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

Medicaid is the primary source of coverage for long-term services and supports (LTSS), which help seniors and people with disabilities with self-care and household activities.1 LTSS needs result from a range of conditions, such as cognitive disabilities, like dementia or Down syndrome; physical disabilities, like multiple sclerosis or spinal cord injuries; mental health disabilities, like depression or schizophrenia; and disabling chronic conditions, like cancer or HIV/AIDS.2 State Medicaid programs must cover LTSS in nursing homes, while most home and community-based services (HCBS) are optional.3  Spending on HCBS surpassed spending on institutional care for the first time in 2013, and comprises 55% of total Medicaid LTSS spending as of 2015.4  Factors contributing to this trend include beneficiary preferences for HCBS, states’ community integration obligations under the Americans with Disabilities Act and the Supreme Court’s Olmstead decision,5 and the fact that HCBS typically cost less than comparable institutional care.

For the past 16 years, the Kaiser Family Foundation has surveyed all 50 states and the District of Columbia (DC) to track Medicaid HCBS enrollment, spending, and program policies.  This report presents our latest survey findings, including 2014 data for the three programs that comprise the majority of HCBS enrollment and spending:  the mandatory home health services state plan benefit, the optional personal care services state plan benefit, and optional Section 1915 (c) HCBS waivers.  In recognition of growing state interest in other program authorities, this year’s report adds 2016 HCBS enrollment and spending data for the Section 1915 (i) HCBS state plan option and the Community First Choice state plan option.

This report also identifies key 2016 state-level HCBS policy developments related to waiver waiting lists, financial and functional eligibility criteria, cost controls, self-direction, waiver consolidation, scope of benefits, provider policies and payment rates, and state progress in implementing the U.S. Department of Labor (DOL) direct care worker minimum wage and overtime rule and the Medicaid home and community-based settings rule.  This year’s report also discusses HCBS enrollment and waiting list changes in the context of the Affordable Care Act’s (ACA) Medicaid expansion, HCBS quality measures, and state progress in implementing selected managed long-term services and supports (MLTSS) provisions of the revised Medicaid managed care rule. The Appendix tables contain detailed state-level data.

Executive Summary Report

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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.