Availability and Use of State Medicaid HCBS
Data Collection and Compilation Methods
Medicaid HCBS can be provided as part of State plan services
or through waivers. State plan HCBS include mandatory services (all States must
offer them), and optional services (offered at States' discretion). Whether the
services are mandatory or optional, if they are provided under the State plan,
they must be offered to all eligible individuals. Services provided under
waivers may be restricted to specific groups based on geographic region, income,
or type of disability. Waivers may include a wider range of service types than
can be provided under State plans. Individuals may receive both State plan and
The findings presented in this section describe State-level
variation in the types of HCBS covered, populations covered, and services used
under both the State plan and 1915(c) waivers. Data are presented for all States
and the District of Columbia.
Most of the data on State plan HCBS were obtained from
"Medicaid At-a-Glance 2005: A Medicaid Information Source," an annual CMS publication
(2010b). These data were supplemented with information from other sources on
the coverage of adult day care (Alteras, 2007) and residential care (Mollica,
et al., 2005) under State plans.
We created a database of specific information about each
1915(c) waiver with an approval in effect in 2005. The CMS report "MAX 2005
Waiver Crosswalk" listed all waivers (1115, 1915(b), 1915(c), and 1915(b/c))
operating in 2005. We selected 1915(c) waivers from this list and used the information
as the basis for our database of 1915(c) waiver characteristics.
For each waiver listed, we identified information about the
qualifying level of care, populations covered, financial eligibility, and
covered services. Information about the waivers was abstracted from the CMS
online database of approved waiver applications (CMS, 2010d). Information for
160 of 284 waivers was available from the CMS Web site. Information for the
remaining 124 waivers was obtained from the University of California-San
Francisco Personal Assistance Services Web site (2010) and State Web sites.
Information from waiver application form version 3.5 or
later was standardized. Information from earlier 1915(c) applications on the
CMS Web site or from other sources was not standardized, making conceptual and
practical expertise of the authors essential to ensuring validity of the data
abstraction process. Frequent communication among those individuals helped to
maintain reliability of data abstraction. Information from sources other than
waiver applications may be incomplete.
Data on HCBS service use were obtained from the MAX files
and include information only about services provided on a fee-for-service
Availability of Home and Community Based Services
The services that may be offered under State plans or
through waiver programs can be quite similar. In this section, we describe the
patterns of coverage of these services in the States.
Availability of State Plan HCBS
Table 1 shows the availability of select HCBS through
State plans. Mandatory HCBS include those things considered "home health"
services—part-time nursing, registered nurse, health aide services—and medical
supplies/appliances. Optional State plan HCBS shown in this table include some
other home health services (home health therapies, private duty nursing),
personal care, hospice care (which may be provided inside or outside of the
home), transportation, adult day care, and residential care. "Targeted case
management" is an optional service under State plans, offered to individuals
who do not have access to case management services under a 1915(c) waiver plan.
It should be noted that optional State plan services may not
be limited on the basis of disability group (e.g., limited only to people with
brain injuries, people with developmental disabilities), nor may they be
restricted to specific geographic areas within a State. However, State plan
services may be restricted to groups based on Medicaid eligibility status:
categorically needy, optional categorically needy, medically needy, or other
populations with eligibility added through an 1115 waiver. There also may be
limits placed on the amount of service (e.g., a limit on the number of home
health visits). The information shown in Table 1 does not address variations
in coverage. It only indicates whether the service was available to one or more
of these eligible groups as a State plan service. As seen in the table, there
was great variation in the number and types of optional HCBS offered under State
- Nearly all States offer four optional services: home health
therapies (49), targeted case management (48), hospice care (48), and
- Home health therapies include physical therapy, speech and
language therapy, occupational therapy, and audiology services. All of the 49 States
that offer home health therapies offer physical and occupational therapies. Speech
and language therapy is offered by 48 States, and audiology services by 44 States
(data not shown).
- Few States (8) offer adult day care as a State plan option.
- Few States (14) offer residential care as a State plan option. However,
these data are drawn from a study (Mollica, et al., 2005) that was focused on
residential care types that serve elders (e.g., assisted living). Other types
of residential care may be used by people with developmental disabilities or
other types of needs (e.g., group homes, adult family homes). The data shown
here may therefore understate the extent to which residential care is provided
as a State plan service.
- On average, States offer 5.5 of the 8 optional State plan
services shown in this table (data calculated by authors). All States offer at
least two of these optional State plan HCBS, but only two States
(Massachusetts, New York) offer all of these optional State plan HCBS.
