Medicaid Home and Community-Based Services Enrollment and

February 2020 | Issue Brief

Medicaid Home and Community-Based Services

Enrollment and Spending

Molly O’Malley Watts, MaryBeth Musumeci, and Priya Chidambaram

Executive Summary

Medicaid fills in gaps in the overall health care system by serving as the primary source of coverage for

long-term services and supports (LTSS), including home and community-based services (HCBS), as

these services are typically unavailable and/or unaffordable through private insurance or Medicare.

HCBS help seniors and people with disabilities and chronic illnesses live independently outside

institutions by assisting with daily needs. This issue brief presents the latest (FY 2018) Medicaid HCBS

enrollment and spending data from KFF’s 18th annual 50-state survey. Appendix Tables contain detailed

state-level data. Key findings include the following:

 Most HCBS enrollees receive services provided at state option. Over 2.5 million individuals

receive HCBS through an optional Section 1915 (c) or Section 1115 waiver, and nearly 1.2 million

receive optional personal care state plan services, while 600,000 receive home health state plan

services, the sole required benefit. Fewer individuals receive HCBS through the relatively newer state

plan options including Section 1915 (i) and Community First Choice.

 Joint federal and state Medicaid HCBS spending totaled $92 billion in FY 2018, with nearly all

spending for optional services.

 National per enrollee spending varies among the HCBS authorities, ranging from under $8,000

for Section 1915 (i) state plan services to nearly $30,000 for Section 1915 (c) waivers.

 Per enrollee spending by Section 1915 (c) waiver target population is highest for people with

intellectual/developmental disabilities ($46,000). Per enrollee spending is relatively lower for

seniors/adults with physical disabilities ($16,000).

State Medicaid programs will face increased pressure to meet the health and LTSS needs of a growing

elderly population in the coming years, and their ability to do so could be affected by an economic

downturn that could leave states with limited resources and require reductions in services offered at state

option. In addition, if the ACA ultimately is struck down in Texas v. Azar, states would lose authority to

offer some HCBS as well as some flexibility to design benefit packages. The 2020 elections also could

have important implications for Medicaid and HCBS as policymakers may consider a range of proposals,

from those that could cap federal Medicaid financing program-wide as in the President’s FY 2020 budget

to proposals advocated by some Democrats to create a single, federal, universal health insurance

program known as Medicare-for-all.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

2

Introduction

Medicaid continues to be the primary source of coverage for long-term services and supports (LTSS),

financing over half of these services in 2018 (Figure 1). LTSS help seniors and people with disabilities

with self-care, such as bathing and dressing, and household activities, such as preparing meals and

managing medication. LTSS needs arise from a range of conditions, such as cognitive disabilities, like

dementia or Down syndrome; physical disabilities, like multiple sclerosis or spinal cord injury; mental

health disabilities, like depression or schizophrenia; and disabling chronic conditions, like cancer or

HIV/AIDS.

1

State Medicaid programs must cover LTSS in nursing homes, while most home and community-based

services (HCBS) are optional.

2

Spending on HCBS surpassed spending on institutional care for the first

time in 2013, and comprises 57% of total Medicaid LTSS spending as of 2016 (Figure 2). Factors

contributing to this trend include beneficiary preferences for HCBS, the fact that states are encouraging

HCBS as an alternative to typically more costly institutional care, and states’ community integration

obligations under the Americans with Disabilities Act and the Supreme Court’s Olmstead decision. In

Olmstead, the Supreme Court held that the unjustified institutionalization of people with disabilities is

illegal discrimination and violates the Americans with Disabilities Act.

NOTE: Total LTSS expenditures include spending on residential care facilities, nursing homes, home health services, and home and community-

based waiver services. Expenditures also include spending on ambulance providers and some post-acute care. This chart does not include Medicare

spending on post-acute care ($83.3 billion in 2018). All home and community-based waiver services are attributed to Medicaid.

SOURCE: KFF estimates based on 2018 National Health Expenditure Accounts data from CMS, Office of the Actuary.

Long-term services and supports (LTSS) spending, by payer,

2018.

Figure 1

Medicaid, 52%

Out-of-Pocket,

16%

Private Insurance,

11%

Other Public

and Private,

20%

Total National LTSS Spending = $379 billion

Medicaid LTSS Spending

= $196.9 billion

Medicaid Home and Community-Based Services Enrollment and Spending Growth

3

This issue brief presents the latest (FY 2018

3

) state-level Medicaid HCBS enrollment and spending data

from KFF’s 18th annual survey of all 50 states and DC. The survey tracks Medicaid HCBS across four

types of state plan benefits and two types of waivers, which are described in more detail in Table 1,

4

and

also presents enrollment and spending by target population where relevant. In general, state plan benefits

are provided to all Medicaid beneficiaries for whom they are medically necessary. Waivers allow states to

provide services to specific populations, set enrollment caps, and expand income and asset limits. State

plan HCBS include home health; personal care; Section 1915 (i), which authorizes HCBS targeted to a

particular population with functional needs that are less than an institutional level of care; and Community

First Choice (CFC) attendant services and supports. HCBS waivers include Section 1915 (c) and Section

1115,

5

both of which allow states to expand financial eligibility and offer HCBS to seniors and people with

disabilities who would otherwise qualify for an institutional level of care, while limiting enrollment.

6

The

Appendix Tables contain detailed state-level data. A related brief presents the latest data and highlights

themes in state HCBS policies.

SOURCE: Steve Eiken, Kate Sredl, Brian Burwell, and Angie Amos, Medicaid Expenditures for Long-Term Services and Supports in FY 2016 (IBM

Watson Health, May, 2018), https://www.medicaid.gov/medicaid/ltss/downloads/reports-and-evaluations/ltssexpenditures2016.pdf.

Medicaid long-term services and supports spending, by

institutional vs. community setting.

Figure 2

1995 2000 2005 2010 2012 2013 2014 2015 2016

Home and

Community-Based

LTSS

Institutional LTSS

$57

$76

$107

$139

$142

$146

$152

$159

$167

82%

63% 52%

51%

49%

73%

18%

27%

37%

48%

49% 51%

47%

53%

54%

46%

57%

43%

Annual Medicaid LTSS Spending, in billions:

Medicaid Home and Community-Based Services Enrollment and Spending Growth

4

Table 1: Medicaid Home and Community Based Services (HCBS) Authorities

State Plan Benefits

Home

Health

Services

 Part-time or intermittent nursing services, home health aide services, and medical

supplies, equipment and appliances suitable for use in the home

 At state option - physical therapy, occupational therapy, and speech pathology and

audiology services

Required

Personal

Care

Services

 Assistance with self-care (e.g., bathing, dressing) and household activities (e.g.,

preparing meals)

Optional

Community

First

Choice

 Attendant services and supports for beneficiaries who would otherwise require

institutional care

 Income up to 150% FPL or eligible for benefit package that includes nursing home

services; state option to expand financial eligibility to those eligible for HCBS waiver

Optional

Section

1915 (i)

 Case management, homemaker/home health aide/personal care services, adult day

health, habilitation, respite, day treatment/partial hospitalization, psychosocial

rehabilitation, chronic mental health clinic services, and/or other services approved

by the Secretary

 Beneficiaries must be at risk of institutional care

 Population targeting permitted

Optional

HCBS Waivers

Section

1915 (c)

 Same services as available under Section 1915 (i)

 Beneficiaries must otherwise require institutional care

 Secretary can waive regular program income and asset limits

 Cost neutrality required (average per enrollee cost of HCBS cannot exceed average

per enrollee cost of institutional care)

 Enrollment caps permitted

 Geographic limits permitted

 Population targeting permitted

Optional

Section

1115

 Secretary can waive certain Medicaid requirements and allow states to use Medicaid

funds in ways that are not otherwise allowable under federal rules for experimental,

pilot, or demonstration projects that are likely to assist in promoting program

objectives

 Federal budget neutrality required

 HCBS enrollment caps permitted

Optional

Medicaid Home and Community-Based Services Enrollment and Spending Growth

5

HCBS Enrollment and Spending by Authority

Nearly all HCBS are provided at state option. Home health state plan services are the only HCBS that

are required for states participating in Medicaid, covering 616,800 enrollees. Among the optional HCBS

authorities, waivers continue to be the most commonly used. While some states have taken up Section

1915 (i) and/or CFC, these relatively newer state plan options have not supplanted waivers as the primary

authority through which HCBS are provided. Personal care services are the most commonly used HCBS

state plan option, offered in 34 states (Figure 3 and Appendix Table 1).

