Combined Federal and State Spending on
Medicaid Home and Community-Based Services (HCBS) Totaled $116 billion in
FY 2020, Serving Millions of Elderly Adults and People with Disabilities
Two New KFF Analyses Provide Context About
Scope and Cost of Such Services, Which Vary By State
The federal government
and the states together spent a total of $116 billion on Medicaid home
and community-based services (HCBS) in FY 2020, serving millions of
elderly adults and people with disabilities, a new KFF
analysis finds.
Medicaid is the nation’s primary payer for such services, which include
assistive technology, personal care to help people with bathing or
preparing meals, and therapies to help people regain or acquire self-care
and independent living skills. There is long-standing unmet need for such
services nationally, as well as perennial shortages in the direct care
workforce. Both have been exacerbated by the pandemic and rising demand
for services related to the aging population.
Congress took a step toward approving new funding for HCBS when lawmakers
included $150 billion for such services in the House-passed Build Back
Better Act (BBBA). But the bill faces legislative challenges in the
Senate and the fate of the proposed funding remains uncertain.
The new analysis, based on KFF’s 19th survey of state officials
administering Medicaid HCBS programs in all 50 states and DC, finds that
most enrollees receive home and community-based services that are
optional coverage choices made by state Medicaid programs, usually in the
form of waivers or optional state plan benefits. That results in
substantial variation in HCBS eligibility, spending and benefits across
states.
A second
analysis based on KFF’s survey examines the landscape of state
policy choices about Medicaid HCBS in FY 2020, presenting the latest data
available, and the first since the onset of the pandemic. For the last
decade states have pursued expanding HCBS as an alternative to
institutional long-term care. Spending on HCBS accounted for 59 percent
of total Medicaid long-term services and supports spending in FY 2019,
the most recent year for which data is available.
Nationally, 3 million people receive HCBS through waivers. Over 2.5
million people receive HCBS as part of the state plan benefit package.
However, the total number of people who received HCBS across all
authorities is not available because some individuals may receive both
waiver and state plan services.
Because
states can limit enrollment in HCBS waivers, most states report having
HCBS waiver waiting lists, totaling over 665,000 people nationally.
However, state variation in policies makes waiting lists an incomplete
measure of program needs and state capacity, and makes it difficult to
compare waiting lists across states or from year to year. Notably, the
majority of people on waiting lists are in seven states that do not
screen for waiver eligibility before placing individuals on such lists.
Spending
data shows that among waiver target populations, annual per person costs
for people with intellectual and developmental disabilities ($48,900)
were much higher than per person costs for seniors and adults with
physical disabilities ($17,600).
States
vary in scope of services provided as well as reimbursement for
providers. The average provider reimbursement rate for home health agency
services is $118.82 per visit, based on analysis of the survey data
provided by 20 states. The average provider reimbursement rate paid to
personal care agencies is $23.09 per hour in 22 of 37 states reporting
this data.
Federal
funding for Medicaid HCBS was temporarily boosted by the American Rescue
Plan Act of 2021 (ARPA). The House-passed BBBA would provide a permanent
increase in the federal matching rate and $150 billion in new federal
funds for Medicaid HCBS. Information in these KFF analyses can serve as a
useful baseline to measure the impact of changes in ARPA as well as
changes from BBBA if enacted.
For more data and
analyses about Medicaid HCBS, visit
kff.org.
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