REP O RT Medicaid Home and October 2016 Community-Based Ser vices Programs: 2013 DATA UPDATE Prepared by: Terence Ng and Charlene Harrington University of California, San Francisco and MaryBeth Musumeci and Petry Ubri Kaiser Family Foundation As states continue to implement various aspects of the Affordable Care Act (ACA), developing and expanding home and community-based alternatives to institutional care remains a priority for many state Medicaid programs. 2013 marked the first time that home and community-based services (HCBS) accounted for a majority (51%) of national Medicaid long-term services and supports (LTSS) spending, increasing from 18 percent in 1995.1 The share of Medicaid LTSS spending devoted to HCBS has continued to rise, reaching 53 percent in 2014. 2 At the same time, state Medicaid programs are operating at a time when state revenues are 0F slowing, forcing more moderate spending growth and, as of 2016, continue to face the competing priorities of implementing the ACA's streamlined eligibility and enrollment processes, determining whether to adopt the ACA's Medicaid expansion, and pursuing a variety of delivery and payment system reforms. This report summarizes the key national trends to emerge from the latest (2013) participant and expenditure data for the three main Medicaid HCBS programs: (1) the mandatory home health services state plan benefit, (2) the optional personal care services state plan benefit, and (3) optional § 1915 (c) HCBS waivers. It also briefly discusses the provision of Medicaid HCBS through § 1115 demonstration waivers and highlights findings from a 2015 survey of Medicaid HCBS participant eligibility, enrollment, and provider reimbursement policies, including those related to the U.S. Department of Labor (DOL) direct care worker rules and the Centers for Medicare and Medicaid Services' (CMS) home and community-based settings rule. States also may provide HCBS through various options offered by the ACA, which are outside the scope of this report.  In 2013, almost 3 million people accessed LTSS through one of the three main Medicaid HCBS programs (Figure 1). Within this population, the number of people receiving § 1915 (c) waiver services increased slightly from 2012 to 2013 (by 3%), while the number of people receiving personal care state plan services and home health state plan services decreased (by 18% and 11%, Figure 1 respectively). A total of 672,137 Growth in Medicaid HCBS Participants, by Program, people received home health state 2003-2013 In Thousands plan services (in 50 states and DC), 3.1 M 3.2M 3.2M 3.2M 3.0M 3.0M 774,243 received personal care state 2.6M 2.8M 2.8M 2.8M 2.5M plan services (in 32 states), and 1,071 1,124 1,181 1,262 1,368 1,405 1,452 1,500 § 1915(c) Waivers 1,548 almost 1.55 million were served 984 1,018 State Plan Personal through § 1915 (c) waivers (in 47 Care 755 912 814 813 894 911 950 961 945 states and DC). The number of 716 774 State Plan Home Health individual § 1915 (c) waivers declined 813 833 799 822 837 806 835 805 793 758 672 slightly from 290 to 289 nationwide in 2013. States also may offer HCBS 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 through the newer ACA options or § % Change : +5% -- +4% +7% -1% +3% +5% +1% +1% -<1% -6% 1115 managed care programs instead NOTE: Figures updated annually and may not correspond with previous reports. Data exclude enrollment in Community First of or in addition to these three Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. authorities. Medicaid Home and Community-Based Services Programs: 2013 Data Update 1  In 2013, Medicaid HCBS Figure 2 expenditures for home health Growth in Medicaid HCBS Expenditures, by Program, state plan services, personal 2003-2013 care state plan services, and § In Billions $55.0B $55.0B $56.5B $52.7B 1915 (c) waivers totaled $56.5 $50.6B $45.9B billion, increasing slightly from $41.5B $37.7B 2012, and lower than the 10- $35.3B $36.8 $38.7 $40.8 $41.4 § 1915(c) Waivers $32.1B $34.3 year average of seven percent $28.2B $27.0 $30.6 State Plan $24.3 Personal Care (Figure 2). In 2013, spending $20.9 $23.3 $19.0 State Plan Home growth in HCBS programs was led by Health $10.9 $10.2 $10.5 $9.1 personal care state plan services $6.5 $7.1 $7.7 $8.7 $9.5 $10.1 $8.4 (9%) followed by home health state $2.7 $4.0 $4.3 $4.6 $5.0 $5.1 $5.4 $5.7 $5.8 $5.8 $5.9 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 plan services (2%), while § 1915 (c) % Change : waivers increased by only one -- +14% +10% +7% +10% +11% +10% +4% +4% +<1% +3% percent. NOTE: Figures updated annually and may not correspond with previous reports. Data exclude spending for Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys.  Per participant annual spending on Medicaid HCBS averaged $18,870 in 2013, but there was considerable variation among states and programs. Across states, Medicaid HCBS expenditures per participant served ranged from $9,641 in Michigan to $49,212 in Delaware. Per participant spending also varied across the three main HCBS programs, ranging from a national average of $8,827 for home health state plan participants to $26,768 for § 1915 (c) waiver participants. These program-to-program differences were due to the types and extent of services offered in the different home and community-based programs. Per participant spending also varied among § 1915 (c) waivers targeted to different beneficiary populations. For example, per participant spending in § 1915 (c) waivers targeted to beneficiaries with intellectual/developmental disabilities (I/DD) was considerably higher than for other beneficiary groups, reflecting the I/DD population's relatively more intensive need for LTSS.  The aged/disabled population Figure 3 made up the largest share of Medicaid 1915(c) HCBS Waiver Enrollees and waiver enrollment (48%) but Expenditures, by Enrollment Group, 2013 accounted for 21 percent of 171,546 (11%) $3.4B (8%) Other spending on waiver services in Other $8.8B Aged and Disabled 2013 (Figure 3). People with I/DD (21%) accounted for 41 percent of HCBS Aged and Disabled 750,783 (48%) waiver enrollment in 2013, but 71 Persons with percent of spending on waiver $29.2B Intellectual/Developmental Disabilities (71%) services was devoted to this Persons with 625,976 Intellectual/Developmental population, again reflecting their Disabilities (41%) more intensive need for LTSS Enrollees Expenditures relative to other groups. Total = 1.5 million Total = $41.4 billion NOTES: Percentages may not sum to 100 percent due to rounding. Data exclude enrollment and spending for Community First  A minority of states use § 1115 Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. The "Other" enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people demonstration waivers to with traumatic brain and spinal cord injuries. SOURCES: KCMU and UCSF analysis of CMS Form 372 data. Medicaid Home and Community-Based Services Programs: 2013 Data Update 2 deliver HCBS through capitated managed care. As of 2013, three states (Arizona, Rhode Island, and Vermont) do not operate any § 1915 (c) waivers and instead use § 1115 waivers to administer statewide Medicaid managed care programs that include all covered HCBS for all populations and services. Another five states (Delaware, Hawaii, New York, Tennessee, and Texas) use § 1115 waivers for capitated Medicaid managed care programs that include HCBS for at least some geographic areas and/or populations. S  In 2015, all states reported using cost controls in § 1915 (c) waivers, such as restrictive financial and functional eligibility standards, enrollment limits, or waiting lists. About 25 percent of § 1915 (c) waiver programs used financial eligibility standards that were more restrictive than those used to determine eligibility for Medicaid coverage for institutional care. However, six § 1915 (c) waivers used more restrictive functional eligibility criteria than those used for institutional care. More than one half of states offering personal care state plan services (59%, or 20 states) had some form of cost controls in place, with the majority utilizing service unit limitations. Over half of states (59%, or 30 states) had some form of expenditure or service restriction in place in their home health state plan programs.  In 2015, more than 640,000 people were on 133 § 1915 (c) waiver waiting lists, and the average waiting time exceeded two years. The growth in the number of people on waiting lists grew by 10 percent from 2014 to 2015, outpacing the growth rate of 8.5 percent in the previous period. The average national waiting time for § 1915 (c) waiver services was 27 months, with wide variations among waivers for different target populations and across states. The average length of time a person spent on a waiting list ranged from four months for HIV/AIDS waivers to 43 months for I/DD waivers.  The use of beneficiary self-direction as an alternative service delivery model was present in each of the three major Medicaid HCBS programs. The self-direction model includes initiatives such as beneficiary choice in the allocation of Medicaid service budgets and/or the selection and dismissal of service providers. Forty-three states (or 91%) with § 1915 (c) waivers permitted or required self-direction in at least one of their waivers in 2015. Of the states offering personal care state plan services, 24 (or 71%) permitted self-direction. In contrast, seven states (or 14%) allowed self-direction of home health state plan services in 2015.  In 2015, seven states reported plans to restrict caregiver hours or make other policy changes in response to the DOL direct care worker minimum wage and overtime rules, and six states had cost or service caps on self-directed services in place in 2015. Seven states indicated that state funds were budgeted for direct care worker overtime pay in FY 2016, and five states indicated state funds were budgeted for worker travel time.  Twenty-one states anticipated having to change state rules or policies as part of their transition to CMS's rule defining the qualities of home and community-based settings, as of 2015. In addition, 11 states planned to submit information to CMS seeking to overcome the regulatory presumption that certain settings are institutional in nature.  Provider reimbursement rates increased slightly from 2014 to 2015, for both home health and personal care agencies. The national average reimbursement rate per visit for home health agencies was $92.69 and $93.93 in 2014 and 2015, respectively. The hourly reimbursement rate for agencies providing personal care services increased slightly ($18.82 in 2015 and $18.73 in 2014). Medicaid Home and Community-Based Services Programs: 2013 Data Update 3 Over the past three decades, the increase in access to community-based alternatives to institutional care has resulted in some rebalancing of national Medicaid LTSS dollars, but the size and scope of Medicaid HCBS programs vary across states. Section 1915 (c) waivers account for the majority (73%) of spending on LTSS provided in community settings. In the coming years, states will be challenged to continue to expand access to high quality, person-centered HCBS in a cost-effective manner, and it will remain important to monitor states' adoption of state plan options and other initiatives to expand Medicaid HCBS, differences in services and spending, and the impact of cost control policies on access and quality. Developing home and community-based alternatives to institutional care has been a priority for many state Medicaid programs over the past three decades. The national share of Medicaid long term services and supports (LTSS) spending on home and community-based services (HCBS) has nearly tripled, from 18 percent in 1995 to 53 percent in 2014. 3 States' efforts to expand HCBS have been driven by beneficiary needs and 2F preferences, the United States Supreme Court's 1999 Olmstead decision finding that the unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act, 4 and efforts to 3F control growth in total LTSS expenditures. Spending on LTSS comprised 32 percent of total Medicaid spending in 2014,5 with HCBS typically costing less than comparable institutional care. Budgetary constraints during a 4F time when overall state revenues are slowing, forcing more moderate spending growth across state budgets, and the administrative complexities of implementing and coordinating the various Medicaid LTSS options may pose challenges as states and the federal government continue to work to increase beneficiary access to HCBS and rebalance LTSS expenditures. Over the last fifteen years, the Kaiser Family Foundation's Commission on Medicaid and the Uninsured (KCMU) has worked with researchers at the University of California, San Francisco (UCSF) to track the development of the three main Medicaid HCBS programs: (1) the home health services state plan benefit, (2) the personal care services state plan benefit, and (3) § 1915 (c) HCBS waivers. Medicaid HCBS also may be provided through options created and expanded by the Affordable Care Act (ACA), such as the § 1915 (i) HCBS state plan option, the Money Follows the Person demonstration, 6 and the Community First Choice state plan 5F option; participants and expenditures attributable to these programs are outside the scope of this report. In addition, a minority of states provide some or all of their HCBS through § 1115 demonstration waivers, which are briefly discussed in this report. Beginning in 2002, we also surveyed the policies states use to control spending growth in § 1915 (c) waiver programs, such as eligibility criteria and waiting lists. In 2007, we expanded the policy survey to include home health and personal care services state plan benefits and, in 2015, we added questions about state policy changes in response to new U.S. Department of Labor (DOL) minimum wage and overtime rules affecting direct care workers and the Centers for Medicare and Medicaid Services' (CMS) rules defining characteristics of Medicaid home and community-based settings. In these state-level surveys, we collect data on eligibility criteria, providers, services, and reimbursement rates. This report summarizes the main trends to emerge from the latest (2013) participant and expenditure data for the three main Medicaid HCBS programs and findings from the 2015 survey of policies impacting the home health and personal care services state plan benefits and § 1915 (c) waivers. Medicaid Home and Community-Based Services Programs: 2013 Data Update 4 In 2013, almost 3 million individuals Figure 4 received services through the three Medicaid HCBS Participants, by Program, 2013 main Medicaid HCBS programs (Table 1A). Of those participants, 672,137 individuals received home health State Plan services through the mandatory state Personal Care Services plan benefit, 774,243 individuals 774,243 (26%) Section 1915(c) received personal care services through Waiver Services 1,548,305 the optional state plan benefit, and State Plan Home (52%) 1,548,305 individuals were served Health Services 672,137 through § 1915 (c) waivers (Figure 4). (22%) All states and DC offered the mandatory home health services state plan benefit in their Medicaid Total Participants = 3.0 million programs (Table 1B), while 32 states NOTE: Data exclude enrollment in Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. actively offered the optional personal SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. care services state plan benefit,7 with Kansas as the latest state to elect this option in 2007 (Table 1C). Forty- seven states and DC operated multiple § 1915 (c) waivers in 2013 (Table 1D). Participation in the three main HCBS programs declined by six percent between 2012 and 2013, the largest decline in the study period, and Figure 5 accelerating from less than a one Growth in Medicaid HCBS Participants, by Program, percent decline the previous year. This 2003-2013 was also well below the 10-year average In Thousands 3.2M 3.2M 3.1 M 3.2M growth rate of two percent (Table 1A 2.8M 3.0M 3.0M 2.8M 2.8M and Figure 5). Some of this decline may 2.5M 2.6M 1,368 1,405 1,452 1,500 be attributable to states offering HCBS 1,018 1,071 1,124 1,181 1,262 1,548 § 1915(c) Waivers 984 through other authorities, such as State Plan Personal Care Community First Choice, § 1915 (i), 716 755 912 814 813 894 911 950 961 945 State Plan Home 774 and/or § 1115 waivers. Health 813 833 799 822 837 806 835 805 793 758 672 Leading the 14 states with a decline in 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 total HCBS enrollment between 2012 % Change : and 2013 was Delaware, with a 52 -- +4% +7% -1% +3% +5% +5% +1% +1% -<1% -6% percent decline reported. Maine NOTE: Figures updated annually and may not correspond with previous reports. Data exclude enrollment in Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. recorded the second largest decline SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. Medicaid Home and Community-Based Services Programs: 2013 Data Update 5 with a 44 percent drop in total HCBS enrollment between 2012 and 2013 (Table 1A). Delaware's decline in total HCBS enrollment was due largely to a drop in its § 1915 (c) waiver enrollment as the state shifted most of these waivers to a § 1115 capitated managed care waiver. Maine's overall decline could be due to its 78 percent drop in its home health program enrollment after two years of growth, attributed to changes in reporting. On the other hand, Indiana, Louisiana, and New Mexico saw the largest increases (16%, 14%, and 14%, respectively) in total HCBS participants in 2013. All three states' participant growth was driven by large increases in their § 1915 (c) waiver programs. The decline in total HCBS enrollment Figure 6 in 2013 was led by declines in State Variation in the Number of Medicaid HCBS Program participation in both the home health Participants, 2012 state plan program (-11%) and the personal care state plan program (- WA ND VT ME MT NH 18%) (Tables 1B and 1C). Declines in OR MN WI NY MA ID SD MI RI participation rates in both programs WY IA PA CT NJ NE OH DE accelerated from last year, some of NV UT IL IN WV VA MD CO DC MO KY which may be attributable to states CA KS NC TN offering services through Community AZ NM OK AR SC MS AL GA First Choice, § 1915 (i), and/or § 1115 AK TX LA < 25,000 (19 states and DC) 25,000 – 49,999 (13 states) waivers. Oregon led the decline in FL 50,000 – 74,999 (5 states) 75,000 – 99,999 (5 states) home health program enrollment with HI ≥ 100,000 (8 states) an 87 percent drop, attributed to a U.S. Total = 3.2 million change in reporting, while Texas led NOTE: Data include enrollment in state plan home health and personal care services and Section 1915 (c) waivers and exclude enrollment in Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers with HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. the decline in personal care state plan participation with an 80 percent drop in 2013, also attributed to a change in reporting. Nationally, § 1915 (c) waiver program participation increased by three percent from 2012 to 2013, the same rate of increase as the previous year, although nine states reported declines in participation led by Delaware (-71%) and Texas (-16%) (Table 1D). Delaware's decline is attributable to the state discontinuing several § 1915 (c) waivers and instead providing services through a § 1115 Figure 7 waiver. Figure 6 illustrates the variation in total Medicaid HCBS Medicaid HCBS Expenditures, by Program, 2012 program participation among the states. State Plan Personal Care Services $9.1 billion State Plan (16%) $5.9 Home Health Section 1915(c) Services Waiver Services $5.9 billion $41.4 billion (10%) (73%) In 2013, total Medicaid spending on HCBS across the three main programs was $56.5 billion (Table 2A). As in past Total Expenditures = $56.5 billion years, the large majority of Medicaid NOTE: Data exclude spending for Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. Medicaid Home and Community-Based Services Programs: 2013 Data Update 6 spending on HCBS was for § 1915 (c) waivers. In 2013, Medicaid spending on § 1915 (c) waivers was $41.4 billion, compared to $9.1 billion on personal care state plan services and $5.9 billion on home health state plan services (Tables 2B, 2C, 2D and Figure 7). Between 2003 and 2013, total annual Medicaid spending on HCBS in the three main programs doubled, with an average annual increase of seven Figure 8 percent (Figure 8). After the lowest Growth in Medicaid HCBS Expenditures, by Program, growth in HCBS spending within the 2003-2013 study period between 2011 and 2012, In Billions $55.0B $55.0B $56.5B $52.7B spending growth rebounded to three $50.6B $45.9B percent between 2012 and 2013. This $41.5B was lower than the 6.9 percent growth $35.3B $37.7B $38.7 $40.8 $41.4 § 1915(c) Waivers $32.1B $34.3 $36.8 recorded for total Medicaid spending $28.2B $27.0 $30.6 State Plan $24.3 during the same period. Amid slow 8 7F $20.9 $23.3 Personal Care $19.0 State Plan Home growth in HCBS expenditures, nine Health states reported a decline in total $7.1 $7.7 $8.7 $9.5 $10.1 $10.9 $10.2 $10.5 $8.4 $9.1 $6.5 Medicaid HCBS expenditures between $2.7 $4.0 $4.3 $4.6 $5.0 $5.1 $5.4 $5.7 $5.8 $5.8 $5.9 2012 and 2013. Declines were led by 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % Change : Oregon and Texas (-17% and -13% -- +14% +10% +7% +10% +11% +10% +4% +4% +<1% +3% respectively) (Table 2A). NOTE: Figures updated annually and may not correspond with previous reports. Data exclude spending for Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. However, Medicaid HCBS expenditures as a proportion of total Medicaid LTSS expenditures continued to increase between 2012 and 2013 as they have done every year since 1995.9 National total Medicaid HCBS expenditure data mask state-to-state variations in spending across the three major programs. First, while national per participant spending on Medicaid HCBS averaged $18,870 in 2013, state spending ranged from $9,641 in Figure 9 Michigan to $49,212 in Delaware State Variation in Medicaid HCBS Program Expenditures (Table 3A and Figure 9). With the Per Person Served, 2012 move of Delaware's other HCBS waiver programs from § 1915 (c) to a § 1115 WA ND VT ME MT NH managed LTSS waiver, the only § 1915 OR MN WI NY MA ID SD MI RI (c) waiver remaining in Delaware is for WY IA PA CT NJ NE OH DE people with intellectual or NV UT CO IL IN WV VA MD MO KY DC developmental disabilities (I/DD), and CA KS NC TN that population's more intensive needs AZ NM OK AR SC MS AL GA may account for the higher per TX LA < $10,000 (5 states) AK participant spending. FL $10,000 - $19,999 (25 states) $20,000 - $29,999 (16 states and DC) HI ≥ $30,000 (4 states) Second, differences exist in spending National Average = $17,151 across the three major Medicaid HCBS NOTES: Data include enrollment in state plan home health and personal care services and Section 1915 (c) waivers and exclude enrollment in Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers with HCBS. programs. National per participant SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. expenditures ranged from $8,827 for home health state plan services participants to $26,768 for § 1915 (c) waiver participants in 2013 (Table 3B, 3C, Medicaid Home and Community-Based Services Programs: 2013 Data Update 7 3D and Figure 10). This difference was Figure 10 likely due to the types and extent of Medicaid HCBS Average Expenditures Per Person Served, services provided in each of the three 2003-2013 main HCBS programs. The lower State Plan Home Health State Plan Personal Care § 1915 (c) Waivers national per participant spending on In Thousands $26 $27 $27 $27 $25 home health state plan services likely $23 $24 $22 $22 reflects shorter periods of per $19 $21 participant service utilization compared to either § 1915 (c) waivers $12 $12 $12 or the personal care services state plan $11 $11 $11 $11 $9 $9 $9 $9 $8 option. Third, there was also $6 $6 $7 $7 $8 $5 $6 $6 significant per participant expenditure $3 $5 variation among § 1915 (c) waivers targeted to different populations 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 (Tables 4 and 7). NOTE: Figures updated annually and may not correspond with previous reports. Data exclude spending for Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys. Between 2012 and 2013, the number of § 1915 (c) waivers declined slightly from 290 to 289. In 2013, with the exception of Arizona, Rhode Island, and Vermont, which operate their entire Medicaid LTSS programs through § 1115 waivers and therefore do not offer any § 1915 (c) waivers, every state and DC had at least one § 1915 (c) waiver targeted to populations that would otherwise require institutional care. These beneficiary groups include: the aged (age 65 and over), aged or disabled, individuals with physical disabilities, individuals with I/DD, children who are medically fragile or technology-dependent, individuals with HIV/AIDS, and individuals with traumatic brain and/or spinal cord injury (TBI/SCI). Table 4 details, by waiver type, § 1915 (c) waiver enrollment, total expenditures, and per participant expenditures for the two most recent reporting years. In 2013, 1,548,305 participants were served through Medicaid § 1915 (c) waivers (Tables 4 Figure 11 and 5). The three percent (or 47,963 Medicaid 1915(c) HCBS Waiver Enrollees and beneficiaries) increase from 2012 to Expenditures, by Enrollment Group, 2013 2013 is the same rate of increase as between 2011 to 2012. The largest Other 171,546 (11%) $3.4B (8%) Other $8.8B share of § 1915 (c) waiver participants (21%) Aged and Disabled in 2013 (750,783 beneficiaries, or 48%) Aged and Disabled 750,783 (48%) received services through waivers that Persons with targeted the aged and aged or disabled. $29.2B Intellectual/Developmental (71%) Disabilities The next largest group of waiver Persons with 625,976 participants (625,976) was enrolled in Intellectual/Developmental Disabilities (41%) § 1915 (c) waivers for people with Enrollees Expenditures I/DD, representing 41 percent of Total = 1.5 million Total = $41.4 billion national § 1915 (c) waiver enrollment NOTES: Percentages may not sum to 100 percent due to rounding. The "Other" enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people with traumatic (Table 5 and Figure 11). Enrollment in brain and spinal cord injuries. Data exclude enrollment and spending for Community First Choice, Section 1915 (i) HCBS, and Section 1115 waivers that include HCBS. SOURCES: KCMU and UCSF analysis of CMS Form 372 data. waivers targeted solely to persons with Medicaid Home and Community-Based Services Programs: 2013 Data Update 8 physical disabilities accounted for only six percent (88,949) of § 1915 (c) waiver participants nationwide. The § 1915 (c) waivers with the smallest enrollment were those for individuals with mental health disabilities (4,243), individuals with HIV/AIDS (12,287), individuals with TBI/SCI (17,134), and children who are medically fragile or technology-dependent (48,933) (Tables 4 and 5). The § 1915 (c) waivers with the largest annual increase in participation were those targeted to seniors (11%), followed by those serving children with disabilities (9%). There was a decline (-9%) in participants for waivers serving individuals with HIV/AIDS, the only decline recorded among all waiver groups (Table 4). In 2013, overall expenditures for § 1915 (c) waivers increased to $41.4 billion, a one percent increase compared to 2012, and a slowdown from the six percent rise recorded between 2011 to 2012. The vast majority of spending on § 1915 (c) waivers was for individuals with I/DD. Although individuals enrolled in I/DD waivers accounted for just 41 percent of total waiver participants, expenditures for this population accounted for 71 percent of all § 1915 (c) waiver spending (Tables 4 and 6 and Figure 10). Between 2012 and 2013, the annual rate of expenditure growth was highest for waivers serving seniors (15%) and children with disabilities (11%), primarily due to increases in participation. There was a sharp fall (-24%) in expenditures on waivers serving people with mental health disabilities (of which there are only five nationally) as well as a four percent decline recorded in waivers serving individuals with HIV/AIDS (Table 4). Growth in § 1915 (c) waiver expenditures per participant declined by two percent from 2012 to 2013, the first decline since the study began, with a 10-year average growth of three percent (Tables 4 and 7). People with I/DD had the highest spending per participant served ($46,644). Although this amount was more than four times higher than average waiver spending on both aged ($11,907) and aged or disabled ($11,689) waiver participants, average spending per I/DD participant fell by two percent from 2012. On the other hand, per participant expenditures grew by six percent from 2012 to 2013 for waivers for people with HIV/AIDS while waivers serving people with mental health disabilities and the aged and disabled fell by 28 percent and two percent respectively (Table 4). Our survey also collected service type data for individual § 1915 (c) waivers. States may provide many different services within these waivers, which our survey collapses into six categories: (1) case management; (2) respite/home health/personal care; (3) habilitation/day care; (4) nursing/therapy; (5) residential/foster care; and (6) other services. Participants within a waiver may use more than one service, and as such, the sum of these participants does not equal the unduplicated total waiver participants. Most participants (1,532,316) received "other" services including assistance with chores, meals, transportation, and home modifications. More than 866,000 participants received respite, home health or personal care services within these waivers in 2013, with Ohio providing these services to the most waiver enrollees (75,623) (Table 8). Of the total $41.4 billion spent on § 1915 (c) waivers in 2013, almost 40% ($16.5 billion) was spent on habilitation or adult day care services, with New York spending more than $5.1 billion and Pennsylvania spending more than $1.7 billion. States spent more than $12.3 billion on respite, home health or personal care services within § 1915 (c) waivers, with Ohio, Virginia and Wisconsin each spending more than $1 billion on such services (Table 9). The most expensive waiver service on a per participant basis in 2013 was habilitation or adult day care services, with $25,068 spent per waiver participant nationwide. There is large inter-state Medicaid Home and Community-Based Services Programs: 2013 Data Update 9 variation in habilitation or adult day care services spending per participant, ranging from $2,028 in New Jersey to $62,304 in Massachusetts. Case management was the least expensive § 1915 (c) waiver service nationwide at $1,786 per participant (Table 10). In addition to the Medicaid home health and personal care services state plan benefits and § 1915 (c) waivers, states can deliver HCBS through § 1115 demonstration waivers. 10 Section 1115 of the Social Security Act allows 9F the Secretary of the Department of Health and Human Services to waive state compliance with certain federal Medicaid requirements and authorizes the use of federal Medicaid funds in ways that are not otherwise allowable. Section 1115 waivers enable "experimental, pilot or demonstration project[s] which, in the judgment of the Secretary, [are] likely to assist in promoting the objectives [of the Medicaid program]." 11 Section 1115 10F waivers have been used to implement a variety of initiatives related to HCBS, such as self-direction of personal care services, 12 payments to spouses who provide personal care services, and mandatory enrollment in 1F capitated managed LTSS. In 2013, three states (Arizona, Rhode Island, and Vermont13) used § 1115 waivers to administer statewide Medicaid capitated managed care programs14 that include all HCBS covered for all populations; these states do not offer any § 1915 (c) waivers. In 2013, Arizona spent $1.1 billion on HCBS for 45,026 participants, Rhode Island spent $481 million on HCBS for 4,912 participants, and Vermont spent $254 million on HCBS for 5,212 participants.15 In addition to Arizona, Rhode Island, and Vermont's statewide programs, another five states 1 13F (Delaware, Hawaii, New York, Tennessee, and Texas)16 use § 1115 waivers for Medicaid capitated managed care programs that include HCBS for at least some populations in 2013 (not captured in this report); these states also offer § 1915 (c) waivers for other populations receiving HCBS (which are included in this report). 1714F The Medicaid § 1915 (c) waiver authority allows states to use a range of cost-containment strategies to meet federal cost neutrality requirements and limit spending so that expenditures do not exceed state budgetary restrictions. To understand how states controlled spending on HCBS waivers in 2015, we surveyed all state § 1915 (c) waiver program administrators to assess financial and functional eligibility standards, use of enrollment and/or expenditure caps, and waiting list status (i.e., number of individuals on the list(s) and average waiting time). The survey finds that every state used some type of cost-containment tool in its § 1915 (c) waivers beyond the federal cost neutrality requirement that average annual per participant waiver spending not exceed average per participant spending if services were provided in an institutional setting under the state plan absent the waiver. The following summary of the 2015 survey findings illustrates how states use cost control policies to limit access to § 1915 (c) waivers. Most states set their Medicaid financial eligibility standard for nursing facility services at 300 percent of the Medicaid Home and Community-Based Services Programs: 2013 Data Update 10 Supplemental Security Income (SSI) Figure 12 federal benefit rate ($2,199/month Medicaid 1915(c) HCBS Waiver Financial Eligibility Limits, for an individual in 2015). States may 2015 set financial eligibility standards for Medicaid § 1915 (c) waivers at the same level as that for nursing 100% SSI FBR facilities. There is, however, wide (19%) variation in financial eligibility 101-299% SSI FBR 300% SSI FBR standards across states and HCBS (6%) (75%) waiver programs as shown in Table 11. Twenty-five percent of reporting waiver programs used more restrictive financial eligibility standards (e.g., 100% of SSI) than Total = 290 reporting waivers used for nursing facilities (300% of NOTE: In 2015, 300% of Supplemental Security Income (SSI) Federal Benefit Rate (FBR) was $2,199 a month for an individual. SOURCE: KCMU and UCSF analysis of waiver policy survey. SSI) in 2015 (Table 11 and Figure 12). Another way states limit eligibility for § 1915 (c) waivers is by using functional eligibility criteria that are stricter than those used to qualify for coverage of nursing facility care. For example, a state could require an individual to exhibit difficulty in performing at least three activities of daily living (ADLs, e.g., bathing, dressing, transferring, eating, toileting) for waiver eligibility but require limitations in only two ADLs for nursing facility services. The 2015 survey found that six § 1915 (c) waiver programs (2%) used functional eligibility criteria that are more restrictive than the criteria used for institutional care (no table shown); these waivers were reported in Alabama, Georgia, Idaho, Kansas, New York, and Wisconsin. Approximately 88 percent (42 states) of all states with § 1915 (c) waivers utilized some form of cost controls above and beyond the federally mandated cost neutrality formula in 2015. Many states used a mixture of fixed expenditure caps, service provision and hourly caps, and geographic limits (Table 12). Of the states with waiver cost controls in place, more than half (22 states) utilized more than one form, such as a combination of expenditure caps and service limitations (Table 12). Many states have incorporated some form of mandatory or optional self-direction within their § 1915 (c) waivers. The self-direction service delivery model can include initiatives such as beneficiary choice in the allocation of service budgets and/or the selection, training, and dismissal of service providers. In 2015, 43 states (91% of states) either allowed or required some form of self-direction (Table 12). In 2015, states are working to implement the DOL rules that extend Fair Labor Standards Act (FLSA) minimum wage and overtime pay protections to direct care workers who previously were exempt from these requirements.18 Direct care workers who provide HCBS can include certified nursing assistants, home health aides, personal care aides, and other caregivers. The new DOL rules recognize the professionalization and Medicaid Home and Community-Based Services Programs: 2013 Data Update 11 expansion of the direct care workforce as these workers provide increasingly skilled care and more people receive services at home instead of in institutions.19 The changes may affect Medicaid services provided through a self-directed model; CMS anticipates that "many states will determine that, for purposes of the FLSA, home care workers in self-direction programs have joint third party employer(s) [such as the state or another entity] in addition to being employed by the beneficiary"20 and thus the state or other entity is subject to minimum wage and overtime requirements. Consequently, CMS observes that "many states will need to develop policies and consider programmatic changes to address the costs related to overtime and/or worker time spent traveling between worksites (i.e., individuals' homes), to avoid or minimize negative impacts to individual [service] budgets, and to preserve the ability of individuals to self-direct services and supports effectively."21 This year's survey asked states about policy changes in response to the new DOL rules. In 2015, 11 waivers in seven states (California, Kentucky, Maryland, Maine, New Mexico, Oregon, and Washington) planned to control caregiver hours or make other changes in response to the DOL minimum wage and overtime rules. For example, California increased provider payment rates to meet the DOL requirements, while four states were limiting caregiver hours as a result of the new rule (40 hours per week limit in Maine and New Mexico; 50 hour limit in Oregon; independent providers working over 40 hours in Washington may work overtime up to 65 hours). In addition, 12 waivers in six states (Louisiana, New Mexico, New York, Oregon, Texas, and Washington) had cost or service caps on self-directed § 1915 (c) services in place in 2015. Eighteen waivers in seven states (California, Connecticut, Kentucky, Oregon, Pennsylvania, South Carolina, and Washington) indicated that state funds were budgeted for direct care worker overtime pay in FY 2016, while eleven waivers in five states (California, Connecticut, Oregon, South Carolina, and Washington) reported that state funds were budgeted for direct care worker travel time pay in FY 2016 (no table shown). State policies may continue to evolve in this area as states gain more experience operating under the new rules. States often have more individuals who need Medicaid home and community-based waiver services than the number of available spaces, called "slots," in a § 1915 (c) waiver (Table 13). Many states maintain waiting lists when their program slots are filled or when state legislatures do not fully fund the maximum number of slots approved by CMS. In 2015, 35 states Figure 13 reported waiver waiting lists, while 12 Medicaid 1915(c) HCBS Waiver Waiting Lists, by states and DC reported no such lists Enrollment Group, 2005-2015 (Table 14). In 2015, there were 640,841 Others individuals on waiver waiting lists Aged/Disabled 10% 14% across 133 § 1915 (c) waivers. Section Persons with Intellectual/Developmental Disabilities 8% 10% 11% 23% 1915 (c) waivers for people with I/DD 9% 26% 29% 32% 29% 6% had the greatest number of individuals 10% 28% 6% 30% on waiting lists (428,151 individuals, or 6% 5% 26% 29% 67% 60% 67% of total waiting list enrollment) 41% 42% 63% 62% 58% 60% 61% followed by waivers serving people who 68% 64% 53% 53% are aged and aged or disabled (145,424 individuals, or 23% of total waiting list 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 enrollment) (Table 14, Figure 13). Most Total: 260,916 280,176 331,689 393,096 365,553 428,571 511,174 523,710 536,464 582,066 640,841 states reported that virtually all of the NOTES: Percentages may not sum to 100 percent due to rounding. The "Other" enrollment group includes waiver enrollees who are people with physical disabilities, children, people with HIV/AIDS, people with mental health needs, and people with traumatic brain and spinal cord injuries. people on waiver waiting lists currently SOURCES: KCMU and UCSF analysis of waiver policy surveys . Medicaid Home and Community-Based Services Programs: 2013 Data Update 12 reside in the community, although they may still be at risk of institutionalization. Due to the varying number of waiver slots available for each population, the average length of time an individual spent on a waiting list differed by population and ranged from four months for HIV/AIDS waivers to 43 months for I/DD waivers, with an average national waiting time of 27 months across all § 1915 (c) waivers with waiting lists (Table 14). The number of individuals on § 1915 (c) waiver waiting lists grew by 10 percent from 2014 to 2015, outpacing the 8.5 percent growth rate in the 2013-2014 period. From 2005 to 2015, waiting list enrollment grew by an average of 14 percent annually. Waiting lists for some § 1915 (c) waiver target populations increased, with the exception of waivers for people who are aged and disabled, physically disabled, children who are medically frail, and those for people with TBI/SCI (Table 14). The maintenance and length of state waiver waiting lists has implications for states' compliance with the Olmstead decision, which requires states to provide services outside of institutions if beneficiaries are able to live in the community and do not oppose doing so. In 2015, two-thirds (67%) of all § 1915 (c) waivers with waiting lists had a policy of screening individuals for Medicaid waiver eligibility before being placed or while on a waiting list (Table 13). In addition, more than two- thirds (70%) of all waivers with waiting lists had a policy of prioritizing certain individuals for waiver services (e.g., people transitioning to the community from an institution get priority for waiver services when slots become available). Ninety-two percent of all waivers with waiting lists provided non-waiver services (i.e., state plan services) to Medicaid eligible individuals on waiver waiting lists. States also are working to come into compliance with CMS's January, 2014 rule defining the qualities of home and community-based settings in which § 1915 (c) waiver services can be provided.22 This rule seeks to ensure that beneficiaries receiving Medicaid HCBS have "full access to the benefits of community living and the opportunity to receive services in the most integrated setting."23 To be considered community-based, the rule requires that both residential and non-residential settings support an individual's full access to the greater community; are selected by the individual from options including non-disability specific settings; ensure individual privacy, dignity, respect and freedom from coercion or restraint; optimize individual autonomy in making life choices; and facilitate individual choice regarding services and providers. There are additional criteria applied to provider-owned or –controlled residential settings to ensure individual privacy and autonomy. States had to submit transition plans, which were subject to public notice and comment, that explain how their existing § 1915 (c) waivers will come into compliance with these new standards; most of these plans currently are pending approval by CMS.24 This year's survey asked states about policy changes in response to the home and community-based settings rule. Twenty-one states (California, Colorado, Connecticut, Idaho, Indiana, Kentucky, Louisiana, Maryland, