The number of participants and overall expenditures for state Medicaid 1915(c) waiver programs increased from 2013 to 2014, but average expenditure per participant decreased during that time, according to a report on Medicaid home- and community-based services released this month by the Henry J. Kaiser Family Foundation.

Fifteen states allow for the provision of Section 1915(c) services at residential care, foster care and assisted living facilities, the report noted. Arizona, Rhode Island and Vermont do not offer any Section 1915(c) waivers.

Highlights of the report:

  • Across the country, the number of state Medicaid 1915(c) HCBS waiver participants totaled 1.6 million in 2014, a 2% change from 2013.

  • Almost 160,000 (159,005) adults aged 65 or more years were covered by Section 1915(c) waivers in 12 states, from a low of 53 in Oklahoma to a high of 61,909 in Illinois. More than 580,000 (587,376) seniors and nonelderly adults with physical disabilities were covered over 36 states, ranging from a low of 372 in North Dakota to a high of 54,277 in Florida.

  • Medicaid 1915(c) HCBS waiver expenditures in 2014 totaled $41.8 billion, a 1% change from 2013. Expenditures ranged from $103,407 in Nevada to $5.2 million in New York.

  • Medicaid 1915(c) HCBS waiver expenditures per participant served averaged $26,563 in 2014, a decrease of –0.8% from 2013, and ranged from $2,763 in Oregon to $105,999 in Delaware (in Delaware, all enrollees had intellectual or developmental disabilities).

States continue to work toward the 2022 deadline to comply with the Centers for Medicare & Medicaid Services HCBS rule, which defines the qualities of residential and nonresidential settings in which Medicaid-funded HCBS can be provided, the report noted. As of Jan. 3, 2018, CMS had given final approval to the transition plans of six states (Arkansas, Delaware, Kentucky, Oklahoma, Tennessee and Washington) and the District of Columbia, the authors said.

Overall in 2014, according to the report, Section 1915(c) waivers represented half of total Medicaid HCBS enrollment across the three main Medicaid programs — the mandatory home health services state plan benefit, the optional personal care services state plan benefit and optional Section 1915(c) HCBS waivers. Seniors and adults with physical disabilities were 54% of all Section 1915(c) waiver enrollees, the authors said.

Seventy-two percent of Medicaid HCBS spending was for Section 1915(c) waivers in 2014, according to the report. Waiver services targeted to seniors and nonelderly adults with physical disabilities represented 27% of waiver spending.

Seventy-seven percent of Section 1915(c) HCBS waivers set financial eligibility at the federal maximum (300% of Social Security income), according to the report, and almost all use the same functional eligibility criteria for their waivers as is used for nursing home eligibility. Most states have fixed expenditure caps, hourly service limits or some other form of cost control in each of the three main HCBS programs, the authors said.

The entire report can be downloaded from the foundation website.