The Data Speak: A Progress Report on Providing Medicaid HCBS for Elders

Although states have progressed in rebalancing services for elders and increasing the use of home- and community-based services, the process is slow. The federal-state Medicaid program plays a critical role in long-term care (LTC) financing for both nursing home and home- and community- based services (HCBS). In 2008, Medicaid paid for 38 percent of the nation's $195 billion in LTC expenditures (CMS, 2011a). The Medicaid program is facing growing financial pressures to pay for LTC as the total number of elderly participants receiving Medicaid LTC has increased, along with LTC spending (CMS, 2011b). As Medicaid nursing home costs have increased, social and legal pressures have mounted on state Medicaid programs to rebalance their LTC systems away from providing nursing home care toward HCBS. The main legal support for such rebalancing is the 1999 Olmstead Supreme Court ruling stating that individuals have the right to live in the least restrictive setting, and that forcing individuals who could live at home into nursing homes constitutes discrimination (Carlson and Coffey, 2010). This ruling has spawned more than 130 lawsuits against states for failure to provide adequate HCBS. Over the past thirty years, the federal government and Congress have developed Medicaid-optional programs to pay for HCBS including the 1915(c) waiver program and the Personal Care Services program. In addition, they have encouraged rebalancing through legislative and program initiatives, including the New Freedom Initiative of 2002, the Deficit Reduction Act of 2005, and the Affordable Care Act of 2010. Medicaid HCBS Programs for Elders Institutional services have been mandated as Medicaid benefits for elders (and all other populations) along with home healthcare, while other HCBS programs are optional (Kitchener, Ng, and Harrington, 2007a). In addition to home healthcare, the two major optional Medicaid programs that serve elders are HCBS waivers and the state plan Personal Care Services (PCS) benefit. The following section compares the main features of the three Medicaid HCBS programs, emphasizing that they are not direct substitutes for one another, and participants may receive services from one or more HCBS programs. HCBS waivers Since 1981, states have used the authority under Section 1915(c) of the Social Security Act to request a waiver of certain federal Medicaid requirements (including statewide program coverage) to establish 1915(c) waiver programs. Typical services provided in elderly waivers include case management, modification of the home and vehicles to accommodate mobility issues, and respite, among others. These programs must be targeted to individuals in specific groups, such as elders or the physically disabled, who otherwise qualify to be in an institution or are risk of being placed in an institution. The waiver programs must also be cost-neutral, by demonstrating that each waiver's participant costs are no greater than per participant institutional costs for a comparable level of care (Harrington, Ng, and Kitchener, 2011). States can control costs in three ways (Harrington, Ng, and Kitchener, 2011): states can set limits on the number of available participant slots on each waiver; states can set financial eligibility as well as need criteria for waivers and cap spending on services provided; and states may limit waiver programs to certain geographical areas. States are required to report annual waiver data to the Centers for Medicaid & Medicare Services (CMS) on Form 372 waiver reports. Although some waivers are targeted specifically to elders, many states serve this population in waivers that also serve the disabled. Therefore, the data for elders cannot be separated from that for the disabled in combination waivers, so both elderly and the combination of elderly and disabled waivers are included in this article as elderly waivers. Personal Care Services Personal Care Services, established under a Medicaid state plan option in 1975, allow individuals to maintain independence in their home and the community (Kitchener, Ng, and Harrington, 2007b). …