Enrollment across the various HCBS authorities ranges from 81,000 individuals receiving Section

1915 (i) state plan services to 1.8 million individuals receiving Section 1915 (c) waiver services

(Figure 3 and Appendix Table 1). Most HCBS enrollees receive services provided through an optional

authority. Over 2.5 million individuals receive HCBS through a Section 1915 (c) or Section 1115 waiver,

and nearly 1.2 million individuals are served in the personal care state plan option, while about 600,000

individuals receive home health state plan services through the sole required HCBS benefit. Total home

health state plan enrollment omits some or all individuals in four states (AZ,

7

HI,

8

NE,

9

and TX

10

) and total

personal care state plan enrollment omits individuals in two states (KS

11

and NM

12

) that provide services

through capitated managed care and cannot separately report enrollment data. In addition, New York is

unable to report enrollment for CFC and Section 1115.

13

HCBS enrollment under a state plan authority is slightly less than enrollment under a waiver

authority (2.3 million vs. 2.5 million) (Figure 3). Total HCBS enrollment across all authorities is not

presented as individuals may receive services under more than one authority. For example, in some

states, an individual could receive some personal care hours through the state plan option and additional

personal care hours through a Section 1915 (c) waiver. States can choose to allow enrollees to self-direct

their personal care and/or home health services. Box 1 contains enrollment data for those services.

NOTES: Home health omits AZ and HI and includes only fee-for-service in NE and TX (omits capitated managed care). Personal care omits KS and

NM. CFC and Section 1115 omit NY. Section 1115 includes states with Section 1115 HCBS waivers without any accompanying Section 1915 (c)

waivers. SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Enrollment in Medicaid HCBS by program authority, FY 2018.

Figure 3

616,800

1,173,900

392,700

81,000

1,806,600

698,500

Home health services Personal care services Community First Choice Section 1915 (i) Section 1915 (c) Section 1115

Number of enrollees:

State plan services enrollment = 2,264,400

51 states

Waiver enrollment = 2,505,300

Mandatory

Optional

34 states

8 states

11 states

48 states

12 states

Medicaid Home and Community-Based Services Enrollment and Spending Growth

6

Box 1: Enrollment in Self-Directed Personal Care and

Home Health State Plan Services

Nearly 700,000 people are self-directing personal care state plan services in 15 (of 20) states

reporting this data.

14

Self-direction typically allows enrollees to select and dismiss their direct care

workers, determine worker schedules, set worker payment rates, and/or allocate their service

budgets.

15

The number of individuals self-directing services varies considerably from state to state.

California has the greatest number of individuals (over 516,000) self-directing personal care state

plan services, followed by Michigan (61,000) and Massachusetts (45,000). Self-direction of home

health state plan services is less common. Among the three states that allow self-direction for home

health state plan services, one state reports enrollment data (over 12,400 individuals in NJ).

16

Medicaid HCBS spending totaled $92 billion in FY 2018, with nearly all spending for services

provided at state option. Six percent of total HCBS spending is devoted to mandatory home health state

plan services (Figure 4 and Appendix Table 2). Additionally, over two-thirds of all Medicaid HCBS

spending is on services provided under a waiver authority compared to a state plan authority. Total

spending under a state plan authority is under $30 billion, or about one-third of total Medicaid HCBS

spending. Total home health state plan spending omits some or all spending in four states (AZ,

17

HI,

18

NE,

19

and TX

20

) and total personal care state plan spending omits two states (KS

21

and NM

22

) that provide

services through capitated managed care and cannot separately report spending data. In addition, New

York is unable to report spending for CFC and Section 1115,

23

and DC is unable to report spending for

Section 1915 (i).

NOTE: Home health omits AZ and HI and includes only fee-for-service in NE and TX (omits capitated managed care). Personal care omits KS and

NM. CFC and Section 1115 omit NY. Section 1915 (i) omits DC. Section 1115 includes Section 1115 HCBS waivers without an accompanying Section

1915 (c) waiver. SOURCE: KFF Medicaid FY 2018 HCBS program surveys.

Medicaid HCBS spending by program authority, FY 2018.

Figure 4

Home health state plan,

$5.5 billion,

6%

Personal care

state plan,

$15.1 billion,

17%

Community First

Choice, $8.7 billion,

9%

Section 1915 (i)

state plan,

$641 million,

1%

Section 1915 (c)

waiver, $53.5 billion,

58%

Section 1115

waiver,

$8.9 billion,

10%

Total Medicaid HCBS spending = $92 billion

Waiver spending =

$62.5 billion

State plan spending

= $29.5 billion

Medicaid Home and Community-Based Services Enrollment and Spending Growth

7

National per enrollee spending varies among the HCBS authorities, ranging from under $8,000 for

Section 1915 (i) state plan services to nearly $30,000 for Section 1915 (c) waivers (Figure 5 and

Appendix Table 3). This variation likely is due to the type and extent of services provided in the different

HCBS authorities. For example:

 Lower per enrollee spending for Section 1915 (i) compared to other authorities may reflect that

Section 1915 (i) serves enrollees with functional needs that are less than an institutional level of

care. By contrast, Section 1915 (c) waivers generally require enrollees to meet an institutional

level of care and therefore are likely to serve individuals with more extensive and intensive – and

therefore generally costlier -- service needs.

 Lower per enrollee spending on home health state plan services compared to other authorities

likely reflects shorter periods of service utilization. In contrast, Section 1915 (c) waiver enrollees

typically use services over an extended period of time, due to chronic long-term needs.

24

 Lower per enrollee spending for Section 1115 waivers compared to Section 1915 (c) waivers may

reflect that most Section 1115 waiver states use this authority for seniors and adults with physical

disabilities but continue to serve people with intellectual or developmental disabilities (I/DD), the

costliest population, through Section 1915 (c).

Enrollment and spending increased in each HCBS authority from FY 2017 to FY 2018, except

home health state plan services (Table 2).

25

The two authorities with the largest percent increases in

total spending were CFC and personal care state plan services; spending increases in these authorities

appear to be driven by increased per enrollee costs rather than by increased enrollment. Notable state-

level changes from FY 2017 to FY 2018 include the following:

SOURCE: KFF Medicaid FY 2018 HCBS program surveys.

Medicaid HCBS spending per enrollee, by program authority,

FY 2018

Figure 5

$9,000

$12,800

$22,000

$7,900

$29,600

$12,800

Home health state plan Personal care state plan Community First Choice Section 1915 (i) state

plan

Section 1915 (c) waiver Section 1115 waiver

Spending Per Enrollee:

State plan spending per enrollee = $13,200 Waiver spending per enrollee = $24,900

Mandatory

Optional

Medicaid Home and Community-Based Services Enrollment and Spending Growth

8

 Sizeable growth in CFC total spending and spending per enrollee is largely attributable to

substantially increased spending in California (76%). More modest growth in CFC enrollment

primarily reflects an increase from 61,000 to nearly 80,000 individuals in Washington.

 Increased total spending and spending per enrollee for personal care state plan services reflects

notable spending growth in South Dakota, Colorado, and California. Although enrollment in

personal care state plan services increased slightly across all states electing this option, two

states (MD and MT) had enrollment declines in both FY 2017 and FY 2018, as individuals

transitioned to CFC services.

 Growth in Section 1915 (c) waiver spending reflects notable increases in Nebraska (36%) and

Pennsylvania (19%). Specifically, spending in one I/DD waiver in Nebraska grew substantially

(87%), while spending in three Pennsylvania waivers serving seniors and adults with physical

disabilities and individuals with I/DD grew by more than 20 percent.

 Growth in Section 1115 waiver enrollment was driven by an increase in New Jersey (19%).

 Growth in Section 1915 (i) enrollment is largely due to an increase from 3,100 to 7,000 individuals

in Ohio.

Home health state plan services is the only authority with both enrollment and spending declines, which

could be attributable at least in part to increased enrollment in capitated managed care, and states’

inability to isolate home health enrollment and spending from other services included in the capitation

payment. States with substantial home health state plan enrollment declines as a result of such data

limitations include Texas (-55%) and Nebraska (-85%). Overall enrollment across all HCBS state plan

authorities also decreased from FY 2017 to FY 2018, likely driven by the home health decrease.

Year Home Health

Personal

Care

Community

First Choice

Section

1915 (i)

State Plan

Authority

Total

Section

1915 (c)

Section

1115

Waiver

Authority

Total

FY 2017 659,118 1,156,455 381,599 77,073 2,274,245 1,744,590 660,295 2,404,885

FY 2018 616,762 1,173,943 392,678 80,997 2,264,380 1,806,838 698,499 2,505,337

% Change -6% 2% 3% 5% -0.40% 4% 6% 4%

FY 2017 $6,021,542 $13,477,500 $5,951,319 $606,844 $26,057,205 $50,038,136 $8,636,374 $58,674,510

FY 2018 $5,530,014 $15,070,520 $8,650,291 $640,850 $29,891,675 $53,469,983 $8,944,964 $62,414,947

% Change -8% 12% 45% 6% 15% 7% 4% 6%

FY 2017 $9,136 $11,654 $15,596 $7,874 $11,458 $28,682 $13,080 $24,398

FY 2018 $8,966 $12,838 $22,029 $7,912 $13,201 $29,593 $12,806 $24,913

% Change -2% 10% 41% 0% 15% 3% -2% 2%

SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Table 2: Medicaid HCBS Enrollment and Spending, by Authority, FY 2017 and FY 2018

State Plan Services

Waiver Services

National Enrollment

National Average Spending (in thousands)

National Average Spending Per Enrollee

Medicaid Home and Community-Based Services Enrollment and Spending Growth

9

HCBS Enrollment and Spending by Target Population

Section 1915 (c) waivers

26

People with I/DD account for less than half of overall Section 1915 (c) waiver enrollment but more

than two-thirds of spending (Figure 6 and Appendix Tables 4 and 5).

27

Spending for this population is

disproportionate to their enrollment as a result of their generally more intensive needs. By contrast,

seniors and people with physical disabilities comprise over half of Section 1915 (c) waiver enrollment and

over a quarter of spending.

28

Other target populations, including people with mental health disabilities,

29

people with traumatic brain or spinal cord injuries (TBI/SCI),

30

children who are medically fragile or

technology dependent,

31

and people with HIV/AIDS,

32

together account for a small share of Section 1915

(c) waiver enrollment and spending.

NOTES: Percentages may not sum to 100% due to rounding. Other Populations include children who are medically fragile or technology dependent,

people with HIV/AIDS, people with mental health disabilities, and people with traumatic brain or spinal cord injuries.

SOURCE: KFF Medicaid FY 2018 HCBS program surveys.

Medicaid § 1915 (c) HCBS waiver enrollment and spending

by target population, FY 2018.

Figure 6

People with Intellectual/

Developmental

Disabilities,

786,000

43%

People with Intellectual/

Developmental

Disabilities,

$36 billion

68%

Seniors and People with

Physical Disabilities,

958,000

53%

Seniors and People with

Physical Disabilities,

$15.4 billion, 29%

Other Populations,

63,000

3%

Other Populations,

$1.7 billion

3%

Enrollees Expenditures

Total = $53.5 billionTotal = 1.8 million

NOTES: I/DD = intellectual and developmental disabilities. TBI/SCI = traumatic brain injuries/spinal cord injuries. Other states serve HCBS waiver

populations through Section 1115.

SOURCE: KFF Medicaid FY 2018 HCBS program surveys.

Section 1915 (c) waiver per enrollee spending, by target

population, FY 2018

Figure 7

$46,300

$16,000

$35,200

$11,100

$12,700

$43,700

I/DD Seniors &/or Adults with

Physical Disabilities

Medically Fragile/Tech.

Dep. Children

HIV/AIDS Mental Health TBI/SCI

Number of

states

serving

population:

11

21

48

42

18

5

Per enrollee spending by target population:

Medicaid Home and Community-Based Services Enrollment and Spending Growth

10

The fact that services for people with I/DD comprise over two-thirds of total Section 1915 (c)

waiver spending reflects high per enrollee costs for this population. There is substantial variation in

per enrollee spending among Section 1915 (c) waiver target populations, ranging from about $11,000 for

people with HIV/AIDS to over $46,000 for people with I/DD (Figure 7 and Appendix Table 6). Per enrollee

spending for people with I/DD is closely followed by the TBI/SCI population ($44,000) and medically

fragile children ($35,000). In addition to people with HIV/AIDS, per enrollee spending is relatively lower for

seniors and adults with physical disabilities ($16,000) and people with mental health disabilities

($13,000).

Section 1915 (i) state plan option

People with I/DD account for the vast majority of enrollment and spending in the Section 1915 (i)

state plan option, largely due to California’s program (Figure 8).

33

Unlike waivers which require an

institutional level of care, Section 1915 (i) state plan HCBS are provided to people with functional needs

that are less than an institutional level of care. The next largest Section 1915 (i) target population for both

enrollment and spending is people with mental health disabilities.

34

Nearly three-quarters of Section 1915

(i) enrollment for this population is in Iowa and Ohio, while Iowa’s program comprises most of the

spending ($94 million). Seniors and adults with physical disabilities account for a very small share of

Section 1915 (i) enrollment and spending.

35

Per enrollee spending is similar across Section 1915 (i) state plan HCBS target populations.

Section 1915 (i) state plan HCBS per enrollee spending was nearly $10,000 (in 2 of 3 states reporting

36

)

for seniors and adults with physical disabilities, less than $9,000 for people with I/DD (in 4 states

37

), and

under $6,000 for people with mental health disabilities (in 4 states

38

). Lower per enrollee spending for

Section 1915 (i) state plan HCBS compared to Section 1915 (c) waivers could reflect a more limited

scope benefit package and/or the fact that Section 1915 (i) enrollees have fewer and/or less intensive

needs (less than an institutional level of care) that Section 1915 (c) waiver enrollees (who must meet an

institutional level of care).

NOTES: Percentages may not sum to 100% due to rounding. Seniors/physical disabilities omits spending data for DC.

SOURCE: KFF Medicaid FY 2018 HCBS program surveys.

Medicaid § 1915 (i) HCBS state plan option enrollment and

spending by target population, FY 2018.

Figure 8

People with

Intellectual/

Developmental

Disabilities,

61,000,

75%

People with

Intellectual/

Developmental

Disabilities,

$520 million,

81%

Mental Health,

19,000,

24%

Mental Health,

$113 million,

18%

Seniors/

Physical

Disabilities,

1,000,

1%

Seniors/

Physical

Disabilities,

$8 million,

1%

Enrollees Expenditures

Total = $641 millionTotal = 81,000

Medicaid Home and Community-Based Services Enrollment and Spending Growth

11

Looking Ahead

Medicaid HCBS enrollment ranges from 81,000 individuals receiving Section 1915 (i) state plan services

to 1.8 million individuals receiving Section 1915 (c) waiver services, with joint federal and state spending

across all HCBS authorities totaling $92 billion in FY 2018. Medicaid HCBS promote independence and

self-determination for seniors and people with disabilities and chronic conditions by enabling them to

receive assistance with self-care needs and household activities outside an institution. Medicaid provides

substantial federal funding to help states meet their community integration obligations under Olmstead

and the Americans with Disabilities Act.

