Interstate Variation and Progress Toward Balance in Use of and Expenditure for Long-Term Services and Supports in 2009. D. Progress on Home and Community-Based Services Use and Expenditures from 2006 to 2009

03/18/2014

The share of Medicaid LTSS expenditures allocated to HCBS and the share of LTSS users receiving HCBS reveal slight but notable increases in most states between 2006 and 2009 (Figure II.5).14 We compared performance on these two LTSS measures for the 35 states with reliable data in both 2006 and 2009 and found that the median state increased the percentage of LTSS expenditures for HCBS by 3.7 percentage points and the percentage of LTSS users receiving HCBS by about 3.3 percentage points.

Most states reported that HCBS accounted for a greater share of expenditures and users (roughly 1-5 percentage points for most) in 2009 than in 2006, although results varied somewhat across subpopulations of enrollees, and a few states experienced more substantial changes in performance. (See Appendix Tables D7-D12 for state-level detail.) Although the change was modest in most states, a few shifted notably toward greater emphasis on HCBS. Even in states that experienced observable declines in HCBS use, the decline was generally not observed in all populations or for both measures. New York, for example, reported the largest overall percentage point drop in LTSS users receiving HCBS (from 68.2 percent in 2006 to 64.5 percent in 2009). During the same period, however, the percentage of LTSS expenditures for HCBS increased by about 5 percentage points (from 45.3 percent to 50.0 percent), suggesting a complex shift in their LTSS system.


FIGURE II.5. Progress in Re-Balancing Toward HCBS from 2006 to 2009, 35 States

FIGURE II.5. Progress in Re-Balancing Toward HCBS from 2006 to 2009, 35 States

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data. Analysis of 2006 MAX data taken from Wenzlow et al. 2011. Figure includes all states with reliable LTSS data in both years.
NOTE: Excludes enrollees in managed care and those eligible for only restricted Medicaid benefits. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21.

(See Table D.15 for data.)


A number of factors may have caused the changes we identify in each state. These may include changes in MAX data reporting practices and demographic changes in the state's FFS LTSS population, as well as changes in state LTSS policies and programs. Moreover, the small size of certain subpopulations of enrollees in some states can lead to inordinately large and possibly misleading percentage point changes in expenditures or users from year to year.

Further investigation of changes in two states reveals the difficulty of interpreting comparisons to performance in previous years. First, in New York during this period, MAX shows that the proportion of individuals with disabilities who were enrolled in managed care plans, including managed LTSS plans, increased. This change may have affected the composition of the population that remained in FFS coverage, which may have affected the types of services these enrollees used.15 Second, the District of Columbia reported dramatic increases in both expenditures for HCBS and HCBS users from 2006 to 2009. The rates reported in MAX were comparable to rates reported in other data sources, including the CMS Form 64 and Form 372 data, but we were unable to identify state policy changes or changes in data reporting that appear to have directly caused these increases. Changes we identify in each state's LTSS system were probably complex and may be less dramatic than a straight comparison of performance indicates.

Figure II.6 shows the change (in percentage points) in the percentage of Medicaid LTSS expenditures allocated to HCBS for three subpopulations between 2006 and 2009: enrollees age 65 and older, enrollees under 65 with ID/DD, and other enrollees under age 65 with disabilities. As the figure shows, nearly all states that reported data showed increases in the percentage of LTSS expenditures going to HCBS for one or more subpopulations of enrollees. The percentage of Medicaid LTSS expenditures accounted for by HCBS increased by at least 5 percentage points for enrollees with ID/DD in 13 states, for aged enrollees in nine states, and for enrollees with other disabilities in eight states. Increases in shares of LTSS expenditures for HCBS occurred among states at all levels, including states that are relatively high performers on this measure (such as Missouri and Nevada), as well as states that have traditionally reported relatively lower rates HCBS use and expenditures (including Arkansas, Louisiana, and North Carolina).


