Descriptive Overview and Summary of Balancing Incentive Program Participating States at Baseline


Joshua M. Wiener, PhD, Sarita L. Karon, PhD, Mary McGinn-Shapiro, MPP, Brieanne Lyda-McDonald, MS, and Trini Thach, BS
RTI International

Diane Justice, MA, Scott Holladay, MPA, and Kimm Mooney, BA
National Academy for State Health Policy

Mary Sowers, BA
National Association of State Directors of Developmental Disability Services

August 2015

Long-term services and supports (LTSS) are used by people with disabilities or chronic health conditions who need help with activities of daily living (e.g., bathing, dressing, eating) or instrumental activities of daily living (e.g., preparing meals, managing money). Historically, the financing and delivery of Medicaid LTSS has favored institutional care over home and community-based services (HCBS), such as personal care assistance. Despite the preferences of people with disabilities to live in the community, it is only in very recent years that Medicaid spending on institutional settings, such as nursing facilities, intermediate care facilities for individuals with intellectual disabilities, and psychiatric hospitals has been reduced to around 50% of LTSS expenditures. This picture of national spending on LTSS, however, masks wide variation across states and subpopulations of individuals who use LTSS. For example, the share of HCBS as a percentage of total Medicaid LTSS spending by state ranged from 27% in New Jersey to 78% in Oregon in Fiscal Year 2012.

The Affordable Care Act included several provisions designed to increase the provision of Medicaid HCBS and to improve the infrastructure for provision of those services. States that were, in 2009, spending less than 50% of total Medicaid LTSS expenditures on HCBS were eligible to participate in the Balancing Incentive Program. Participating states are expected to increase the share of LTSS dollars spent on HCBS, and to improve the LTSS infrastructure to create a more consumer-friendly, consistent, and equitable system, in exchange for which they receive an enhanced federal match rate for HCBS services. The rate of the enhanced federal match and the targeted rate of HCBS expenditures are dependent on the baseline spending of the state. All participating states are required to achieve three infrastructure goals: creation of a no wrong door (NWD)/single entry point system of application for LTSS, implementation of a core standardized assessment (CSA), and establishment of a conflict-free case management (CFCM) system.

To assess the status of the Balancing Incentive Program participating states at the beginning of the program or baseline, RTI International and our partners at the National Academy of State Health Policy and the National Association of State Directors of Developmental Disability Services reviewed states' Balancing Incentive Program applications and work plans, available data on state LTSS expenditures, and other sources of data. This report presents findings from that work. We describe the baseline status of the 21 states participating in the Balancing Incentive Program, including patterns of LTSS expenditures and progress toward the required infrastructure goals. Based on these data, we developed a "challenge score" for each state, which summarized the amount of work required to be completed relative to the amount of time available to the state. In addition, we describe the challenges each state faced and the strengths and resources they brought to the task. These strengths and challenges are affected by the additional, non-mandatory goals that states set for themselves, and the resources that states may have as a result of participating in other HCBS options and initiatives. The findings presented here offer a context for evaluation of states' progress toward the required goals.

Findings from this baseline review indicate the following:

  • There is significant variation among states in how close they are to achieving each of the goals. Some states are closer than others, but each faces some challenges.

  • States generally are closer to achieving expenditure goals than they are to achieving the infrastructure goals. Two states had achieved the required expenditure goals at the time of their application but were still eligible because the statute specified 2009 as the year in which the degree of rebalancing was to be measured.

  • States vary in how close they are to the required expenditure goal for different target populations. Overall, people with intellectual or developmental disabilities (I/DD) are being served in the community, but other populations have a longer way to go to achieve expenditure balance. Despite these differences in baseline status, most states are focusing their Balancing Incentive Program efforts across populations, rather than on a single population group.

  • At baseline, no state had achieved any one or more of the three required infrastructure reforms. States were closer to achieving a CSA and a NWD entry approach than they were to achieving CFCM.

  • States identified numerous strengths and challenges in their applications. Frequently mentioned strengths included making progress toward implementing the infrastructure goals, and the active use of other rebalancing options.

  • Frequently mentioned challenges concerned lack of adequate services, inadequate information systems, concerns with case management, and other issues related to general state policy.

  • All of the Balancing Incentive Program states are operating multiple Medicaid initiatives to improve the balance of LTSS provision. All Balancing Incentive Program states are participating in the Money Follows the Person program and are operating at least one 1915(c) waiver. Several states are participating in other waiver initiatives as well.

  • Engagement in multiple initiatives offers the opportunity to leverage resources, as well as the ability to address goals beyond those required under the Balancing Incentive Program. Many of the additional goals identified by states, although meaningful in their own right, also can play a role in moving states closer to achieving the mandatory Balancing Incentive Program goals. Several states are working to expand waiver programs and eliminate waiting lists, as well as to expand other programs to better serve new populations. Higher payment rates also may increase the share of LTSS dollars that are spent on HCBS. Improved quality measurement is an important goal, with no direct tie to the required goals.

  • Very few states chose to target their efforts to specific populations of users. One state (Maryland) planned to focus its efforts on the population with the lowest share of LTSS dollars being spent on HCBS: elders and people with physical disabilities. Other states (Indiana, Kentucky) that plan to focus on specific populations are placing emphasis on people with I/DD, who already are receiving much of their LTSS in the community. Massachusetts is unusual in its choice to focus efforts on people with behavioral health needs.

Together, these findings paint a picture of Balancing Incentive Program states that are highly engaged in rebalancing efforts, with numerous strategies being employed to achieve the required improvements in service and infrastructure. The range of strengths, challenges, and strategies being used offers opportunity throughout the evaluation to learn what approaches are most successful, and to offer guidance for future efforts.

The Full Report is also available from the DALTCP website ( or directly at