How The Delivery Of HCBS Has Changed In The US Since The Pandemic

In order to aid home- and community-based services, states are increasing provider payments to stave off the effects of workforce shortages.

Plenty of states have also increased self-directed and family caregiving opportunities for HCBS beneficiaries throughout the pandemic.

Those are two of the main takeaways from a recent study done by the Kaiser Family Foundation that took a closer look at the ongoing impacts of the COVID-19 pandemic on Medicaid HCBS programs.


The latest survey from KFF — its 20th — includes responses from state officials administering Medicaid HCBS programs in all 50 states and Washington D.C. The data was collected from April to September of 2022.

To no surprise, workforce shortages continue to affect the industry in a negative way. All 50 states reported that they were experiencing shortages of direct care workers in 2022.

Of those, 44 states reported at least one permanent closure of a Medicaid HCBS provider during the pandemic, up from 30 states in 2021. This is an indication that HCBS providers continue to feel the brunt of COVID-19’s effects, despite the significant need for these services.


All but two states – Alaska and Mississippi – responded to the workforce crisis by increasing HCBS provider payment rates. Half of those states required the rate increase to be passed through to workers’ wages.

Source: KFF

Some of those provider payment increases may have been supported through temporary American Rescue Plan Act (ARPA) funding or emergency PHE authorities, KFF reported.

However, more than half of the 48 states that increased pay rates plan to continue rate increases even after temporary funding expires.

Other changes

Self-directed and family caregiving opportunities also have spiked recently.

“All states offer at least one HCBS program with the option for enrollees to self-direct their services,” KFF reported. “48 states allow legally responsible relatives (LRRs) to be paid caregivers, up from 36 states in 2020.”

More than half of states (35) said they were using the ARPA funding on initiatives with high start-up costs that will hopefully save them money down the line.

Those initiatives included provider bonuses, incentive payments, developing and expanding worker training or certification programs, expanding workforce registries and upgrading IT systems.

Source: KFF

HCBS are a way to fill gaps in care for seniors with complex medical conditions. Medicaid is often the main source of coverage for long-term services and supports (LTSS).

Medicaid paid for about two-thirds of all HCBS in 2020. Waivers are the primary authority that states use to offer HCBS benefit packages with all 50 states and Washington D.C.

Unlike Medicaid state plan authorities — which require states to cover everyone who meets certain eligibility criteria — waivers allow states to provide services to specific populations and thus limit the number of people served.

While this process expands financial eligibility for states, it can also create waiting lists for HCBS.

The value in HCBS is clear, but workforce shortages and a lack of permanent funding could prove to be a major challenge moving forward.

“While states have adopted a number of policies to bolster the HCBS workforce, it remains to be seen whether initiatives undertaken during the pandemic will yield more systemic changes longer-term,” KFF wrote. “Although there is consensus on broad policy goals, there is little consensus on how to pay for significant federal investments needed to achieve these goals, suggesting it may be some time before major reforms are enacted.”

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