Most HCBS enrollees receive services provided through an optional authority, and nearly all HCBS

spending is devoted to authorities provided at state option. Although home health state plan services are

the only HCBS that states participating in Medicaid must offer, all states elect at least one optional HCBS

authority. While nearly all Medicaid HCBS authorities are optional, Medicaid fills a gap by covering HCBS

that are typically not available through private insurance or Medicare, and not affordable for many paying

out-of-pocket, especially those with lower incomes. The optional nature of most HCBS results in

substantial variation across states in enrollment and spending, reflecting states’ different choices about

optional authorities, benefit package contents, and scope of covered services. States would lose some of

their existing optional HCBS authorities and flexibility if the entire ACA ultimately is struck down in Texas

v. Azar.

39

Specifically, the option to offer CFC services would cease to exist, as would provisions that

provide states with the flexibility to offer the current full scope of Section 1915 (i) services and to target

those services to specific populations.

40

The optional nature of most HCBS has implications for federal and state spending, especially during

economic recessions. States face increasing pressures from revenue shortfalls during times of economic

downturn. Optional Medicaid eligibility pathways and services, including HCBS, may be at risk for cuts as

states must make difficult choices to balance their budgets.

41

The 2020 elections also could have important implications for Medicaid and HCBS as policymakers may

consider a range of proposals that could affect these populations and services. At one end of the

spectrum, a Medicaid program-wide federal financing cap is proposed in President Trump’s FY 2020

budget, though efforts to repeal and replace the ACA and cap federal Medicaid funding through a block

grant or per capita cap were narrowly defeated in Congress in 2017.

42

In addition, Tennessee has

submitted a proposal to CMS that seeks capped federal Medicaid funding through a Section 1115 waiver

pursuant to state legislation that includes some seniors, nonelderly adults with physical disabilities, and

children and adults with I/DD receiving HCBS.

43

Depending on how they are structured, policies that

would cap federal Medicaid funding could affect coverage, services, provider payment rates, and access

to care for vulnerable populations.

At the other end of the policy spectrum, continued attention to Medicaid HCBS enrollment and spending

is important to understanding proposals from some Democrats to create a single, federal, universal health

insurance program known as Medicare-for-all. One of the most fundamental changes under Medicare-for-

Medicaid Home and Community-Based Services Enrollment and Spending Growth

12

all would be uniform coverage of community-based long-term care services for all Americans. The current

Medicare-for-all proposals would require and explicitly prioritize HCBS over institutional services,

eliminating the state variation in eligibility, benefits, and payment and delivery systems that exists today

under Medicaid, while also shifting responsibility for designing and implementing much of health policy

from states to the federal government.

44

While the economy, the litigation challenging the ACA, and the upcoming election all will have

implications for Medicaid and HCBS, changing demographics also will result in increased pressure for

states to meet the health and LTSS needs of a growing elderly population in the coming years. The

number of adults age 65 and older is expected to more than double in size between 2014 and 2060, with

the largest increase during this period (18 million) expected in this decade, from 2020 to 2030.

45

With the

aging of the baby boomers, one in five U.S. residents will be age 65 or older by 2030,

46

and for the first

time in U.S. history, older adults are projected to outnumber children by 2034.

47

All of these factors make

continued attention to Medicaid’s role in providing HCBS an important policy area to watch.

MaryBeth Musumeci and Priya Chidambaram are with KFF.

Molly O’Malley Watts is with Watts Health Policy Consulting.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

13

Appendix Tables

Appendix Table 1: Medicaid HCBS Enrollment, by State and Authority, FY 2018

Appendix Table 2: Medicaid HCBS Spending, by State and Authority, FY 2018

Appendix Table 3: Medicaid HCBS Spending Per Enrollee, by State and Authority, FY 2018

Appendix Table 4: Medicaid Section 1915 (c) HCBS Waiver Enrollment, by Target Population and State,

FY 2018

Appendix Table 5: Medicaid Section 1915 (c) HCBS Waiver Spending, by Target Population and State,

FY 2018

Appendix Table 6: Medicaid Section 1915 (c) HCBS Waiver Spending Per Enrollee, by Target Population

and State, FY 2018

Medicaid Home and Community-Based Services Enrollment and Spending Growth

14

Appendix Table 1: Medicaid HCBS Enrollment, By State and Authority, FY 2018

State

State Plan Services

Waivers

Home health

Personal care

Community

First Choice

Section 1915 (i)

Section 1915 (c)

Section 1115

Alabama

5,900

15,100

Alaska

300

3,700

4,300

Arizona

included in 1115

52,400

Arkansas

5,000*

13,700

15,500*

California

37,500*

273,800

228,200

55,800

149,500

474,300*

Colorado

23,500

100

46,300*

Connecticut

30,700

3,200

600

28,300

Delaware

14,000

400

1,200

6,900

DC

8,600*

6,000*

200*

6,900*

Florida

20,800

3,200

102,500

Georgia

6,200

42,600

Hawaii

included in 1115

2,900

8,500

Idaho

1,900

8,500

4,000

20,200

Illinois

14,400

161,600*

Indiana

16,300

4,700

49,100

Iowa

12,400

7,100

30,400*

Kansas

3,300

included in 1115

28,700

Kentucky

15,400

24,300*

Louisiana

6,600

14,200

20,600

Maine

1,900

3,300

7,500

Maryland

4,000

1,000

13,500

25,800

Massachusetts

52,200

45,000

30,600*

Michigan

3,300

60,700

24,700

Minnesota

28,900

43,700

81,500

Mississippi

1,400

700

25,800

Missouri

4,100

65,600

33,900

Montana

600

500

3,400

5,700

Nebraska

200^

3,800

11,800

Nevada

1,300

10,300

200

5,700

New Hampshire

1,400*

100*

9,200

New Jersey

50,300

49,500

10,700*

25,000

New Mexico

4,000

included in 1115

5,100

28,000

New York

101,400*

116,200*

NR

98,000*

NR

North Carolina

9,900

44,700

25,300*

North Dakota

1,100

1,300

5,800*

Ohio

26,900

7,000

111,400

Oklahoma

3,600

3,800

26,200*

Oregon

300

3,100

36,500

64,200*

Pennsylvania

26,300

119,700

Rhode Island

8,800

400

5,500

South Carolina

500

35,200*

South Dakota

11,200

1,600

5,900*

Tennessee

11,200

7,800

17,500

Texas

11,600^

369,700

30,000

200

48,100

68,800

Utah

3,100

200

9,300

Vermont

3,700

1,400

10,600

Virginia

1,600

51,300*

Washington

4,600

1,200

77,900

64,500

1,000

West Virginia

8,100

5,700

10,900

Wisconsin

5,900

17,900

89,900

Wyoming

400

5,300*

U.S. TOTAL

(51 states):

616,800

(51 states)

1,173,900

(34 states)

392,700

(8 states)

81,000

(11 states)

1,806,600

(48 states)

698,500

(12 states)

NOTES: Totals may not sum due to rounding. NR indicates state did not report data. Included in 1115 indicates that state was unable to

report state plan services separately from Section 1115 waiver services. Blank cell indicates state does not elect option. Total HCBS

enrollment across all authorities is not presented as individuals may receive services under more than one authority. *Data from year

other than FY 2018, as noted in table endnotes. ^NE and TX home health data are fee-for-service only and exclude capitated managed

care.

SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

15

Appendix Table 2: Medicaid HCBS Spending, By State and Authority, FY 2018 ($, in thousands)

State

State Plan Services

Waivers

Total HCBS

Spending

Home health

Personal care

Community

First Choice

Section

1915 (i)

Section

1915 (c)

Section

1115

Alabama

30,700

437,500

468,200

Alaska

1,400

61,900

265,100

328,400

Arizona

included in

1115

1,544,700

Arkansas

11,800*

94,300

389,600*

495,700

California

153,900*

2,960,800

5,562,600

494,600

3,810,300

4,679,100*

17,661,300

Colorado

345,800

1,200

903,700*

1,250,700

Connecticut

203,700

85,300

6,100

1,358,600

1,653,700

Delaware

63,900

500

137,200

87,200

288,800

DC

229,500*

254,000*

NR

295,000*

778,500

Florida

413,100

63,200

2,103,500

2,579,800

Georgia

4,700

1,212,900

1,217,600

Hawaii

included in

1115

135,600

104,200

239,800

Idaho

5,500

58,600

17,500*

364,000

445,600

Illinois

73,400

1,285,500*

1,358,900

Indiana

115,800

10,600

1,083,500

1,209,900

Iowa

44,600

94,400

647,900

786,900

Kansas

7,300

Included in 1115

1,198,300

1,205,600

Kentucky

30,500

805,100*

835,600

Louisiana

30,200

170,500

571,300

772,000

Maine

3,200

31,400

441,300

475,900

Maryland

2,900

7,300

300,400

1,145,200

1,455,800

Massachusetts

513,600

794,600

1,563,900*

2,872,100

Michigan

3,900

328,200

789,200*

1,121,300

Minnesota

67,800

1,017,200

2,911,800

3,996,800

Mississippi

1,600

7,600

400,800

410,000

Missouri

4,800

741,700

1,024,900

1,771,400

Montana

600

900

45,500

161,000

208,000

Nebraska

100^

15,400

365,700

381,200

Nevada

23,800

111,200

2,000

133,200

270,200

New Hampshire

6,500*

4,300*

315,700*

326,500

New Jersey

61,400

557,900

605,000*

183,000

1,407,300

New Mexico

12,000

included in 1115

379,900

329,400

721,310

New York

2,306,700*

3,274,500*

NR

6,426,100*

NR

12,007,300

North Carolina

12,800

450,500

897,500*

1,360,800

North Dakota

9,800

37,000

206,800*

253,600

Ohio

216,700

3,200

2,871,200

3,091,100

Oklahoma

15,700

10,900

476,400*

503,000

Oregon

300

7,100

673,700

100,700*

781,800

Pennsylvania

30,200

6,023,100

6,053,300

Rhode Island

115,400

6,300

71,800

193,500

South Carolina

4,200

657,700*

661,900

South Dakota

15,500

7,400

145,300*

168,200

Tennessee

226,500

684,400

297,400

1,208,300

Texas

13,900^

3,637,700

550,300

4,400

1,946,400

1,245,100

7,397,800

Utah

21,000

800

357,600

379,400

Vermont

7,600

13,900

401,700

423,200

Virginia

1,900

1,684,800*

1,686,700

Washington

6,000

6,400

1,432,500

728,600

1,300

2,174,800

West Virginia

9,400

69,400

406,300

485,100

Wisconsin

46,000

273,700

2,451,600

2,771,300

Wyoming

2,300

163,500*

165,800

U.S. TOTAL:

5,530,000

(51 states)

15,070,500

(34 states)

8,650,300

(8 states)

640,900

(11

states)

53,470,000

(48 states)

8,945,000

(12 states)

92,306,600

NOTES: Totals may not sum due to rounding. NR indicates state did not report data. Included in 1115 indicates that state was unable to

report state plan services separately from Section 1115 waiver services. Blank cell indicates state did not elect option. *Data from year

other than FY 2018, as noted in table endnotes. ^NE and TX home health data are fee-for-service only and exclude capitated managed

care. SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

16

Appendix Table 3: Medicaid HCBS Spending Per Enrollee, By State and Authority, FY 2018 ($)

State

State Plan Services

Waivers

Home health

Personal care

Community

First Choice

Section 1915 (i)

Section 1915 (c)

Section 1115

Alabama

5,200

29,000

Alaska

4,500

16,900

61,100

Arizona

included in

1115

29,500

Arkansas

2,300*

6,900

25,200*

California

4,100*

5,400

24,400

8,900

25,500

9,900*

Colorado

14,700

11,100

19,500*

Connecticut

6,600

26,600

9,800

48,100

Delaware

4,600

1,200

119,200

12,700

DC

26,800*

42,000*

NR

42,500*

Florida

19,800

20,000

20,500

Georgia

800

28,500

Hawaii

included in

1115

47,400

12,200

Idaho

2,900

5,400

7,600*

18,000

Illinois

5,100

8,000*

Indiana

7,100

2,200

22,000

Iowa

3,600

13,200

21,300*

Kansas

2,200

included in 1115

41,700

Kentucky

2,000

33,100*

Louisiana

4,500

12,000

27,700

Maine

1,700

9,500

59,200

Maryland

700

7,500

22,300

44,400

Massachusetts

9,800

17,600

51,100*

Michigan

1,200

5,400

32,000*

Minnesota

2,300

23,300

35,700

Mississippi

1,100

10,500

15,500

Missouri

1,200

11,300

30,300

Montana

1,000

1,800

13,200

28,200

Nebraska

300

4,000

31,100

Nevada

18,100

10,800

10,600

23,200

New Hampshire

4,700*

35,200*

34,300*

New Jersey

1,200

11,300

56,500*

7,300

New Mexico

3,000

included in 1115

75,200

11,800

New York

22,700*

28,200*

NR

65,600*

NR

North Carolina

1,300

10,100

35,500*

North Dakota

8,900

29,200

35,800*

Ohio

8,100

500

25,800

Oklahoma

4,400

2,900

18,200*

Oregon

1,000

2,300

18,500

1,600*

Pennsylvania

1,200

50,300*

Rhode Island

13,100

15,200

13,000

South Carolina

7,900

18,700*

South Dakota

1,400

4,700

24,500*

Tennessee

20,200

87,400

17,000

Texas

1,200

9,800

18,300

27,500

40,500

18,100

Utah

6,900

5,200

38,600

Vermont

2,100

9,700

37,900

Virginia

1,200

32,800*

Washington

1,300

5,300

18,400

11,300

1,300

West Virginia

1,200

12,100

37,300

Wisconsin

7,800

15,300

27,300

Wyoming

5,900

30,900*

U.S. TOTAL:

9,000

(51 states)

12,800

(34 states)

22,000

(8 states)

7,900

(11 states)

29,600

(48 states)

12,800

(12 states)

NOTES: Totals may not sum due to rounding. NR indicates state did not report data. Included in 1115 indicates that state was unable to

report state plan services separately from Section 1115 waiver services. Blank cell indicates state did not elect option. *Data from year

other than FY 2018, as noted in table endnotes.

SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

17

Appendix Table 4: Medicaid Section 1915 (c) HCBS Waiver Enrollment, by Target Population and by State, FY 2018

State

Total No.

of

§ 1915 (c)

Waivers

Enrollment by Target Population

Total

I/DD

Seniors

Seniors &

Adults with

Physical

Disabilities

Adults

with

Physical

Disabilities

Med.

Fragile/

Tech

Dep.

Children

HIV/

AIDS

Mental

Health

TBI/

SCI

Alabama

6

5,500

8,900

600

15,100

Alaska

4

2,200

2,000

200

4,300

Arkansas

4

4,500*

11,000

15,500

California

7

129,100

10,500

4,600

3,800

300

1,200

149,500

Colorado

11

12,500*

27,400*

1,800*

4,000*

600*

46,300

Connecticut

11

10,200

15,300

1,100

300

800

600

28,300

Delaware

1

1,200

DC

2

3,300*

3,700*

6,900

Florida

4

31,800

70,800

< 50

102,500

Georgia

4

13,000

28,100

1,500

42,600

Hawaii

1

2,900

Idaho

4

8,800

11,500

20,200

Illinois

9

22,800*

84,700*

10,800*

36,100*

900*

1,500*

4,900*

161,600

Indiana

4

26,600

22,300

200

49,100

Iowa

7

12,600

2,800

< 50

1,000

1,400

30,400

Kansas

7

9,600

6,000

6,700

600

5,300

500

28,700

Kentucky

6

14,800

9,000*

< 50

500

24,300

Louisiana

7

12,100

5,900

2,600

20,600

Maine

5

5,300

1,900

200

7,500

Maryland

6

16,200

9,200

200

100

25,800

Massachusetts

10

15,600*

14,600*

500*

30,600

Michigan

4

8,700

15,300

700

24,700

Minnesota

5

19,900

30,300

29,400

600

1,300

81,500

Mississippi

5

2,600

20,000

2,400

800

25,800

Missouri

9

15,000

16,500

2,300

100

33,900

Montana

4

2,700

2,600

400

5,700

Nebraska

5

4,900

6,900

<50

11,800

Nevada

3

2,200

2,700

800

5,700

New Hampshire

4

5,100

3,900

300

9,200

New Jersey

1

10,700*

10,700

New Mexico

3

5,100

New York

9

85,400*

2,500*

600*

6,400

3,100*

98,000

North Carolina

3

12,500*

10,000

2,900

25,300

North Dakota

6

5,500*

300

< 50

5,800

Ohio

7

40,200

64,600

6,600

111,400

Oklahoma

6

5,400*

20,800

100*

26,200

Oregon

6

22,500*

41,400

300*

64,200

Pennsylvania

10

40,300

44,700

33,800

1,000

119,700

South Carolina

7

11,500

20,400*

100*

1,400

800*

1,100

35,200

South Dakota

4

3,700*

2,100

100*

5,900

Tennessee

3

7,800

Texas

6

39,600

6,200

2,300

48,100

Utah

8

5,500

600

2,300

100

700

100

9,300

Virginia

5

13,100

38,200*

51,300

Washington

8

19,400

43,600

1,600

64,500

West Virginia

3

4,600

6,200

100

10,900

Wisconsin

6

28,800

61,100

89,900

Wyoming

5

2,600

2,500*

100

200*

5,300

TOTAL

(48 states):

265

785,800

(48

states)

162,500

(8

states)

667,000

(37 states)

128,200

(16 states)

17,100

(18

states)

3,600

(5

states)

25,100

(11

states)

17,500

(21

states)

1,806,800

No Section 1915 (c) Waivers (3 states)

Arizona

Rhode Island

Vermont

NOTES: I/DD = intellectual and developmental disabilities. TBI = traumatic brain injury. SCI = spinal cord injury. Totals may not sum due to rounding.

States may offer more than one Section 1915 (c) waiver per target population category. Programs with enrollment under 50 individuals are noted as < 50.

Blank cell indicates state does not offer Section 1915 (c) waiver for that population. *Data from year other than FY 2018, as noted in table endnotes.

SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

18

Appendix Table 5: Medicaid Section 1915 (c) HCBS Waiver Spending, by Target Population and by State, FY 2018 ($, in thousands)

State

Total No.

of § 1915

(c)

Waivers

Spending by Target Population

Total

I/DD

Seniors

Seniors &

Adults with

Physical

Disabilities

Adults with

Physical

Disabilities

Med.

Fragile/

Tech Dep.

Children

HIV/

AIDS

Mental

Health

TBI/

SCI

Alabama

6

351,300

78,400

7,800

437,500

Alaska

4

186,900

69,000

9,100

265,100

Arkansas

4

240,100*

149,500

389,600

California

7

3,474,900

39,800

108,900

175,400

2,600

8,700

3,810,300

Colorado

11

462,200*

361,500*

18,100*

38,300*

23,500*

903,700

Connecticut

11

883,000

395,400

2,100

100

14,700

63,300

1,358,600

Delaware

1

137,200

DC

2

226,100*

68,900*

295,000

Florida

4

1,067,000

1,036,500

< 50

2,103,500

Georgia

4

639,200

493,300

80,400

1,212,900

Hawaii

1

135,600

Idaho

4

266,900

97,000

364,000

Illinois

9

71,600*

429,400*

127,800*

558,200*

1,900*

24,000*

72,600*

1,285,500

Indiana

4

812,100

266,700

4,700

1,083,500

Iowa

7

520,600*

60,500*

23,600*

300*

10,300

32,500

647,900

Kansas

7

523,400

210,900

304,300

55,900

79,000

24,900

1,198,300

Kentucky

6

670,900

86,100*

2,600

45,600

805,100

Louisiana

7

454,900

112,500

3,900

571,300

Maine

5

385,100

40,000

16,100

441,300

Maryland

6

994,900

135,400

2,700

12,200

1,145,200

Massachusetts

10

1,301,200*

211,900*

50,900*

1,563,900

Michigan

4

444,600*

339,900

4,700*

789,200

Minnesota

5

1,403,400

435,600

932,600

42,400

97,900

2,911,800

Mississippi

5

104,300

233,900

44,100

18,400

400,800

Missouri

9

924,200

63,300

35,000

2,400

1,024,900

Montana

4

113,600

42,000

5,400

161,000

Nebraska

5

252,700

112,400

700

365,700

Nevada

3

114,400

13,900

4,900

133,200

New Hampshire

4

243,700*

48,900

23,100

315,700

New Jersey

1

605,000*

605,000

New Mexico

3

379,900

New York

9

5,970,300*

158,500*

5,400*

97,300

194,600*

6,426,100

North Carolina

3

652,100*

196,000

49,500

897,500

North Dakota

6

199,500*

6,900

200

100

206,800

Ohio

7

1,968,100*

777,500

125,600

2,871,200

Oklahoma

6

305,900*

165,900

4,600*

476,400

Oregon

6

58,500*

41,600

600*

100,700

Pennsylvania

10

3,177,600

1,481,600

1,331,200

32,700

6,023,100

South Carolina

7

423,300

192,200*

1,800*

3,300

4,700*

32,600

657,700

South Dakota

4

121,000*

20,600

3,700*

145,300

Tennessee

3

684,400

Texas

6

1,545,300

390,400

10,712

1,946,400

Utah

8

275,400

7,200

50,900

2,600

14,900

6,600

357,600

Virginia

5

908,100

776,700*

1,684,800

Washington

8

650,100

24,700

53,800

728,600

West Virginia

3

305,400

99,400

1,500

406,300

Wisconsin

6

632,800

1,818,800

2,451,600

Wyoming

5

118,100

37,400*

< 50

7,900*

163,500

TOTAL

(48 states):

265

36,386,500

(48 states)

1,592,700

(8 states)

10,132,900

(37 states)

3,629,900

(16 states)

604,000

(18

states)

40,000

(5

states)

318,100

(11

states)

765,900

(21

states)

53,470,200

No Section 1915 (c) Waivers (3 states)

Arizona

Rhode Island

Vermont

NOTES: I/DD = intellectual and developmental disabilities. TBI = traumatic brain injury. SCI = spinal cord injury. Totals may not sum due to rounding. States may offer

more than one Section 1915 (c) waiver per target population category. Programs with enrollment under 50 individuals are noted as < 50. Blank cell indicates state does not

offer Section 1915 (c) waiver for that population. *Data from year other than FY 2018, as noted in table endnotes.

SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

19

Appendix Table 6: Medicaid Section 1915 (c) HCBS Waiver Spending Per Enrollee, by Target Population and by State, FY 2018 ($)

State

Total

No. of

Waivers

Per Enrollee Spending by Target Population

Total

I/DD

Seniors

Seniors &

Adults with

Physical

Disabilities

Adults with

Physical

Disabilities

Med.

Fragile/

Tech

Dep.

