Report Discusses HCBS Utilization
May 22, 2014 09:50 AM
The Henry J. Kaiser Family Foundation recently released a report titled Medicaid Home and Community-Based Services Programs: 2010 Data Update (the Report). The Report summarized utilization and spending data from three main sources of HCBS programs: the mandatory home health services state plan benefit; 2) the optional personal care services state plan benefit; and 3) the optional 1915(c) HCBS waivers.
Not discussed in the Report were HCBS programs from the 1915(i) State Plan option, 1915(k) Community First Choice, Balancing Incentive Program, and Money Follows the Person. The Council discusses the Report’s key findings, providing approximate numbers in most instances. The exact numbers can be found in the original Report, here.
Total HCBS Utilization
According to the Report, states spent a total of $52.7 billion in Medicaid HCBS expenditures in 2010, paying for services for 3.2 million people. Of the 3.2 million participants, approximately 44%, or 1.4 million, received services through 1915(c) waivers, 952,000 received services through state plan personal care services, and 26%, or 808,000, received services through state plan home health services. Of the $52.7 billion in total Medicaid HCBS expenditures, 70%, or $36.8 billion, was spent on 1915(c) waiver services, 19%, or $10.2 billion, was spent on state plan personal care services, and 11%, or $5.7 billion, was spent on state plan home health services.
From 2000 to 2010, the number of total HCBS participants grew at an average of 4% each year, while total expenditures grew from between 6% to 14% each year. For details, see Figures 4 and 7 of the Report, here.
Top states. Out of the total 3.2 million HCBS participants in 2010, the states with the top five largest numbers of participants were: California (587,000), Texas (367,000), New York (280,000), North Carolina (117,000), and Ohio (111,000). For details, see Table 1A of the Report, here. Of the total $52.7 billion in Medicaid HCBS expenditures, $9.7 billion was in New York, $6.5 billion was in California, $2.9 billion was in Texas, $2.7 billion was in Pennsylvania, and $2.3 billion was in Minnesota. For details, see Table 2A of the Report, here.
Medicaid 1915(c) Waivers
Out of the total 1.4 million people receiving services through 1915(c) waivers in 2010, approximately half (49%, or 681,000) were aged and disabled, while another 40%, or 567,000, were intellectually or developmentally disabled (I/DD) enrollees. The latter group, however, was responsible for 71%, or $26.2 billion, in expenditures, while only 21%, or $7.8 billion of expenditures came from the aged and disabled population. The remainder of expenditures and utilization was in a miscellaneous group composed of: the physically disabled, medically fragile/technology-dependent children, HIV/AIDS patients, those with mental health needs, and those suffering from traumatic brain and/or spinal cord injuries. For details, see Figure 10 of the Report, here.
Top states. Of the 1.4 million recipients of 1915(c) waiver services, the states with the top five largest numbers of recipients were: New York (101,000), California (100,000), Illinois (91,000), Texas (80,000), and Florida (77,000). For details, see Table 1D of the Report, here. Of the $36.8 billion in expenditures for 1915(c) waiver services, $5.7 billion was spent in New York, $2.5 billion was spent in Pennsylvania, $2.1 billion was spent in California, $1.9 billion was spent in Minnesota, and $1.8 billion was spent in Texas. For details, see Table 2D of the Report, here.
Self-direction. According to the Report, in 2012, 88% of states offering 1915(c) waivers had a self-direction requirement or option. This amounted to 166 waiver programs in 42 states.
Waiting lists. Waiting lists continue to be a significant concern for states with 1915(c) waiver programs. According to the Report, 39 states had such waiting lists in 2012, which together totaled approximately 524,000 people. Of this number, 304,000 on the waiting lists were people with I/DD, while 165,000 were aged and disabled. According to most states surveyed, almost all of the people on waiting lists currently reside in the home and community, and not in an institution. For a graph showing the growth of the 1915(c) waiver waiting lists from 2002 through 2012 by enrollment group, see Figure 12 of the Report, here.
Medicaid Home Health and Personal Care Services State Plan Benefits
Self-direction. According to the Report, in 2012, 20 states with personal care services state plan options had a self-direction option, while only seven states that had home health state plan services offered it.
Provider Reimbursement. The Report also discussed provider reimbursements. Home health visits were reimbursed to home health agencies at an average of $93.16 per visit in 2012, versus $89.73 in 2011. States that paid registered nurses directly paid an average of $86.16 per visit in 2012, down from $94.06 in 2011. Those that paid home health aides directly paid them at $53.81, up from $50.84 in 2011. For details on 2012 provider reimbursement, see page 13 and Table 12 of the Report, here. For details on 2011 provider reimbursement, see Table 12, here. For a recent Council survey on Medicaid fee-for-service reimbursement rates, click here.
Waiting Lists. The National Council on Medicaid Home Care – a NAHC affiliate - voices concern about the continued growth of the waitlists nationally. While most of those on waitlists reside in the home and community, they are not receiving the services they need and are thus at risk for institutionalization. This trend threatens to undermine states’ gains in rebalancing away from institutional care. Home care agencies should continue to lobby their states for the reduction and elimination of these wait lists.
Self-direction. Home care agencies should note that self-direction is most widely adopted in HCBS waivers. The Council supports self-directed models of care that are compliments of, and not replacements for, agency models of care. The Council also supports these self-directed models as long as beneficiaries are afforded the same level of care and protections as those in an agency-model of care. For details, see pages 14 and 15 of our 2014 policy blueprint, here.
Provider Reimbursement. While the Council welcomes the positive developments of average reimbursement rates increasing for the most part in both home health services and personal care services from 2011 to 2012, it notes that the average registered nurse reimbursement did decrease among those surveyed. Further, in some states, the Report reflects a decrease in specific state reimbursement for home health agency (New Mexico, Texas, Washington State), registered nurse (Colorado, Michigan, Washington State), and home health aides (Idaho, Indiana, and Washington State) rates, in addition to personal care services agency rates (Montana) and personal care services provider rates (Maine) from 2011 to 2012.
While a small minority of states have faced such reimbursement rate cuts, home care agencies should nevertheless remain vigilant as states move to tighten their budgets and move into managed care. To assist in agencies’ advocacy efforts, the Council has compiled a comprehensive survey of Medicaid home care fee-for-service rates, found here.
Home care agencies are advised to continue to monitor HCBS utilization in their states, and contact the Council with any questions or concerns.