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Charlene Harrington PhD*Terence Ng JD, MA
Department of Social & Behavioral SciencesUniversity of California, San Francisco
3333 California Street, Suite 455San Francisco, CA 94118
* 415-476-4030 [email protected]
www.pascenter.orgFunded by: Kaiser Commission on Medicaid & the Uninsured, and National Institute on Disability & Rehabilitation Research (NIDRR)
Medicaid LTC & HCBSTrends in Programs and Policies
Total US Long-Term Care (LTC) Expenditures, 2011 $221 billion
Medicare 29%
Medicaid/Other Public 41%
Out-of-Pocket22%
Private Insurance 8%
Source: Historical National Health Expenditure Data, CMS 2011 https://www.cms.gov/nationalhealthexpenddata/02_nationalhealthaccountshistorical.asp
Medicaid HCBS Policy Issues
1. State & federal budget deficits and increased austerity.
2. Continued demands of institutional provision
3. Consumer preferences
4. Legal pressures- Americans with Disabilities Act (1990) & the Olmstead decision (1999).
5. Litigation against states
6. Legislation including Deficit Reduction Act and Affordable Care Act
7. Program initiatives such as Money Follows the Person and Cash & Counseling
Study Aims & Method
Aims Examine trends in participation & expenditure on
Medicaid HCBS programs Examine state HCBS policies
Method
1. CMS Form 372 reports for HCBS waivers (n = 283 in 2008)
2. State Survey of Medicaid State Plan Personal Care (PCS) Optional Benefit (n = 32)
3. State Survey of Medicaid Home Health (n=51)
Medicaid HCBS Programs
Personal Care optional benefit (UCSF Annual Survey)
- Optional, actively available in 32 states (2010)
- Must be statewide, available to Medicaid categorically
eligible groups
Home Health (UCSF Annual Survey)
- Mandatory
Medicaid HCBS Waivers
HCBS 1915c waivers (CMS Form 372 Reports) - In 2008, 49 states offer 283 waivers (VT and AZ use 1115
managed care waiver & RI started in 2009)- Optional program - provides range of HCBS and may
include personal care- Must be targeted to selected recipient groups (up to
14 waivers in some states) - Must be nursing home eligible - Financial & medical eligibility vary across states- Slots, geography & expenditures can be limited- Must be cost neutral
- Waiting lists can be established
Medicaid HCBS Participants & Expenditures by Program, 2008
Home Health922,396 (30%)
Personal Care 902,943 (29%)
Waivers 1,241,411 (41%)
Ng & Harrington , 2011. Medicaid HCBS Program Data 92-08. San Francisco, CA: UCSF
Waivers $30B (66%)
Home Health $5B (11%)
Personal Care $10B(23%)
Total Participants: 3.07 million
Total Expenditures: $45 billion
Medicaid HCBS Participants by Program, 1999 - 2008
1999 2000 2001 2002 2003 2004 2005 2006 2007 20080
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
679671703908704631766321851260876591864157879210923103922396
528412578207 582298683067720385761308918293814589822509902943
687,982769,723841,217923,699
982,5901,014,8591,066,3331,117,1381,170,1441,241,411
Home Health Personal Care Waivers
3.1m2.9m
1.9m 2.1m 2.1m2.4m
2.6m 2.7m2.8m 2.8m
Ng & Harrington , 2011. Medicaid HCBS Program Data 92-08. San Francisco, CA: UCSF
Medicaid HCBS, Participant per 1,000 Pop.2008. US – 10.09
Medicaid HCBS Expenditures by Program, 1999 - 2008
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008$0
$5,000,000,000
$10,000,000,000
$15,000,000,000
$20,000,000,000
$25,000,000,000
$30,000,000,000
$35,000,000,000
$40,000,000,000
$45,000,000,000
$50,000,000,000
209409489322804012162472456345268185501927892698604098590974435274586846051451534962490956506870703140805935554556604883526140999354914682576534087158715852628477110325468654524566948253368110060209490
1112604706317143464148681692291470118943750971
2084717673423228311919
2527550129720
29844422822
Home Health Personal Care Waivers
$17b$19b
$22b$25b
$28b$32b
$35b$38b
$42b
Ng & Harrington , 2011. Medicaid HCBS Program Data 92-08. San Francisco, CA: UCSF
$45b
Medicaid HCBS, Expenditures per Capita2008. US - $147.91
Waiver Participants & Expenditures by Target Group, 2008
Participants Expenditures0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MR/DD507,279(41%)
MR/DD $21.8bn(73%)
