KFF estimates that just about 6 million people obtain Medicaid long-term services and products and helps (LTSS) for help with actions of day-to-day residing (corresponding to consuming, bathing, and dressing) and instrumental actions of day-to-day residing (corresponding to getting ready foods, managing drugs, and house responsibilities). LTSS are equipped to those that want such services and products as a result of getting older, continual sickness, or incapacity and is also equipped in institutional settings corresponding to nursing amenities (1.6 million other people) or in other people’s houses and the network (4.2 million other people). This research examines the traits of Medicaid enrollees who use LTSS, how enrollees who use LTSS fluctuate from those that don’t use LTSS, and the way enrollees who use various kinds of LTSS fluctuate from every different. For main points on strategies, please see KFF’s earlier data note, which described the quantity of people that use LTSS and what sort of Medicaid spends on the ones other people.
Key takeaways come with:
- Age, Intercourse, and Race: Over part (56%) of Medicaid enrollees who use LTSS extensively are underneath 65, however the age distribution varies via form of provider. Maximum enrollees who use Medicaid home- and community-based services and products (HCBS) are underneath age 65, whilst maximum enrollees who use institutional LTSS are ages 65 and older. Amongst enrollees who use LTSS, men are most often more youthful than women. Over two times as many men are underneath the age of 18 in comparison with women (16% vs. 8%). Simply over part (51%) of all Medicaid enrollees who use LTSS are White, 19% are Black, and 14% are Hispanic.
- Eligibility Crew: Over two-thirds (70%) of enrollees who use LTSS and are underneath 65 qualify for Medicaid as a result of a incapacity. The Inexpensive Care Act (ACA) Medicaid growth has expanded get entry to to LTSS: 1 in 5 enrollees underneath 65 who use institutional LTSS and 1 in each 10 enrollees underneath 65 who use Medicaid HCBS are eligible for Medicaid during the ACA growth.
- Medicare Protection: 62% of Medicaid enrollees that use LTSS also are enrolled in Medicare, and the percentage is upper amongst those that use institutional LTSS (79%) in comparison with those that use HCBS (56%).
- Well being Stipulations: Enrollees who use LTSS are a lot more prone to be identified with ongoing well being prerequisites than enrollees who don’t use LTSS, with the easiest charges of diagnoses amongst older enrollees who use institutional LTSS.
What are the demographic traits of Medicaid enrollees who use LTSS?
Over part (56%) of Medicaid enrollees who use LTSS are underneath 65, however those that use LTSS are nonetheless older than those that don’t use LTSS (Determine 1). LTSS are recurrently related to other people ages 65 and older, however many more youthful enrollees use LTSS as a result of continual sickness or incapacity. The rest 45% of enrollees who use LTSS are 65 and older. When compared, best 5% of Medicaid enrollees who don’t use LTSS are ages 65 and older.
Male Medicaid enrollees who use LTSS are much more likely to be underneath 65 and two times as prone to be underneath 18 as feminine enrollees who use LTSS (Determine 1). The more youthful age distribution of men is also associated with higher rates of diagnoses of highbrow and developmental disabilities amongst younger boys than amongst younger ladies. Male enrollees who use LTSS can also be more youthful than feminine enrollees who use LTSS since ladies most often live longer than males.
Medicaid enrollees who use LTSS are much more likely to be White and not more prone to be Hispanic in comparison to people who don’t use LTSS (Determine 1). Those information are from the 31 states that reported “low/medium concern” information high quality ranges with their race and ethnicity information in 2020. People who find themselves White include simply over part (51%) of all Medicaid enrollees who use LTSS, however best 39% of enrollees who don’t use LTSS. People who find themselves Hispanic include simply 14% of all Medicaid enrollees who use LTSS, however 25% of enrollees who don’t use LTSS. This development would possibly, partly, replicate variations in age distribution throughout racial and ethnic teams, with over part (53%) of Hispanic enrollees underneath age 19 in comparison with 37% of White enrollees (information no longer proven). The percentage of enrollees who’re Black is the same amongst those that use LTSS and people who don’t (19% and 20% respectively).
