How Many People Use Medicaid Long-Term Services and Supports and How Much Does Medicaid Spend on Those People?

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In 2020, KFF estimates that 4.2 million other folks used Medicaid long-term services and products and helps (LTSS) delivered in domestic and network settings and 1.6 million used LTSS delivered in institutional settings (Determine 1). LTSS surround the huge vary of paid and unpaid clinical and private care services and products that help with actions of day by day residing (similar to consuming, bathing, and dressing) and instrumental actions of day by day residing (similar to getting ready foods, managing drugs, and house responsibilities). They’re equipped to those who want such services and products as a result of growing older, power sickness, or incapacity and could also be equipped in institutional settings similar to nursing amenities or in other folks’s properties and the network. Services and products equipped in non-institutional settings are most often known as home- and community-based services and products (HCBS) and come with quite a lot of services and products similar to grownup daycare, domestic well being, non-public care, transportation, and supported employment. In 2020, Medicaid used to be the principle payer for LTSS, masking over half of all LTSS spending in within the U.S. Regardless of Medicaid’s important position in investment LTSS within the U.S., eligibility for Medicaid LTSS is complicated and varies broadly via state. This knowledge word supplies an summary of Medicaid protection of LTSS, KFF estimates of what number of Medicaid enrollees used LTSS in 2020, how a lot Medicaid spent on enrollees who used LTSS, and coverage problems to look at within the coming years. Key takeaways come with:

  • In 2020, there have been 5.6 million individuals who used Medicaid LTSS, of which 4.0 million (72%) used best HCBS, 1.4 million (24%) used best institutional care, and nil.2 million used each (4%) (Determine 1). The proportion of other folks the usage of Medicaid LTSS best in domestic and community-based settings ranged from 45% in Maine to 94% in North Carolina (Determine 2).
  • Medicaid spending per-person used to be just about 9 occasions upper for individuals who used LTSS than for many who didn’t use LTSS ($38,769 vs. $4,480), with specifically top spending for individuals who used institutional LTSS (Determine 4).
  • Individuals who used Medicaid LTSS comprised 6% of Medicaid enrollment however 37% of federal and state Medicaid spending, reflecting the generally high cost of LTSS and extra intensive well being wishes that result in upper use of alternative well being care services and products and medication (Determine 5).

KFF’s estimates vary from the collection of other folks the usage of Medicaid LTSS reported via the Facilities for Medicare & Medicaid Services and products (CMS), which discovered that about 11 million Medicaid enrollees used LTSS in 2019. CMS counts are upper than KFF counts as a result of CMS defines LTSS extra extensively and comprises enrollees who might best use LTSS on a unmarried day. CMS counts come with people who find themselves the usage of services and products similar to behavioral well being, rehabilitation, well being properties, and case control, however no different LTSS, while KFF best incorporated enrollees in the event that they have been the usage of the services and products known within the information word under. CMS additionally counted other folks as the usage of LTSS if they’d a number of claims for a provider, however KFF’s definition goals to seize best people who find themselves the usage of the services and products on an ongoing foundation.

What are Medicaid Lengthy-Time period Services and products and Helps?

Medicaid LTSS are usually labeled via the positioning through which they’re equipped: both in an institutional environment or in home- and community-based settings, often referred to as HCBS. Institutional care comprises care equipped in a nursing facility, which is a mandatory Medicaid receive advantages, and care equipped in an intermediate care facility for other folks with highbrow disabilities, which is an non-compulsory receive advantages that every one states lately make a choice to hide. HCBS come with a broader vary of advantages, which can be all non-compulsory with the exception of for domestic well being care. HCBS first was to be had as a Medicaid “waiver” possibility and in that capability, services and products have been usually to be had to positive forms of Medicaid enrollees similar to the ones with highbrow disabilities or the ones with bodily disabilities.

Within the remaining two decades, a number of new authorities had been created, permitting states to additionally be offering HCBS in the course of the Medicaid state plan (see Appendix Table 1 for a listing of HCBS government). If services and products are equipped thru a state plan, they should be introduced to all eligible people. Against this, services and products equipped below waivers, similar to 1115s or 1915(c)s, could also be limited to express teams in keeping with geographic area, source of revenue, or form of incapacity. Waivers may additionally come with a much wider vary of provider varieties than will also be equipped below state plans. Traditionally, Medicaid spent extra money on LTSS in institutional settings than on LTSS delivered in domestic and community-based settings, however tasks to balance HCBS and institutional care have modified that pattern. Since 2013, Medicaid has spent extra on HCBS than institutional care.

How Many Other folks Used Medicaid LTSS in 2020?

