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40 states now cover around-the-clock Medicaid HCBS as provided in assisted living

(Credit: Henglein and Steets / Getty Images)

The number of state Medicaid waiver programs covering around-the-clock home- and community-based services like those provided by assisted living communities has grown over the past couple of decades, according to an analysis of data from the Centers for Medicare & Medicaid Services published in the August issue of Health Affairs.

Covered by waiver programs in 27 states in 1998, around-the-clock HCBS were covered in 40 states in 2020. The high point in recent years was 2010, when 41 states offered such services.

The analysis, looked at trends in Medicaid HCBS Section 1915(c) waivers and Section 1115 demonstration projects targeting older adults between 1998 and 2020. For purposes of the analysis, Washington, DC, was treated as a state.

Overall, the authors found that state Medicaid programs have expanded the use of HCBS over the years, with almost all of the 17 service categories examined seeing an increase in coverage and spending. The analysis found that the number of waivers grew, and the array of services covered through these programs also increased.

“Long a priority of many state policymakers, expansion of Medicaid home and community based services has been high on the federal policy agenda,” the authors wrote, adding that President Biden’s stalled social spending bill (Build Back Better) proposed increasing federal funding for Medicaid HCBS by $150 billion over 10 years. “Regardless of the fate of current efforts, there is momentum behind the trend,” they said.

The analysis found that almost all service categories experienced coverage growth. The most prevalent services were home-based services, with 49 to 51 states providing them throughout the study period (49 in 2020), followed by day services and caregiver support, as well as equipment, technology and home modifications (with 47 states providing services in all of those categories in 2020).

Two coverage areas that experienced large growth were services supporting self-direction and community transition. In 1998, only one state provided either service type, compared with 19 states providing self-direction services and 34 states providing community transition services in 2020.

The least prevalent service in 2020 was expenses for live-in caregivers, which were provided by one state, followed by mental health and behavioral services and participant training (14 states each).

The study found a “notable and persistent” lack of coverage for mental health and behavioral services, which the authors called “worrisome” given that 18.4% of people aged 65 or more years experienced symptoms of depression in 2019. But they noted that some state plans cover those services.

Total Section 1915(c) waiver spending more than tripled during the study period, going from $2.8 billion in 1999 to $9.9 billion in 2017. And spending in all categories, except other health and therapeutic services, increased.

Other trends noted in the analysis included a reduction in the number of Section 1915(c) waivers due to a greater use of Section 115 demonstrations and waiver consolidation.

The authors concluded that their results highlight that HCBS expansions take many forms and that understanding which bundles of services improve access and outcomes, and are effective in allowing people to age in place, should be the focus of future efforts.

CMS recently released its first-ever HCBS quality measure set in an effort to promote consistent quality measurement within and across state Medicaid HCBS programs.

Read more about the study in McKnight’s Home Care.

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