Simply over two-thirds (70%) of people that use Medicaid LTSS and are underneath age 65 qualify for Medicaid as a result of a incapacity (Determine 1). Amongst Medicaid enrollees underneath age 65 who don’t use LTSS, best 12% are eligible for Medicaid as a result of a incapacity. The rest 30% of enrollees who use LTSS are eligible during the kid eligibility workforce, the Inexpensive Care Act (ACA) growth workforce, or thru any other grownup eligibility workforce.
Enrollees who use Medicaid HCBS are much more likely to be more youthful, Black or Hispanic, and obtain Medicaid as a result of a incapacity when in comparison to enrollees who use institutional LTSS (Determine 2). There are notable variations within the traits of people that use HCBS and institutional LTSS. Amongst individuals who use HCBS, 14% are underneath age 19, and 49% are ages 19-64, while over two-thirds of people that use institutional LTSS are ages 65 and older. Amongst each teams, women who use LTSS have an older age distribution than men who use the similar form of LTSS. Enrollees who use HCBS are much more likely to be Black or Hispanic (36%) than enrollees who use institutional LTSS (24%). People who find themselves White include 47% of people that use HCBS however 64% of people that use institutional LTSS. Those variations most likely replicate to the more youthful age distribution of Hispanic enrollees who use any LTSS: 19% of Hispanic enrollees who use LTSS are ages 0-18 in comparison with 10% of White enrollees (information no longer proven). Amongst each enrollees who use institutional LTSS or HCBS, the general public underneath the age of 65 are eligible for Medicaid as a result of a incapacity, however the proportion of other people eligible for Medicaid thru an ACA growth is 10% amongst individuals who use HCBS and 20% amongst individuals who use institutional LTSS.
What percentage of Medicaid enrollees who use LTSS also are enrolled in Medicare?
Maximum (62%) Medicaid enrollees who use LTSS also are enrolled in Medicare (“dual-eligible people”) (Determine 3). Handiest 8% of Medicaid enrollees who don’t use LTSS have Medicare. The prime fee of Medicare protection amongst Medicaid enrollees who use LTSS displays the older age distribution of enrollees who use LTSS and prime charges of eligibility for Medicaid in keeping with a incapacity. To be eligible for Medicare, other people will have to most often be ages 65 and older, or have a incapacity that qualifies them for the federal incapacity insurance coverage program (other people in that program are best eligible for Medicare after a 2-year ready duration). Just about all enrollees over age 65 are enrolled in Medicare without reference to whether or not they use LTSS. Enrollees underneath 65 who use LTSS have upper charges of Medicare protection when put next to people who don’t use LTSS (35% in comparison with 4%).
The share of enrollees with Medicare is upper amongst those that use institutional LTSS (79%) in comparison with those that use HCBS (56%) (Determine 3). 34% of enrollees who’re underneath 65 and use HCBS even have Medicare protection, in comparison to 40% of enrollees who’re underneath 65 and use institutional LTSS. Just about all enrollees over 65 who use both HCBS or institutional LTSS have Medicare protection.
What percentage of Medicaid enrollees who use LTSS have a analysis of no less than one ongoing well being situation?
Charges of ongoing well being prerequisites are upper amongst Medicaid enrollees underneath 65 with out Medicare who use LTSS in comparison with those that don’t use LTSS (Determine 4). Charges of continual prerequisites are best to be had for Medicaid enrollees who do not need Medicare as a result of for dual-eligible people, Medicare is the principle payer of acute care services and products and well being prerequisites would possibly not display up within the Medicaid information (Field 1). All enrollees 65 and older also are excluded as a result of fewer than 5 % of other people 65 and older do not have Medicare. Well being prerequisites come with a listing of 30 chronic conditions maintained via the Facilities for Medicare & Medicaid Services and products and a hallmark for whether or not enrollees had an weight problems analysis within the Medicaid claims information (defined as ICD-10 analysis codes inside of E66.0, E66.1, E66.2, E66.8, E66.9, Z68.3, Z69.4, and Z68.54.)
