Medicaid Home Care Demand Grows, States Grapple with Spending

More long-term care spending is going toward home- and community-based services (HCBS), according to a recent survey of all 50 states and the District of Columbia by Kaiser Family Foundation.

Through the three main Medicaid HCBS programs in 2014—mandatory state plan home health services, personal care services, and Section 1915 (c) waivers—nearly 3.2 million people received services. Forty-seven states offered 287 waivers, which allow states to expand financial eligibility and offer HCBS to seniors and people with disabilities who would otherwise qualify for institutional care.

In total, people who receive section 1915 (c) waivers comprise about half of Medicaid HCBS enrollment; people receiving home health state plan services make up just over 25% of enrollment; and personal care state plan services account for just under 25%, the survey found. Total spending for the three programs reached $58.5 billion in 2014, a 3% increase from 2013.


From 2013 to 2014, personal care state plan services declined 6%, according to the survey, following an 18% decrease from 2012 to 2013. Some of this decline is attributable to the rise of other HCBS services, such as the Community First Choice program and state waiver programs.

Overall, enrollment in all three state programs grew in 2014, in part from the expansion of Medicaid under the Affordable Care Act (ACA).

Medicaid policy changes


Beyond the increase in spending and use in HCBS, the survey took a look at 2016 Medicaid policies that were proving successful toward LTSS—long-term services and supports—goals.

In 2016, three-quarters of states—39—reported waiting lists for HCBS waiver programs, up from 36 states in 2015. The average wait time was 23 months across all HCBS waivers, according to the survey. Most states that expanded Medicaid under the ACA reported no HCBS waiver waiting lists or a decrease from 2015.

The majority of states, 82%, used some form of cost control, such as expenditure caps and geographic limits, on HCBS waivers beyond the federal cost neutrality requirement in 2016.

In addition, many states were grappling with new Department of Labor (DOL) requirements for home care workers that went into effect in 2016. Fifteen states planned to restrict workers’ hours; five states limited worker hours to 40 hours per week; and 10 states reported budgeting state funds for worker overtime and/or travel time pay from the DOL rule.

See the full survey results here.

Written by Amy Baxter

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