Expenditures for home- and community-based services for Medicaid-eligible older adults and disabled individuals through Section 1915(c) waivers, used by some assisted living providers and others, topped $6.6 billion in 2018, according to a report released this week by the Centers for Medicare & Medicaid Services.

The amount was a 26% drop from the outlay of $8.9 billion in 2017, but it represented 7.1% of overall spending for long-term services and supports in 2018.

Twenty-nine states used Section 1915(c) waivers to cover services in residential care settings in 2016, according to separately reported data from the Medicaid and CHIP Payment and Access Commission.

Other highlights from the Medicaid report:

  • During 2017 and 2018, all states except Arizona, Rhode Island and Vermont operated at least one section 1915(c) waiver program.
  • In 2017, 80 programs in 41 states targeted older or disabled individuals.
  • Older or disabled individuals accounted for the majority of total LTSS spending in 2017 and 2018, representing approximately 55% to 56% of total expenditures in these years.
  • Section 1915(c) waiver programs for older or disabled individuals accounted for approximately 22.1% of total Section 1915(c) expenditures in 2017 and 22.4% in 2018. 
  • In 2017, states spent $56.1 billion for LTSS for older or disabled individuals, with 33.7% of total Medicaid LTSS expenditures devoted to HCBS. In 2018, states spent $50.8 billion, with 32.9% of total LTSS for HCBS.

In a separate report also released this week, CMS said that there were 2.24 participants per 1,000 residents in Section 1915(c) waiver programs for older or disabled individuals in 2016 and 2.23 per 1,000 in 2017. Average waiver expenditures per older or disabled individual were $13,543 in 2016 and increased approximately 10% to $14,949 in 2017.

For section 1915(c) waiver programs serving older or disabled individuals, Minnesota, Illinois, Oregon, Mississippi and Idaho served the greatest number of participants as a proportion of their populations, exceeding six per 1,000 residents in both years.

Other highlights of that report:

  • Forty-one of the 47 states (87%) with Section 1915(c) waiver programs in 2016 and 2017 provided services for older or disabled individuals. Delaware, Florida, Hawaii, New Mexico, Tennessee and Texas did not operate any waiver programs for this LTSS population in 2016.
  • The number of older or disabled waiver program participants per 1,000 state residents in 2016 ranged from less than one (Virginia and Colorado tied for lowest) to almost 10 (Minnesota).
  • Six states served fewer than one older or disabled 1915(c) waiver program participant per 1,000 state residents (Virginia, Colorado, California, Wisconsin, North Dakota and Utah) in 2016. Twenty-five of the 41 states (61%) had higher rates than the U.S. rate (2.2) that year.
  • States in the lowest quartile in 2016, with fewer than 1.5 participants per 1,000 residents, were Virginia, Colorado, California, Wisconsin, North Dakota, Utah, Nevada, Louisiana, North Carolina, New York, Maine and Michigan. Those in the highest quartile (where participants were greater than or equal to 4.5 per 1,000 residents) were Kansas, Connecticut, Pennsylvania, Oklahoma, Washington, Ohio, Idaho, Mississippi, Oregon, Illinois and Minnesota.
  • In 2016, average waiver expenditures per Section 1915(c) waiver program older or disabled participant ranged from $913 in Oregon to $37,321 in Kansas. Washington, which had the second-lowest average expenditure, spent $3,857 more per participant on average than Oregon in 2016 (or a total of $4,770 per older or disabled individual). States in the lowest quartile of average waiver expenditures per waiver program participant were Oregon, Washington, Missouri, Nevada, New York, Iowa, California, Idaho, Alabama, Wyoming and Kentucky.
  • In 2016, 18 of 41 states (44%) had average waiver expenditures greater than the U.S. total average. Among those in the highest quartile of average waiver expenditures were Connecticut, Wisconsin, North Carolina, Michigan, Maine, Louisiana, Minnesota, Colorado, Pennsylvania, Alaska and Kansas.
  • In 2017, seven states served fewer than one older or disabled waiver program participant per 1,000 state residents (Virginia, Colorado, New York, Wisconsin, California, North Dakota and Utah). Similar to 2016, 25 of the 41 states (61%) had higher rates than the U.S. rate in 2017 (2.2).
  • In 2017, average waiver expenditures ranged from a low of $1,061 in Oregon to a high of $53,987 in Kansas in 2017, and 19 of 41 states (46%) had average waiver expenditures greater than the U.S. total average.
  • The states in the lowest quartile of average waiver expenditures per older or disabled individual remained the same in 2017 as in 2016, except for the addition of Illinois and Oklahoma to the lowest quartile in 2017, replacing Kentucky and New York. 
  • The state with the largest decline in average waiver expenditures per older or disabled adult Section 1915(c) waiver program participant between 2016 and 2017 was Washington, which was a 69% decline. Among the states with the largest increases from 2016 to 2017 were Wisconsin (12%), California (14%), Connecticut (15%), Oregon (16%), Pennsylvania (17%), Iowa (18%), Virginia (41%), District of Columbia (44%), Kansas (45%) and New York (700 %).