Amongst enrollees underneath 65 with out Medicare, 33% of enrollees ages 0-18 who use LTSS have a analysis of no less than one ongoing well being situation in comparison with 15% of those that don’t use LTSS. In a similar way, 76% of the ones 19-64 who use LTSS have a analysis of no less than one ongoing well being situation in comparison to 38% who don’t use LTSS. Enrollees who do not need a analysis for an ongoing well being situation would possibly obtain LTSS for any choice of different causes, together with frailty. Frailty is a fancy well being state that describes the decline in well being and larger bodily vulnerability that includes getting older, continual and innovative sickness, or within the aftermath of a significant coincidence or stroke. Folks with frailty would possibly not have a analysis for any ongoing well being prerequisites, however frailty is a vital explanation why that folks want lend a hand with day-to-day non-public care actions corresponding to bathing or dressing.
Charges of well being prerequisites are best rather upper amongst those that use institutional LTSS in comparison with those that use HCBS (Determine 4). For enrollees who use HCBS, 33% of the ones ages 0–18 have a prolonged situation in comparison with 74% of the ones ages 19-64. Those charges are best rather less than enrollees who use institutional LTSS. For enrollees who use institutional LTSS, 37% of enrollees ages 0–18 have a prolonged situation in comparison with 89% of enrollees ages 19-64.
Amongst Medicaid enrollees underneath age 65, positive well being prerequisites, specifically, are upper amongst those that use LTSS than amongst those that don’t (Appendix Desk 1). Amongst enrollees ages 0-18, 9% of enrollees with out Medicare who use LTSS have a psychological well being analysis in comparison with best 3% of those that don’t use LTSS. In a similar way, amongst enrollees 19-64, 33% of enrollees who use LTSS have a psychological well being situation in comparison with best 12% of those that don’t use LTSS; and 18% of enrollees who use LTSS have an weight problems analysis in comparison with 8% of enrollees who don’t. Different well being prerequisites, corresponding to pneumonia (10% vs 2%) and diabetes (27% vs 7%), are in a similar fashion extra not unusual amongst enrollees ages 19-64 the use of LTSS when put next to people who don’t.
For Medicaid enrollees underneath age 65 who use LTSS, the commonest continual prerequisites are an identical for individuals who use HCBS and institutional care, despite the fact that the charges of the ones prerequisites are quite upper amongst individuals who use institutional care (Appendix Desk 1). Amongst enrollees underneath age 19, the 3 maximum not unusual prerequisites come with: psychological well being prerequisites (affecting 9% of youngsters who use HCBS and 18% of youngsters who use institutional LTSS), bronchial asthma (affecting 11% of youngsters who use HCBS and 10% of youngsters who use institutional LTSS), and weight problems (affecting 6% of youngsters who use HCBS and seven% of people that use institutional LTSS). Amongst enrollees ages 19-64, the commonest prerequisites come with high blood pressure (affecting 36% of adults who use HCBS and 57% of adults who use institutional LTSS), psychological well being prerequisites (affecting 31% of adults who use HCBS and 45% of adults who use institutional LTSS), and diabetes (affecting 26% of adults who use HCBS and 35% of adults who use institutional LTSS).
|KFF identifies other people’s well being prerequisites thru analysis codes on Medicaid claims and stumble upon information. Claims are data of expenses submitted via suppliers as a way to be reimbursed via the state Medicaid program. Come upon information are data of the services and products won via people who find themselves enrolled in Medicaid well being plans. Not like claims, they don’t come with fee data since the well being plans pay suppliers as an alternative of the state Medicaid program.