In 2020, there have been 5.6 million individuals who used Medicaid LTSS, of which 4.0 million (72%) used best HCBS, 1.4 million (24%) used best institutional care, and nil.2 million used each (4%) (Determine 1). Those counts and stocks didn’t exchange significantly between 2018 and 2020. KFF’s present depend of the collection of other folks the usage of Medicaid LTSS is less than the collection of other folks the usage of LTSS reported via the Facilities for Medicare & Medicaid Services and products (CMS) as a result of KFF best counted other folks as the usage of LTSS in the event that they used institutional care or HCBS on an ongoing foundation. CMS incorporated a broader set of services and products of their definition of LTSS and didn’t require other folks to make use of the services and products on an ongoing foundation. KFF’s present counts additionally vary moderately from KFF’s annual HCBS survey as a result of variations in how states document information in surveys as opposed to how they’re mirrored within the claims. As an example, states don’t document unduplicated counts of general enrollees throughout several types of advantages in KFF’s survey information. See strategies for extra element.

In 2020, just about three-quarters (72%) of people that used Medicaid LTSS have been completely served in domestic and community-based settings, however this ranged from 45% in Maine to 94% in North Carolina (Determine 2). The bigger percentage of other folks receiving care in the neighborhood versus in an establishment displays tasks to make domestic and community-based care extra broadly to be had lately and to take away what has been known as the “institutional bias” in Medicaid. The shift in opposition to HCBS is instantly obvious in analyses of Medicaid spending on LTSS: The share of LTSS spending that will pay for HCBS has greater from best 12% in 1988 to 59% in 2019. Whilst the collection of other folks the usage of Medicaid HCBS exceeds the quantity who use institutional care nationally, a number of states nonetheless serve fewer than part of other folks in completely domestic and community-based settings. Over 5% of Medicaid LTSS customers in 8 states (MN, IN, TN, NJ, IL, CT, KS, and OH) used each institutional care and HCBS. Such other folks can have transitioned between institutional and community-based settings because of adjustments of their degree of want all over the yr.

A few of the 4.2 million individuals who used HCBS in 2020, no less than 1.9 million used services and products equipped thru a state plan similar to domestic well being and private care and no less than 1.7 million won services and products thru a waiver (Determine 3). Federal Medicaid statute requires states to hide domestic well being, however the rest of HCBS are non-compulsory. An extra 837,000 other folks used different HCBS services and products that have been a mixture of state plan and waiver services and products. Amongst individuals who used domestic well being, non-public care, and “different” HCBS, 0.5 million used a couple of form of HCBS. (KFF labeled other folks the usage of waiver services and products as best the usage of waiver services and products, even supposing in some states, other folks may doubtlessly obtain services and products thru a waiver and in the course of the state plan.) In maximum states, the variety of advantages to be had thru a waiver are extra complete than the ones to be had in the course of the state plan (see Appendix Desk), however maximum states prohibit the quantity of people that might use waiver services and products, continuously leading to ready lists. In a 2022 survey of states HCBS systems, states reported that there have been 656,000 people on waiting lists, with other folks ready a median of 45 months to obtain waiver services and products.

What Do We Know About Spending for Other folks Who Used Medicaid LTSS in 2020?

Medicaid spending per-person is upper for individuals who use institutional LTSS and those that use HCBS when put next to people who don’t use any LTSS, however spending for other folks the usage of institutional LTSS is especially top (Determine 4). In 2020, Medicaid spending—together with LTSS and different services and products similar to medical institution care and pharmaceuticals—for the 5.6 million enrollees who used Medicaid LTSS, totaled just about $217 billion. According to-person spending for those enrollees used to be $38,769. When compared, Medicaid spent $4,480 according to enrollee who didn’t use Medicaid LTSS, even supposing that general comprises kids who contain 40% of Medicaid enrollees and have a tendency to have a lot decrease spending per person. Medicaid spent a median of $36,275 according to consumer for individuals who used HCBS and $47,279 according to consumer for individuals who used institutional LTSS.

Individuals who used Medicaid LTSS comprised 6% of Medicaid enrollment however 37% of federal and state Medicaid spending (Determine 5). The 5% of Medicaid enrollees who used HCBS comprised 26% of Medicaid spending and the two% of Medicaid enrollees who used institutional LTSS comprised 13% of Medicaid spending. Top per-person Medicaid spending amongst enrollees who use LTSS most probably displays the generally high cost of LTSS and extra intensive well being wishes amongst such teams that result in upper use of alternative well being care services and products and medication as smartly.

What Present Coverage Questions May Impact Other folks Who Use Medicaid LTSS?

The COVID-19 pandemic a great deal exacerbated shortages of LTSS employees, and plenty of coverage questions pertain to increasing the staff taking care of individuals who use Medicaid LTSS. Contemporary research at the Peterson-KFF Health System Tracker displays that, as of June 2023, the collection of employees in LTSS settings used to be measurably less than in early 2020. Shortages and top turnover amongst LTSS employees replicate hard working conditions and relatively low wages. Team of workers shortages have side effects at the quality of care equipped in institutional LTSS settings, and continuously lead to other folks getting fewer hours or forms of HCBS than they want. All over the pandemic, states relied on family caregivers to lend a hand fill a few of the ones gaps, however many pandemic-era insurance policies will result in November 2023 if they don’t seem to be transitioned into everlasting insurance policies.

