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 charlene.harrington@ucsf.edu

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