Some Medicaid enrollees—referred to as dual-eligible individuals—even have Medicare and for the ones other people, Medicare is the principle payer for many well being care services and products. Medicaid will pay for Medicare premiums and most often, value sharing. For dual-eligible people who are eligible for complete Medicaid, Medicaid additionally covers supplemental advantages corresponding to LTSS and non-emergency clinical transportation. In lots of circumstances, there shall be no Medicaid claims or stumble upon information when services and products are coated via Medicare. With out claims, there aren’t any analysis codes for dual-eligible people. In consequence, it’s not possible to appropriately determine charges of well being prerequisites in Medicaid information for dual-eligible people. Roughly 9.7 million full-benefit duals are excluded from the calculations in Determine 4.
What key problems would possibly have an effect on those that use Medicaid LTSS?
Are there enough employees to fulfill the upper staffing ranges sought in proposed laws? Long-standing staffing shortages in long-term care amenities predate the COVID-19 pandemic, however the pandemic exacerbated them and the quantity of workers employed at professional nursing care and aged care amenities was once nonetheless underneath pre-pandemic ranges in October 2023. The government lately launched a proposed rule that might create new necessities for nurse staffing ranges in nursing amenities. KFF analysis unearths that fewer than 1 in 5 may just these days meet the specified choice of hours for registered nurses and nurse aides, however amenities could have a number of future years into compliance and the proposed rule contains hardship exemptions. For HCBS, the Biden Management lately launched a proposed rule aimed toward making sure get entry to to Medicaid services and products, which has a number of notable provisions aimed toward addressing HCBS staff demanding situations. States could be required to document fee charges for positive HCBS, to exhibit that fee charges are “good enough” to give you the stage of services and products in enrollees’ personalised care plans, and to verify no less than 85% of bills are handed thru to employee reimbursement for positive kinds of HCBS.
Will there be further obstacles to gaining access to Medicaid HCBS as public well being emergency government finish and enhanced federal investment runs out? Spotting the significance of conserving other people out of congregate settings and that HCBS staff demanding situations have been exacerbated right through the COVID-19 public well being emergency, the government equipped states with new government and investment to handle get entry to to HCBS right through the general public well being emergency (PHE). States used the extra investment and versatility to extend fee charges, pay circle of relatives caregivers, and extend get entry to to HCBS. Despite the fact that many states are operating to make the PHE adjustments everlasting, KFF findings point out that some states will revert to their pre-PHE insurance policies, doubtlessly lowering get entry to to HCBS or bills to suppliers. Investment made to be had via the American Rescue Plan Act to “give a boost to, extend, and make stronger” HCBS could also be set to run out in March 2025, despite the fact that states would possibly exhaust the extra investment sooner than that point.
Because the inhabitants continues to age and extra other people want Medicaid LTSS, how would possibly coverage makers intention to extend get entry to to care? Because the 25th anniversary of the Olmstead court decision—which calls for other people with disabilities to be served in essentially the most built-in atmosphere this is suitable—nears, there is also larger consideration at the extent to which integration has took place and the place additional integration remains to be wanted. Alongside the ones traces, a recent proposed rule clarifies the duty for states to supply services and products in essentially the most built-in atmosphere suitable—codifying the Olmstead resolution and clarifying that failing to supply services and products in essentially the most built-in atmosphere suitable is a type of discrimination. Information describing the diversities between people who find themselves the use of institutional LTSS and HCBS is helping remove darkness from which populations are possibly to obtain built-in care and which might be nonetheless served in basically segregated settings. Past the people who find themselves these days the use of Medicaid LTSS, there are with regards to 0.7 million other people on waiting lists or pastime lists for Medicaid HCBS. Whilst those information are a less than excellent measure of unmet want, they do recommend there was constant unmet want for those services and products and feature been described as contributing to the chance of useless institutional for other people with disabilities. Recent research additionally unearths that there are disparities in HCBS spending, get entry to, and results amongst communities of colour, together with upper charges of unmet LTSS wishes.