Aged/Disabled 597,560(48%)
Aged/Disabled $5.8bn(20%)
Others136,573(11%)
Others$2.2bn(7%)
Medicaid HCBS Cost Control Policies
HCBS WaiversLimits on waiver financial for those who are otherwise eligible for institutional care (68 waivers in 19 states less than 300% SSI) 11 waivers in 9 states have more restrictive functional eligibility Gaps in waivers (23 states cover children, 22 TBI/SCI, 15 HIV/AIDS, 1 mental health waivers)Ceilings or caps on services and expenditures per participant Geographical limits within states - 18 waiversLimits on waiver participants (slots) - establish waiting lists
State Plan Personal Care ServicesCeilings or caps on services and expenditures per participant Services vary between states – 18 states limit hoursNot available in 19 states except through waivers
Home HealthServices vary between states
Consumer Direction & Forms of Cost Controls, 2010
HCBS Waivers (n=293)
State Plan PCS (n=32)
Home Health(n=51)
Consumer Direction
119 (41%) 12 (35%) 7 (14%)
Cost Controls
Hourly/Service Limits
49 (17%) 18 (53%) 21 (41%)
Cost Limits 89 (30%) 3 (9%) 5 (10%)
Geographic Limits
18 (6%) 32 active states none
Waiting Lists 149 (51%) none none
Waiver Slots and Waiting Lists by Target Group, 2010
Total Slots: 1,420,365 Waiting List: Total 428,571
Elderly/Dis-
abled706,276(50%)MR/DD
566,561(40%)
Others, 147,528, (10%)
Elderly/Disabled 121,149 (28%)
MR/DD
268,220 (63%)
Others 39,202, (9%)
States with Largest Wait Lists for HCBS Waivers, 2010 (Total: 428,571)
Texas – 125,385 on 6 wait listsAve. wait time: 20 months
Ohio – 44,293 on 3 wait listsAve. wait time: 3 months
Illinois – 33,114 on 3 wait listsAve. wait time unknown
Florida – 32,753 on 10 wait listsAve. wait time: 39 months
Indiana – 32,355 on 5 wait listsAve. wait time: 18 months
Maryland – 27,810 on 7 wait listsAve. wait time: 41 months
The Institutional Bias in Medicaid LTC, 2008
Source: HCBS (Ng and Harrington, 2011) , Institutional (CMS Form 64 Data, Medstat 2010; MSIS 2008 Data)
Expenditures: $107 billionParticipants: 4.8 million
Insti.1.7m
(35%)
HCBS3.1m
(65%)
Chart Title
In-sti. $62bn(58%)
HCBS $45bn(42%)
Chart Title
Study Aims & Method
Aim: To determine whether Medicaid HCBS waivers save money
Methods Examine the national average Medicaid spending on
waiver participants Examine the national average Medicaid spending on
institutional participants who might be served in waivers Examine the cost savings to Medicaid when serving
persons in waivers rather than institutions
Data Sources1. CMS Form 372 reports for HCBS waivers (n = 283 in
2008)
2. Estimation of housing costs through SSI and SSP
Medicaid Annual HCBS Savings, by Waiver Level of Care, 2008
0
40,000
80,000
120,000
160,000
200,000
240,000
Ex
pe
nd
itu
res
pe
r P
art
icip
an
t ($
00
0)
Nursing Facility ICF-MR/DD Hospital
$46,514
$66,432$59,739
$87,928
$127,264
$206,288
Insti.WaiverWaiver
WaiverInsti.
Insti.
Savings$19,918
Savings$67,525
Savings$118,360
Total Savings, 2008 ($m)US Total Savings - $61 Billion
States Can take Advantage of ACA Provisions
• State balancing incentive payment (for states that spend less than 50% on HCBS) -- 5% increase for 0-25% HCBS and 2% for 25-50% HCBS
• Community First Choice Option - Allows states to cover Personal Care for those with an institutional level up with incomes to 300% of SSI (receive 6% increase in federal match) – 19 states have no PCS program
• Allows HCBS waiver to become a state plan option for incomes up to 300% of SSI without cost neutrality requirements
• New regulations allows states to consolidate HCBS waivers
• Expanded Money Follows the Person program to transition individuals out of NHs
Medicaid HCBS : Conclusion
Many gaps in coverage for waiver groups in some states
Aged receive fewer expenditures per participant than DD
Waiver service and cost caps impact on program growth and create unmet needs
Large & long waiting lists for HCBS waiver programs in many states
19 states had no state plan personal care
Wide inter-state variation in HCBS service provision and spending on services
Concern that state may cutback because of deficits and not take advantage of ACA provisions