The government might use its authority to require greater staffing for Medicaid LTSS, however it isn’t transparent what the precise insurance policies shall be or how they are going to be applied. The Biden Management is predicted to unlock a proposed rule that will build up nursing facility staffing ranges within the close to long run, however it’s unknown what the brand new staffing ranges could be. KFF analysis reveals that even supposing just about all amenities would meet a demand of two.5 or fewer HPRD and 85% of amenities would meet a demand of three.0 HPRD, however with regards to part (45%) of all nursing amenities would now not meet a three.5 HPRD necessities, and best 29% would meet an HPRD of four.0. For HCBS, the Biden Management not too long ago launched a proposed rule geared toward making sure get right of entry to to Medicaid services and products, which has a number of notable provisions geared toward addressing HCBS staff demanding situations. Particularly, the states can be required to document fee charges for positive HCBS, to display that fee charges are “ok” to give you the degree of services and products in enrollees’ personalised care plans, and to verify no less than 85% of bills are handed thru to employee repayment for positive forms of HCBS. Upper staffing ranges may build up fee charges and spending for LTSS, nevertheless it’s unknown who would pay the ones further prices.

Even though maximum states have greater fee charges for LTSS, it’s unclear the place further investment would come from to additional build up fee charges and have interaction further body of workers. In an FY 2022 survey carried out of Medicaid officers in all 50 states and D.C., 44 states applied Medicaid fee will increase in FY 2022 for nursing amenities. In a similar fashion, a 2022 survey of Medicaid HCBS systems discovered that almost all states reported experiencing shortages of direct care employees and plenty of reported adopting insurance policies to strengthen the HCBS staff, similar to offering recruitment or retention bonuses and lengthening supplier fee charges. Lots of the HCBS tasks have been funded via additional federal investment to be had in the course of the American Rescue Plan Act, however as that investment expires, states should in finding choice investment resources in the event that they need to handle spending ranges.

Having a look forward, because the inhabitants continues to age, it’s most probably that extra other folks will want Medicaid LTSS and that staff demanding situations will persist. The information on LTSS customers supply a wealthy supply of details about who’s the usage of LTSS and this knowledge word highlights what number of people are lately the usage of LTSS and what forms of LTSS they’re the usage of.

State Plan Advantages
House Well being Services and products Required
  • Phase-time or intermittent nursing services and products, domestic well being aide services and products, and clinical provides, apparatus and home equipment appropriate to be used in the house
  • At state possibility – bodily treatment, occupational treatment, and speech pathology and audiology services and products
House Well being in T-MSIS
Non-public Care Not obligatory
  • Help with self-care (e.g., bathing, dressing) and family actions (e.g., getting ready foods)
Non-public Care in T-MSIS
Phase 1915(i) Not obligatory
  • Case control, homemaker/domestic well being aide/non-public care services and products, grownup day well being, habilitation, respite, day remedy/partial hospitalization, psychosocial rehabilitation, power psychological well being hospital services and products, and/or different services and products authorized via the Secretary
  • Beneficiaries should be vulnerable to institutional care
  • Inhabitants concentrated on accredited
Non-public Care or Different in T-MSIS
Phase 1915(j) Not obligatory
  • Lets in people who find themselves the usage of HCBS to “self-direct” their services and products
  • Self-direction permits other folks to make a choice their very own suppliers, identify fee charges, and allotted other services and products inside of a hard and fast funds
House Well being, Non-public Care, or Different in T-MSIS
Group First Selection (1915(k)) Not obligatory
  • Attendant services and products and helps for beneficiaries who would in a different way require institutional care
  • Source of revenue as much as 150% FPL or eligible for receive advantages package deal that comes with nursing domestic services and products; state way to amplify monetary eligibility to these eligible for HCBS waiver
Non-public Care or Different in T-MSIS
HCBS Waivers
Phase 1915(c) Not obligatory
  • Similar services and products as to be had below Phase 1915 (i)
  • Beneficiaries should in a different way require institutional care
  • Secretary can waive common program source of revenue and asset limits
  • Price neutrality required (reasonable according to enrollee value of HCBS can not exceed reasonable according to enrollee value of institutional care)
  • Enrollment caps and waiting lists accredited
  • Geographic limits accredited
  • Inhabitants concentrated on accredited
1915(c) in T-MSIS*
Phase 1115 Not obligatory
  • Secretary can waive positive Medicaid necessities and make allowance states to make use of Medicaid budget in ways in which aren’t in a different way allowable below federal laws for experimental, pilot, or demonstration tasks which are more likely to help in selling program goals
  • Federal funds neutrality required
  • HCBS enrollment caps accredited
1115 Waiver in T-MSIS*
NOTES: *Signifies the principle class through which KFF categorizes individuals who use HCBS, although now not all states use all fields, so in some instances, many of us shall be grouped with domestic well being or non-public care even if they’re the usage of the ones services and products below any other authority.

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