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Medicaid Home and Community-Based Services: Results From a 50-State Survey of Enrollment, Spending, and Program Policies

Introduction
  1. Kaiser Family Foundation, Medicaid and Long-Term Services and Supports:  A Primer (Dec. 2015), https://www.kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/.

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

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  3. 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), http://kff.org/medicaid/fact-sheet/medicaid-long-term-services-and-supports-an-overview-of-funding-authorities/.

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  4. Steve Eiken et al., Medicaid Expenditures for Long-Term Services and Supports LTSS in FY 2015 (April 14, 2017), https://www.medicaid.gov/medicaid/ltss/downloads/reports-and-evaluations/ltssexpendituresffy2015final.pdf.

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  5. 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), http://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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Report
  1. Among the 34 states (including DC) that offer personal care state plan services, three states (Delaware, Rhode Island, and New Mexico) have CMS approval to offer these services but report no enrollment in our survey.  These states deliver personal care services through Section 1115 MLTSS waivers.

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  2. As noted above, three states (Arizona, Rhode Island, and Vermont) do not offer any Section 1915 (c) waivers and instead provide HCBS through Section 1115 MLTSS waivers.

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  3. This year’s report groups together all waivers serving people with mental health disabilities in one category.  Prior years’ reports grouped waivers serving children with mental health disabilities together with those serving children who are medically fragile or technology dependent and separately grouped waivers serving adults with mental health disabilities.

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  4. Kansas is excluded from this list because it has joint Section 1115/1915 (c) HCBS waivers.

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  5. See Victoria Peebles and Alex Bohl, CMS/Mathematica Policy Research, The HCBS Taxonomy:  A New Language for Classifying Home and Community-Based Services (Aug. 2013), http://www.mathematica-mpr.com/~/media/publications/PDFs/health/max_ib19.pdf.

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  6. The Supreme Court’s decision on the constitutionality of the ACA’s Medicaid expansion effectively made expansion a state option.  Kaiser Family Foundation, A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion (Aug. 2012), https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/.  As of November, 2017, 32 states and DC had adopted the expansion.  Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision (Nov. 8, 2017), https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.  Medicaid expansion coverage became effective on January 1, 2014 in 25 states.  Michigan implemented expansion coverage on April 1, 2014, and New Hampshire implemented expansion coverage on August 15, 2014.  Coverage in five other states (Alaska, Indiana, Louisiana, Montana, and Pennsylvania) was effective after 2014, and the expansion has not yet been implemented in Maine.  Id.

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  7. Kaiser Family Foundation, CMS’s Final Rule on Medicaid Managed Care:  A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.  The revised regulations build on and incorporate elements from CMS’s May 2013 best practices for MLTSS waivers. CMS, Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long-Term Services and Supports Programs (May 2013), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf.

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  8. The informational bulletin indicates that the “use of enforcement discretion will be applied based on state-specific facts and circumstances and focused on states’ specific needs.” CMS Informational Bulletin, Medicaid Managed Care Regulations with July 1, 2017 Compliance Dates (June 30, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib063017.pdf.

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  9. Along with personalized choice counseling, the beneficiary support system must include assistance to beneficiaries with understanding managed care and assistance for enrollees who use or wish to use LTSS.  Kaiser Family Foundation, CMS’s Final Rule on Medicaid Managed Care:  A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.

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  10. Id.

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  11. Id.

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  12. Id.

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  13. Section 1115 MLTSS waiver waiting list data for 2015 is reported in Kaiser Family Foundation, Medicaid Section 1115 Managed Long-Term Services and Supports Waivers: A Survey of Enrollment, Spending, and Program Policies (Jan. 2017), https://www.kff.org/medicaid/report/medicaid-section-1115-managed-long-term-services-and-supports-waivers-a-survey-of-enrollment-spending-and-program-policies/.

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  14. Kaiser Family Foundation, Data Do Not Support Relationship Between States’ Medicaid Expansion Status and Home and Community-Based Services Waiver Waiting Lists (Feb. 2017), https://www.kff.org/medicaid/issue-brief/data-note-data-do-not-support-relationship-medicaid-expansion-hcbs-waiver-waiting-lists/.

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  15. Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision (Nov. 8, 2017), https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

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  16. For purposes of this analysis, Maine is considered a non-expansion state because it has not yet implemented the expansion.

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  17. New York is categorized as “no change” because it reports a waiver waiting list but did not report the number of individuals on the waiting list in both 2015 and 2016.

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  18. For purposes of this analysis, Maine is considered a non-expansion state because it has not yet implemented the expansion.

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  19. Section 1115 MLTSS waiver financial eligibility criteria for 2015 is reported in Kaiser Family Foundation, Medicaid Section 1115 Managed Long-Term Services and Supports Waivers: A Survey of Enrollment, Spending, and Program Policies (Jan. 2017), https://www.kff.org/medicaid/report/medicaid-section-1115-managed-long-term-services-and-supports-waivers-a-survey-of-enrollment-spending-and-program-policies/.

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  20. Federal cost neutrality refers to the statutory requirement that the state’s estimated average per capita expenditures for home and community-based waiver services must not exceed the state’s reasonable estimate of the cost of average per capita expenditures that would have been incurred without waiver services.  42 U.S.C. § 1396n (c)(2)(D).  In addition, under long-standing federal policy, all Section 1115 waivers also are subject to federal budget neutrality, which requires that federal costs under the waiver cannot exceed estimated costs without the waiver.