FIGURE II.6. Percentage Point Differences in Percentage of Medicaid LTSS Expenditures for HCBS from 2006 to 2009, 35 States

FIGURE II.6. Percentage Point Differences in Percentage of Medicaid LTSS Expenditures for HCBS from 2006 to 2009, 35 States

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data. Analysis of 2006 MAX data taken from Wenzlow et al. 2011. Figure includes all states with reliable LTSS data in both years.
NOTES: Excludes enrollees in managed care and those eligible for only restricted Medicaid benefits. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21. In the District of Columbia, Vermont, and Washington, individuals with ID/DD could not be distinguished from enrollees with other disabilities. As a result, these states are excluded from analyses of the population under age 65 with ID/DD and enrollees with other disabilities.

(See Table D.16 for data.)


A few states, including the District of Columbia, Indiana, and Louisiana, reported improvements of about 10 percentage points or more across multiple subpopulations of enrollees. Despite its relatively low ranking on the share of expenditures devoted to HCBS in 2009, Louisiana increased that share by about 10 percentage points for all subpopulations. The increases occurred during a period of high-profile state governmental support for increasing the emphasis on HCBS, including an Executive Order by the Governor that established a two-stage process for reforming the state's LTSS system and receipt of a $3.2 million Real Choice Systems Transformation grant (which state officials proposed to focus on affordable and accessible housing, among other reforms), as well as additional funds provided by the state legislature to increase the number of people served by Medicaid HCBS waivers (Louisiana Department of Health and Hospitals 2007; AARP Public Policy Institute 2008).

Other states that reported progress toward HCBS re-balancing for certain populations of enrollees reported slower progress or declines for other subpopulations. Iowa, for example, increased the percentage of Medicaid LTSS expenditures for HCBS among aged enrollees from 20 percent in 2006 to 29 percent in 2009, while changes for enrollees with disabilities were more modest. As noted above, such differences may reflect state strategies to improve the systems for certain subpopulations, changes in the populations receiving these services, or changes in data reporting processes.


FIGURE II.7. Percentage Point Changes in Percentage of LTSS Users Receiving HCBS from 2006 to 2009, 35 States

FIGURE II.7. Percentage Point Changes in Percentage of LTSS Users Receiving HCBS from 2006 to 2009, 35 States

SOURCE: Mathematica Policy Research analysis of 2009 MAX data for 37 states and the District of Columbia with representative FFS LTSS data. Analysis of 2006 MAX data taken from Wenzlow et al. 2011. Figure includes all states with reliable LTSS data in both years.
NOTES: Excludes enrollees in managed care and those eligible for only restricted Medicaid benefits. HCBS include 1915(c) waiver services and state plan services for personal care, residential care, home health, adult day care, and private duty nursing. ILTC includes services provided in nursing homes, ICFs/IID, mental hospitals for the aged, and inpatient psychiatric facilities for people under age 21. In the District of Columbia, Vermont, and Washington, individuals with ID/DD could not be distinguished from enrollees with other disabilities. As a result, these states are excluded from analyses of the population under age 65 with ID/DD and enrollees with other disabilities.

( See Table D.17 for data.)


The percentage of LTSS users receiving HCBS also increased in most states from 2006 to 2009 (Figure II.7), although fewer states experienced changes of 5 percentage points or more. Nine states reported increased HCBS use of at least 5 percentage points for the aged, compared to five states each that reported this level of increase for individuals with ID/DD and those with other disabilities. Missouri stands out in this figure as experiencing a dramatic shift in rates of HCBS use from an increase of over 30 percent among individuals with ID/DD and a decline of almost 20 percent among individuals with other disabilities. Between 2006 and 2009, MAX data show increased enrollment in Medicaid waivers for individuals with ID/DD in Missouri. Moreover, during this period, average expenditures per waiver claim for individuals in waivers targeting the population of enrollees who were aged or had physical disabilities declined considerably. Such changes may represent a change in data reporting practices or a shift in state resources.


14 Among the 38 states included in the current analysis, New Hampshire and Texas were not included in the 2006 analysis and so performance cannot be compared for these states. In Kentucky, before 2008, many community health service claims were inaccurately reported as HCBS claims. This error in reporting was fixed by 2009, and, as a result, performance in 2009 cannot be reliably compared to performance in 2006.

15 For example, in the data, we observed that the number of enrollees receiving HCBS through the state plan on a FFS basis, including home health care and personal care services, declined during this period.

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