Children

HIV/

AIDS

Mental

Health

TBI/

SCI

Alabama

6

63,600

13,800

12,700

29,000

Alaska

4

86,400

35,100

42,900

61,100

Arkansas

4

53,500*

13,600

25,200

California

7

26,900

3,800

23,600

45,800

8,900

7,200

25,500

Colorado

11

37,000*

13,200*

9,900*

9,600*

41,300*

19,500

Connecticut

11

86,600

25,900

2,000

200

17,900

106,128

48,100

Delaware

1

119,200

DC

2

69,000*

18,800*

42,500

Florida

4

33,600

14,600

2,600

20,500

Georgia

4

49,000

17,600

53,700

28,500

Hawaii

1

47,400

Idaho

4

30,500

8,500

18,000

Illinois

9

3,100*

5,100*

11,900*

15,500*

2,300*

15,800*

14,800*

8,000

Indiana

4

30,500

12,000

24,700

22,000

Iowa

7

41,400*

4,800*

8,300*

9,600*

10,600

22,700

21,300

Kansas

7

54,500

35,200

45,400

93,200

14,900

46,400

41,700

Kentucky

6

45,300

9,600*

66,300

92,700

33,100

Louisiana

7

37,500

19,100

1.500

27,700

Maine

5

72,300

20,700

80,700

59,200

Maryland

6

61,200

14,700

12,600

126,800

44,900

Massachusetts

10

83,500*

14,600*

108,000*

51,100

Michigan

4

51,400*

22,200

6,400*

32,000

Minnesota

5

70,600

14,400

31,700

69,700

76,100

35,700

Mississippi

5

40,200

11,700

18,200

22,500

15,500

Missouri

9

61,800

3,800

15,100

31,300

30,300

Montana

4

41,400

16,100

15,000

28,200

Nebraska

5

51,800

16,400

33,400

31,100

Nevada

3

51,100

5,200

5,900

23,200

New Hampshire

4

47,900*

12,700

88,600

34,300

New Jersey

1

56,500*

56,500

New Mexico

3

75,200

New York

9

69,900*

63,000*

9,000*

15,300

62,100*

65,600

North Carolina

3

52,300*

19,700

17,100

35,500

North Dakota

6

36,500*

23,900

214,500

6,000

35,800

Ohio

7

48,900

12,000

19,100

25,800

Oklahoma

6

56,700*

8,000

52,100*

18,200

Oregon

6

3,800*

1,000

1,900*

1,600

Pennsylvania

10

78,900

33,200

39,400

33,900

50,300

South Carolina

7

36,900

9,400*

30,300*

2,300

5,900*

30,400

18,700

South Dakota

4

32,300*

9,900

34,500*

24,500

Tennessee

3

87,400

Texas

6

39,000

63,500

4,600

40,500

Utah

8

50,200

12,400

22,600

23,800

21,300

47,100

38,600

Virginia

5

69,300

20,300*

32,800

Washington

8

33,500

600

33,700

11,300

West Virginia

3

65,900

16,100

18,300

37,300

Wisconsin

6

22,000

29,800

27,300

Wyoming

5

46,000

15,200*

300

48,500*

30,900

TOTAL

(48 states):

265

46,300

(48

states)

9,800

(8

states)

15,200

(37 states)

28,300

(16 states)

35,200

(18

states)

11,100

(5

states)

12,700

(11

states)

43,700

(21

states)

29,600

No Section 1915 (c) Waivers (3 states)

Arizona

Rhode Island

Vermont

NOTES: I/DD = intellectual and developmental disabilities. TBI = traumatic brain injury. SCI = spinal cord injury. Totals may not sum due to rounding.

States may offer more than one Section 1915 (c) waiver per target population category Programs with enrollment under 50 individuals are noted as <

50. Blank cell indicates state does not offer Section 1915 (c) waiver for that population. *Data from year other than FY 2018, as noted in table

endnotes. SOURCE: KFF Medicaid HCBS Program Surveys, FY 2018.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

20

Table Notes

Arkansas: Home health data are from 2017. Wavier data are from 2015 (#936 I/DD).

California: Home health data are from 2016. Section 1115 waiver data are from 2015.

Colorado: Waiver data are from 2017 (#6 seniors/adults with physical disabilities, #7 I/DD, #268 mental health, #288

TBI/SCI, #293 I/DD, #305 I/DD, #450 children, #961 TBI/SCI, #4157 children, #4180 I/DD.)

District of Columbia: Home health, personal care, CFC, 1915 (i), and waiver data are from 2017.

Idaho: Section 1915 (i) spending and per enrollee spending data include only the adult DD program and exclude data

for the children’s DD program. The state reported 1,700 children with DD enrolled in 2017, but did not report

corresponding spending data.

Illinois: Waiver data are from 2015 (#143 seniors), 2016 (#278 children), and 2017 (#142 adults with physical

disabilities, #202 HIV/AIDS, #326 seniors/adults with physical disabilities, #329 TBI/SCI, #350 I/DD, #464 I/DD, #473

I/DD).

Iowa: Waiver enrollment data are from 2016 (#345 adults with physical disabilities, #4111 adults with physical

disabilities, #4155 seniors) and 2017 (#213 HIV/AIDS, #242 I/DD).

Kentucky: Waiver data are from 2017 (#144 seniors/adults with physical disabilities).

Massachusetts: Waiver data are from 2016 (#59 seniors/adults with physical disabilities) and 2017 (#359 TBI/SCI,

#826 I/DD, #827 I/DD, #828 I/DD, #1027 seniors/adults with physical disabilities, #1028 seniors/adults with physical

disabilities, #40207 I/DD, #40701 TBI/SCI, #40702 TBI/SCI).

Michigan: Waiver spending data are from 2016 (#167 I/DD, #438 mental health, #4119 I/DD).

New Hampshire: Home health and personal care data are from 2015. Waiver spending data are from 2016 (#397

I/DD).

New Jersey: Waiver data are from 2011 (#31 I/DD).

New York: Home health and personal care data are from 2017. Waiver data are from 2016 (#40176 children) and

2017 (#269 spending-only TBI/SCI, #444 spending-only seniors/adults with physical disabilities, #470 I/DD, and #471

children).

North Carolina: Waiver data are from 2016 (#432 I/DD).

North Dakota: Waiver data are from 2017 (#842 spending-only I/DD, #37 I/DD).

Oklahoma: Waiver data are from 2017 (#179 I/DD, #343 I/DD, #351 I/DD, #399 I/DD, #811 children).

Oregon: Waiver data are from 2017 (#117 I/DD, #375 I/DD, #565 children, #40193 children, #40194 I/DD).

South Carolina: Waiver data are from 2016 (#40181 adults with physical disabilities) and 2017 (#186 HIV/AIDS,

#405 seniors/adults with physical disabilities).

South Dakota: Waiver data are from 2016 (#44 I/DD, #264 TBI/SCI, #338 I/DD).

Virginia: Waiver data are from 2017 (#321 seniors/adults with physical disabilities).

Wyoming: Waiver data are from 2017 (#236 seniors/adults with physical disabilities, #370 TBI/SCI).

Medicaid Home and Community-Based Services Enrollment and Spending Growth

21

Endnotes

1

See, e.g., KFF, Medicaid Beneficiaries Who Need Home and Community-Based Services: Supporting Independent

Living and Community Integration (March 2014), http://kff.org/medicaid/report/medicaid-beneficiaries-who-need-

home-and-community-based-services-supporting-independent-living-and-community-integration/.

2

See generally KFF, Streamlining Medicaid Home and Community-Based Services: Key Policy Questions (March

2016), https://www.kff.org/medicaid/issue-brief/streamlining-medicaid-home-and-community-based-services-key-

policy-questions/; KFF, Medicaid Long-Term Services and Supports: An Overview of Funding Authorities (Sept.

2013), http://kff.org/medicaid/fact-sheet/medicaid-long-term-services-and-supports-an-overview-of-funding-

authorities/.

3

The Table Notes indicate where state-level data from a year prior to FY 2018 is used.

4

For additional background and current state policies relating to each of these authorities, see KFF, Key State Policy

Choices About Medicaid Home and Community-Based Services (Feb. 2020), https://www.kff.org/medicaid/issue-

brief/key-state-policy-choices-about-medicaid-home-and-community-based-services.

5

Enrollment and spending data for Section 1115 HCBS waivers includes those for which the state does not have an

accompanying Section 1915 (c) waiver.

6

Unlike HCBS waivers, state plan services must be provided to all beneficiaries for whom they are medically

necessary. However, states can manage enrollment for Section 1915 (i) state plan services by restricting functional

eligibility criteria for future beneficiaries if enrollment will exceed the state’s initial estimate.