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  21. U.S. Dep’t of Labor, Home Care, Minimum Wage and Overtime Pay for Direct Care Workers (accessed Dec. 13, 2017), https://www.dol.gov/whd/homecare/; 29 C.F.R. § § 552.3, 552.6, 552.101, 552.102, 552.106, 552.109, 552.110.

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  22. Specifically, CMS anticipated that “many states will determine that, for purposes of the FLSA, home care workers in self-direction programs have joint third party employer(s) [such as the state or another entity] in addition to being employed by the beneficiary,” requiring the state or other entity to comply with minimum wage and overtime requirements.  CMS Informational Bulletin, Self-Direction Program Options for Medicaid Payments in the Implementation of the Fair Labor Standards Act Regulation Changes (July 3, 2014), https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-03-2014.pdf.

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  23. Thirteen states (Colorado, Delaware, Georgia, Indiana, Kansas, Maine, Minnesota, Mississippi, North Carolina, New Jersey, Ohio, Tennessee, and Texas) participated in the first year of NCI-AD survey data collection from 2015-2016.  Measures related to quality of life include:  proportion of people who are able to participate in preferred activities outside of home when and with whom they want; proportion of people who are involved in making decisions about their everyday lives (where they live, what they do during the day, staff that supports them, with whom they spend time); proportion of people who are able to see or talk to friends and families when they want; proportion of people who are not lonely; proportion of people who are satisfied with where they live; proportion of people who are satisfied with what they do during the day; proportion of people who are satisfied with staff who work with them; proportion of people who feel in control of their lives.  Nat’l Assoc. of State United for Aging and Disabilities and Human Servs. Research Institute, National Core Indicators – Aging and Disability Adult Consumer Survey 2015-2016 National Resultshttps://nci-ad.org/upload/reports/NCI-AD_2015-2016_National_Report_FINAL.pdf.

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  24. Examples of community integration measures include how often in the last three months you could get together with family who live nearby when you wanted to; how often in the last three months you could get together with friends who live nearby when you wanted to; how often in the last three months you could do things in the community that you like; did you need more help than you get from personal assistance or behavioral health staff to do things in your community in the last three months; did you take party in deciding what you do with your time each day in the last three months; did you take part in deciding when you do things each day (get up, eat, go to bed) in the last three months.  Medicaid.gov, CAHPS Home and Community-Based Services Survey (accessed Dec. 14, 2017), https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/cahps-hcbs-survey/index.html.

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  25. Kaiser Family Foundation, Medicaid Section 1115 Managed Long-Term Services and Supports Waivers: A Survey of Enrollment, Spending, and Program Policies, Table 3 (Jan. 2017), https://www.kff.org/medicaid/report/medicaid-section-1115-managed-long-term-services-and-supports-waivers-a-survey-of-enrollment-spending-and-program-policies/.

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  26. Kaiser Family Foundation, CMS’s Final Rule on Medicaid Managed Care:  A Summary of Major Provisions (June 2016), https://www.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/.

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  27. Id.

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  28. Michigan has a Section 1115 capitated MLTSS waiver application pending with CMS seeking to consolidate 3 Section 1915 (c) waivers that serve children and adults with I/DD and children with serious emotional disturbance.  Michigan also has a new Section 1115 waiver application pending with CMS that would authorize HCBS on a fee-for-service basis for people with brain injuries.

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  29. New York has two Section 1115 capitated MLTSS waiver amendments pending with CMS:  one would consolidate six Section 1915 (c) waivers targeted to children who are medically fragile or have behavioral health needs or developmental disabilities, and the other would move a Section 1915 (c) waiver for people with I/DD to Section 1115 MLTSS authority.

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  30. Virginia has a Section 1115 capitated MLTSS waiver application pending with CMS that would consolidate two Section 1915 (c) waivers targeted to seniors and people with physical disabilities using self-direction and those who need technology assistance.

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  31. North Carolina has a Section 1115 MLTSS waiver application pending with CMS but would continue to operate its Section 1915 (c) waivers concurrently with the Section 1115 waiver.

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  32. Washington has a Section 1115 waiver that authorizes a limited HCBS fee-for-service benefit package for seniors with unpaid family caregivers.

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  33. 42 C.F.R. § 441.301 (c)(4)-(6).  In addition to Section 1915 (c) waiver HCBS, the settings rule also applies to Section 1915 (i) and Community First Choice services.  CMS also has indicated that it will include the setting rule requirements in the special terms and conditions of Section 1115 waivers that include 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/hcbs/downloads/final-q-and-a.pdf.

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  34. CMCS Informational Bulletin, Extension of Transition Period for Compliance with Home and Community-Based Settings Criteria (May 9, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/cib050917.pdf.

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  35. Medicaid.gov, Statewide Transition Plans (accessed Jan. 3, 2018), https://www.medicaid.gov/medicaid/hcbs/transition-plan/index.html.

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  36. Indiana offers Section 1915 (i) services targeted to three different populations and uses Section 1915 (i) as an independent pathway to Medicaid eligibility for one of those populations.

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  37. NY did not respond to the CFC portion of the survey.  Data supplemented from NY State Plan Amendment #13-0035, approved by CMS Oct. 23, 2015, https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/NY/NY-13-0035.pdf.

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.