenditure data from Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf; participant data from Rhode Island Executive Office of Health and Human Services, Quarterly Operation Report: Rhode Island Global Consumer Choice Compact 1115 Waiver Demonstration, January 1, 2013 – March 31, 2013, (Providence, RI: Rhode Island Executive Office of Health and Human Services, September 2013), http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/Quarterly%20Global%20Wavier%20Report%20January%20-%20March%20%202013_1.pdf; State of Vermont Agency of Human Services, Global Commitment to Health, Quarterly Report (Waterbury, VT: State of Vermont Agency of Human Services, November 2013), available at http://dvha.vermont.gov/global-commitment-to-health/gc-ffy13-qtr-4-report.pdf. Arizona participation counts as reported by state officials to KCMU and UCSF, 2016.

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  10. Minnesota has a Section 1115 waiver that offers some fee-for-service HCBS, including Section 1915 (i) and Community First Choice services. Kansas has a joint Section 1115/Section 1915 (c) waiver. New Jersey’s Section 1115 waiver was approved in 2012, but enrollment was not effective until July, 2014.

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  11. Kaiser Commission on Medicaid and the Uninsured, Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers (Washington, DC: Kaiser Family Foundation, November 2014), https://www.kff.org/medicaid/issue-brief/key-themes-in-capitated-medicaid-managed-long-term-services-and-supports-waivers/.

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  12. U.S. Dep’t of Labor, Information on the Final Rule: Application of the Fair Labor Standards Act to Domestic Service, http://www.dol.gov/whd/homecare/finalrule.htm. While the new rules were to be effective in January, 2015, enforcement was delayed, and they were challenged in litigation. In August, 2015, the D.C. Circuit Court of Appeals upheld the regulations. Home Care Assoc. of America v. Weil, No. 15-5018 (D.C. Cir. Aug. 21, 2015), http://www.dol.gov/whd/homecare/0821appealdecision.pdf. DOL has revised its time-limited non-enforcement policy, with no actions to enforce the new rules until 30 days after the D.C. Circuit Court’s decision became final, and discretion in enforcement actions considering good faith efforts to comply with the new rule through December 2015.  U.S. Dep’t of Labor, We Count on Home Care, Time-Limited Non-Enforcement Policy, http://www.dol.gov/whd/homecare/non-enforcement_policy.htm; see also 80 Fed. Reg. 55029 (Sept. 14, 2015), http://www.gpo.gov/fdsys/pkg/FR-2015-09-14/pdf/2015-23092.pdf; U.S. Dep’t of Justice, Civil Rights Division and U.S. Dep’t of Health & Human Servs., Office for Civil Rights, Dear Colleague letter (Dec. 15, 2014), http://www.ada.gov/olmstead/documents/doj_hhs_letter.pdf.

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  13. 78 Fed. Reg. 60453-60557 (Oct. 1, 2013), http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=27104.

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  14. CMS Informational Bulletin, Self-Direction Program Options for Medicaid Payments in the Implementation of the Fair Labor Standards Act Regulation Changes (July 3, 2014), http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-03-2014.pdf.

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  15. Id. 

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  16. 42 C.F.R. § 441.301 (c)(4)-(6).  The settings rules also apply to Section 1915 (i) and Community First Choice services. CMS also has indicated it will include these requirements in the special terms and conditions of § 1115 demonstrations that include individuals receiving HCBS. CMS, Questions and Answers – 1915 (i) State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, Setting Requirements for Community First Choice, and 1915 (c) Home and Community-Based Services Waivers - CMS 2249-F and 2296-F,  https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Downloads/Final-Q-and-A.pdf.

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  17. Disabled and Elderly Health Programs Group, Centers for Medicare & Medicaid Services, Final Rule Medicaid HCBS, (Baltimore, MD: Centers for Medicare & Medicaid Services, January 16, 2014), https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/final-rule-slides-01292014.pdf.

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  18. “Statewide Transition Plans,” Medicaid.gov, CMS, accessed October 4, 2016, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/statewide-transition-plans.html. 

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  19. Although Rhode Island and Delaware did not report participants or expenditures for personal care state plan services in 2015, their policy survey responses are included.

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  20. Reimbursement rates for services provided under § 1915 (c) waivers are not included in the policy survey.

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