Medicaid long-term services and supports spending continues to shift toward home- and community-based services, including services provided in assisted living communities, according to two new reports from the federal government.
The reports from the Centers for Medicare & Medicaid Services, Medicaid Long Term Services and Supports Annual Expenditures Report FY 2020 and Medicaid Section 1915(c) Waiver Programs Annual Expenditures and Beneficiaries Report 2018-2019, also provide insights into how states are using waiver programs to provide alternatives to institutional care provided in places such as nursing homes.
1.9M served via section 1915(c) waivers
Programs operating under the 1915(c) waiver, the program most commonly associated with assisted living providers (as well as other providers), served 1.9 million enrollees in 2019, a 5.2% increase from 2018, according to the waiver spending report. Per-enrollee spending increased to just more than $30,000 annually in 2019, whereas average annual spending for older adults and people with physical disabilities came in under $15,000.
Section 1915(c) waiver programs have become “a critical component: of the Medicaid program and are part of a larger “framework of progress” toward integrating older adults and people with disabilities into the larger community, CMS said, noting that the larger community is where many beneficiaries would prefer to receive care.
In 2019, 262 waivers were active across 47 states, five fewer waivers than were in place the year before.
Programs targeting older adults and people with disabilities represented 44.5% of all waiver program participants. Combined with programs targeting people with autism or developmental or intellectual disabilities, those groups represented 84.5% of all waiver program participants.
In 2019, annual average waiver program spending per participant was $30,063, 71.3% of total annual average Medicaid spending. Average waiver program spending varied across target groups.
For the two largest waiver program types — those serving older adults and people with disabilities, as well as those with autism or intellectual or developmental disabilities — participation was similar, but average spending differed markedly. Although average waiver program spending per participant for older adults and people with disabilities was $14,395 in 2019, average spending for the autism and intellectual or disabled group was more than three times as much at $49,192. CMS said that this finding suggests an opportunity for additional study.
Waiver spending reaches $53.8B
CMS noted in the Medicaid LTSS report that all but four states — Arizona, New Jersey, Rhode Island and Vermont — operated at least one section 1915(c) waiver program to provide HCBS in fiscal year 2020. Although waiver program spending growth has fluctuated over the past decade, spending reached $53.8 billion in FY20.
Waiver program spending for two groups — older adults and people with disabilities, and people with autism or intellectual or developmental disabilities — made up 94.2% of all 1915(c) waive program spending in FY20.
According to the report, 17.5% of total waiver program spending was for older adults and people with disabilities, whereas more than three-fourths (76.7%) was for people with autism or intellectual or developmental disabilities, and 5.8% was for all other population groups, including people with brain injuries, medically fragile or technology dependent, pel with serious emotional disturbance or individuals with HIV/AIDS.
State LTSS system rebalancing initiatives to promote more cost effective HCBS reduced the number of eligible older adults and people with disabilities from 29% in FY18 to 18.3% in FY18.
In 2019, 76 programs in 40 states served older adults and people with disabilities, comprising 29% of recipients served under HCBS waiver programs.