7

AZ delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable

to separately report unduplicated home health enrollment data. Instead, AZ’s home health state plan enrollment is

included in its Section 1115 waiver enrollment. In FY 2018, Arizona reported that all 52,400 of its Section 1115 waiver

enrollees received home health services.

8

HI delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable to

separately report unduplicated home health enrollment data. Instead, HI’s home health state plan enrollment is

included in its Section 1115 waiver enrollment. In FY 2018, Hawaii reported that 2,500 of its 8,500 Section 1115

waiver enrollees received home health services.

9

NE reports home health state plan enrollment only for fee-for-service enrollees.

10

TX reports home health state plan enrollment only for fee-for-service enrollees.

11

KS delivers personal care state plan services through a Section 1115 capitated managed care waiver and is

unable to separately report unduplicated personal care enrollment data. Instead, KS’s personal care state plan

enrollment is included in its Section 1115 waiver enrollment.

12

NM delivers personal care state plan services through a Section 1115 capitated managed care waiver and is

unable to separately report unduplicated personal care enrollment data. Instead, NM’s personal care state plan

enrollment is included in its Section 1115 waiver enrollment.

13

NY is unable to report Section 1115 waiver managed LTSS enrollment by community vs. institutional setting. In

2015 (the most recent year for which NY data are available), 49,930 people received long-term institutional or HCBS

in NY’s Section 1115 waiver.

14

Among the 34 states offering the personal care state plan option, 20 allow self-direction. The 15 states reporting

self-directed enrollment data are AK, AR, CA, FL, ID, MA, MI, MO, MT, NJ, OK, TX, UT, VT and WA. The five states

that allow self-directed personal care state plan services but do not report enrollment are ME, MN, NV, NH and NY.

15

For additional information on states’ self-direction policies, see KFF, Key State Policy Choices About Medicaid

Home and Community-Based Services (Feb. 2020), https://www.kff.org/medicaid/issue-brief/key-state-policy-choices-

about-medicaid-home-and-community-based-services.

16

Three of 51 states allow individuals to self-direct home health state plan services. CA and NE allow self-direction

but are unable to report enrollment.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

22

17

AZ delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable

to separately report home health spending data. Instead, AZ’s home health state plan spending is included in its

Section 1115 waiver spending. Total home health state plan spending was $70 million in AZ in FY 2018.

18

HI delivers home health state plan services through a Section 1115 capitated managed care waiver and is unable

to separately report home health spending data. Instead, HI’s home health state plan spending is included in its

Section 1115 waiver spending. Total home health state plan spending was $4 million in HI in FY 2018.

19

NE reports home health state plan spending only for fee-for-service enrollees.

20

TX reports home health state plan spending only for fee-for-service enrollees.

21

KS delivers personal care state plan services through a Section 1115 capitated managed care waiver and is

unable to separately report personal care spending data. Instead, KS’s personal care state plan spending is included

in its Section 1115 waiver spending.

22

NM delivers personal care state plan services through a Section 1115 capitated managed care waiver and is

unable to separately report personal care spending data. Instead, NM’s personal care state plan spending is included

in its Section 1115 waiver spending.

23

NY is unable to report Section 1115 waiver managed LTSS spending by community vs. institutional setting. In 2015

(the most recent year for which NY data is available), total institutional and HCBS Section 1115 waiver spending was

$146,589,000.

24

Section 1915 (c) waiver participants were enrolled about 300 days a year on average in 2016, the most recent year

data are available. KFF analysis based on CMS 372 reports for Section 1915 (c) waivers in 2016.

25

The FY 2018 survey asked states to update prior years’ (FY 2016 and FY 2017) spending and enrollment data if

necessary; therefore, all trend analyses reflected in this report includes the most recently reported FY 2017 data.

26

Section 1115 waiver enrollment is not presented by target population because, unlike Section 1915 (c) waivers,

Section 1115 waivers can include multiple populations, and states only report total Section 1115 waiver enrollment in

our survey.

27

48 states offer Section 1915 (c) waivers targeted to people with I/DD. The other three states (AZ, RI, and VT) serve

their entire I/DD waiver populations under Section 1115. In addition, two states (NY and TN) serve some people with

I/DD under Section 1115 and others under Section 1915 (c).

28

42 states offer Section 1915 (c) waivers targeted to seniors and/or adults with physical disabilities. The other nine

states (AZ, DE, HI, NJ, NM, RI, TN, TX, and VT) serve all senior and adult with physical disabilities waiver

populations under Section 1115. In addition, three states (CA, NY, and WA) serve some seniors and adults with

physical disabilities under Section 1115 and others under Section 1915 (c).

29

11 states offer Section 1915 (c) waivers targeted to people with mental health disabilities. Another two states (DE

and RI) serve people with mental health disabilities under Section 1115. In addition, WA serves some people with

mental health disabilities under Section 1115 and others under Section 1915 (c).

30

21 states offer Section 1915 (c) waivers targeted to people with TBI/SCI. Another four states (DE, RI, VT, and WA)

serve people with TBI/SCI under Section 1115.

31

18 states offer Section 1915 (c) waivers targeted to children who are medically fragile or technology dependent.

Another two states (HI and RI) serve children who are medically fragile or technology dependent under Section 1115.

32

Five states offer Section 1915 (c) waivers targeted to people with HIV/AIDS. Another three states (DE, HI, and RI)

serve people with HIV/AIDS under Section 1115.

33

Four states (CA, DE, ID, and MS) serve people with I/DD under Section 1915 (i).

34

Four states (IA, IN, OH and TX) serve people with mental health disabilities under Section 1915 (i).

35

Three states (CT, DC, and NV) serve seniors and/or people with physical disabilities under Section 1915 (i). DC did

not report spending data.

36

Reporting states include CT and NV; DC did not report.

Medicaid Home and Community-Based Services Enrollment and Spending Growth

23

37

CA, DE, ID, and MS. ID per enrollee spending includes only the program for adults with I/DD because the state

was unable to report spending data for the program for children with I/DD.

38

IA, IN, OH, and TX.

39

KFF, Explaining Texas v. U.S.: A Guide to the 5

th

Circuit Appeal in the Case Challenging the ACA (Jan. 2020),

https://www.kff.org/health-reform/issue-brief/explaining-texas-v-u-s-a-guide-to-the-case-challenging-the-aca/

40

KFF, Potential Impact of Texas v. U.S. Decision on Key Provisions of the Affordable Care Act (Jan. 2020),

https://www.kff.org/health-reform/fact-sheet/potential-impact-of-texas-v-u-s-decision-on-key-provisions-of-the-

affordable-care-act/.

41

See also KFF, State Variation in Medicaid Per Enrollee Spending for Seniors and People with Disabilities (May

2017), https://www.kff.org/medicaid/issue-brief/state-variation-in-medicaid-per-enrollee-spending-for-seniors-and-

people-with-disabilities/.

42

KFF, Medicaid Financing: The Basics (March 2019), https://www.kff.org/medicaid/issuebrief/medicaid-financing-

the-basics/.

43

KFF, Why It Matters: Tennessee’s Medicaid Waiver Block Grant Proposal (Dec. 2019),

https://www.kff.org/medicaid/issue-brief/why-it-matters-tennessees-medicaid-block-grant-waiver-proposal/.

44

KFF, How Will Medicare-for-all Proposals Affect Medicaid? (Sept. 2019), https://www.kff.org/medicaid/issue-

brief/how-will-medicare-for-all-proposals-affect-medicaid/.

45

U.S. Census Bureau, Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Report

Number P25-1143, at 5 (March 2015), https://www.census.gov/library/publications/2015/demo/p25-1143.html.

46

U.S. Census Bureau, Older People Projected to Outnumber Children for First Time in U.S. History, Release

Number CB18-41 (March 13, 2018), https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-

projections.html.

47

Id.; U.S. Census Bureau, An Aging Nation: Projected Number of Children and Older Adults (last revised Oct. 9,

2019), https://www.census.gov/library/visualizations/2018/comm/historic-first.html.