Availability of Waiver HCBS
States may offer multiple waivers, each one targeting
different populations, serving different geographic regions, or providing
different services. Table 2 shows the availability of select HCBS that States
offered through one or more 1915(c) waivers. This table shows whether any
1915(c) HCBS waiver in the State provided the type of service. The service need
not have been offered through all waivers operating in the State for it to be
shown in this table as available. In addition, the services shown here do not represent an
exhaustive list of the types of services available under waivers. The services
shown here are among those offered most often:
- Almost all States offered personal care (44) and case management
(43) services through 1915(c) waivers. Several other services also were offered
by most States. Durable medical equipment/supplies were covered under waivers
in 39 States; adult day/health care programs were offered by 33 States;
residential care was available in 32 States; and transportation was provided in
- Thirteen States offered all of the services listed in this table,
through one or more waivers. Of the services listed, Nebraska offered only
- Arizona offered none of these services under 1915(c) waivers. All
of Arizona's services are provided under an 1115 waiver.
Viewing Tables 1 and 2 together gives an overview of the
range of services provided to at least some portion of the State's population
who are eligible for HCBS. Personal care, case management, transportation,
adult day (health) care, and residential care may be covered either as optional
State plan or 1915(c) waiver services. However, waiver services may not
duplicate State plan services; the waiver must be fundamentally different from
that available through the State plan.
Fundamental differences may include some aspect of the type
of service (e.g., transportation only for medical appointments vs.
transportation for community involvement), or a difference in the intensity of
the service available (e.g., number of visits covered). Some States offer these
services under both types of programs:
- All States offered personal care services and (targeted) case
management to at least some of the people eligible for HCBS, either as an
optional State plan service or 1915(c) waiver service. Twenty-nine States offer
personal care under both types of programs, and 40 States offer case management
under both programs.
- All States except Delaware offered transportation services as a
covered service under either the State plan, one or more 1915(c) waivers, or
- Adult day (health) care programs were offered either as State
plan or waiver services in 37 States, and residential care was offered in 39 States.
Covered HCBS Participants
While State plan HCBS are available to all individuals who
meet the State's eligibility requirement, waiver services are available only to
individuals enrolled in the specific waivers. By design, waivers are available
only to subgroups of individuals within States who meet the eligibility
requirements of the specific waiver. These subgroups may be defined by age,
type of disability (e.g., physical disability, developmental disability,
traumatic brain injury), specific type of service need (e.g., technology
dependent), or geographic location within the State. In addition, waivers may
limit the number of people served ("slots") and may maintain a waiting list of
otherwise eligible people when a slot is not available.
Table 4 shows the number of people in the HCBS population in
total and by waiver use. The total column includes an unduplicated account of
all individuals who were in the HCBS population (i.e., who were enrolled in any
1915(c) waiver, who used any 1915(c) waiver services, or who used any State
plan HCBS services; see Definitions for further details). The waiver plan
column shows only those individuals who were enrolled in any 1915(c) waiver.
Data are shown by the type of waiver in which a person was
enrolled. An individual could be enrolled in more than one waiver plan, in
order to gain access to a broader variety of needed services. The column
labeled "Aged and Disabled" refers to waivers that target people in either of
these population groups, whereas the columns labeled "Aged Only" and "Physically
Disabled Only" are restricted to the people in those groups, respectively. However,
these categories are not mutually exclusive.
- Nearly one-half (1.06 million out of 2.2 million) of the total
HCBS population was enrolled in one or more waiver plans nationwide. The
percentage of the total HCBS population enrolled in a 1915(c) waiver ranged from
a low of 17.5 percent in California to 100 percent in Maine (percentages
calculated by the authors). Some of these people may also have used State plan
- Nationally, the largest numbers of people were enrolled in
waivers that served people by broad population (aged, people with physical
disabilities, people with mental retardation or developmental disabilities). Many
fewer were enrolled in waivers serving people with specific clinical conditions
(brain injury, HIV/AIDS, mental illness) or support needs (technology
- Only four States (CO, IN, KS, VT) had waivers that were designed
specifically for people with mental illness. People served through other types
of waivers may also have mental illness, either alone or in conjunction with other
- People may be enrolled in more than one waiver, so the sum of the
number of people across the waiver types may exceed the total with 1915(c)
waiver use or enrollment. In most States, it appeared rare for people to be
enrolled in multiple waivers, with the sum exceeding the reported total number
of unduplicated people by less than 1 percent. Minnesota was a notable
exception, with the calculated sum exceeding the reported total by more than 9
Use of Home and Community Based Services
Not all individuals who are eligible for State plan services
or who are enrolled in waiver programs use all of the available services. Tables
5 and 6 show the number of individuals who used the various services offered
under State plans and through 1915(c) waivers, respectively. Use of waiver and State
plan services are not mutually exclusive; some of the individuals shown in
Table 5 also may be reflected in Table 6.
The use of HCBS reflected in these tables is based on payments
reported in the MAX data. In some cases, payments were made for services that
are not generally part of the optional State plan (Table 1) or waivers (Table 2). This can result when States determine that specific services are
required to meet an individual's medical needs in the most appropriate,
Use of State Plan HCBS
Table 5 shows the number of individuals who used various State
plan HCBS. As with other data shown in this report, States vary greatly in the
patterns of service use:
- Nationally, the most frequently used optional State plan HCBS was
personal care, which was used by slightly more than one-third (35%) of the 2.2
million people who were eligible for any HCBS use (State plan or waiver). Almost
none (<1%) of the eligible people used this service in Virginia, while
nearly all (98%) eligible people in Arizona used personal care (percentages
calculated by the authors).
- Transportation also was a frequently used optional State plan
service, with 25 percent of eligible people nationwide making use of it. Other
than Arkansas, in which 98 percent of eligible people used transportation as an
optional State plan benefit, transportation was used by between 2 percent
(Virginia) and 48 percent (North Carolina) of eligible people.
- Optional State plan residential care was used by 5 percent of
HCBS-eligible persons nationwide, with State-level use ranging from less than 1
percent of eligible persons to nearly one-third (32%, Massachusetts). Although
provided as an optional State plan service in only 14 States (Table 1),
residential care was used by individuals in at least 36 States. Several of the States
that were described as not covering the service, but with reported use, had
significant numbers of people who used residential care. This was especially
true in Maryland and South Dakota, where more than 20 percent of eligible
individuals were reported to receive residential care as an optional State plan
service. Given the limitations of the residential care data previously
described, it is possible that the residential care services in these States
are those types generally used by people with developmental disabilities or
other people under age 65.
- Very few people used private duty nursing (<1% nationwide). The
greatest use was in Idaho, where 4 percent of people eligible for HCBS used
private duty nursing as a State plan option.
- Hospice also was used by only 1 percent of people nationwide, as
a State plan option. The greatest rates of use were observed in Nevada (10%)
and Utah (15%), suggesting the possibility of a regional phenomenon.
Use of Waiver HCBS
Table 6 shows the number of individuals who used each of
several select HCBS offered through 1915(c) waiver programs. Not all HCBS users
were enrolled in a waiver; nearly half (49%) used only HCBS provided under State
plans (Table 3). In addition, not all waivers provided all of the services
shown in this table.
Nationally, waiver services are used by relatively few
eligible individuals. With the exception of durable medical equipment/supplies,
fewer than 10 percent of eligible people used each of the waiver services shown
(personal care, case management, adult day/health care, residential care,
durable medical equipment/supplies, and transportation).
Durable medical equipment and supplies are an interesting
exception. These were used by the greatest number of individuals (12% of all
HCBS users nationwide). The number of people benefiting from durable medical
equipment/supplies is likely even higher when one considers the "durable"
nature of these items and the timeframe for analysis. That is, we report on use
of the benefits during 1 year, while equipment such as wheelchairs, commodes, and
walkers provide benefit over many years.
- While the use of waiver services shown in this table was low
nationally, the same was not true at the State level, where we observed high
rates of some services, varying by State. More than half of all HCBS users
received durable medical equipment/supplies under waivers in some States (South
Carolina, Oklahoma), while the number of people receiving these services was
too small to report in other States.
- Personal care waiver services were used by 5 percent of eligible
people nationwide. This service was reported to be covered by waivers in nearly
all (44) States (Table 2), but only 14 States showed use by a reportable
number of individuals (>10). States with the greatest share of eligible
persons using personal care were Alaska (29%), Connecticut (41%), Idaho (34%),
Minnesota (34%), South Carolina (62%), Virginia (34%), and Washington (47%).
- As was true for the optional State plan services, some States
report service use even when it does not appear to be a covered service under
the available waivers. This situation was observed with regard to residential
care (15 States), adult day/health care (12 States), and durable medical equipment/supplies
(11 States), as well as a small number of States in which personal care or
transportation were used even when not a covered service.
To fully understand the use of Medicaid HCBS, it is helpful
to consider the use of State plan and waiver services together. While there may
be some differences between the specific services, in general one can think of
the following pairings of services as being similar: State plan and waiver
personal care services; State plan targeted case management and waiver case
management; transportation under both State plan and waivers; State plan adult
day/health care and waiver adult day care; and residential care under both State
plans and waivers. Viewing Tables 5 and 6 together shows the extent to which
these services are used within a State, regardless of the method of accessing
them, and highlights the importance of these service types to individuals.
- In total numbers, most services are used more often under State
plans than waivers. Because State plan services, when available, are available
to all residents of a State, whereas waiver services may be limited by
geographic area or type of disability/health condition, this finding is not
- When one looks only at States in which people used services under
both types of programs, the pattern is more variable. In States where people
received services under both programs, more people received personal care, case
management, and residential care as a waiver benefit than a State plan benefit.
However, adult day care and transportation were received more often as a State
plan benefit than a waiver benefit.
- Although residential care was covered as both a State plan
option and waiver service in only 7 States, residential care actually was used as both a State plan and waiver service in 20 States.
- Although all States offered case management either as a waiver
benefit or as an optional State plan benefit (targeted case management), only
17 percent of the HCBS population used case management services. There was no
use of case management reported for the HCBS population in nine States.
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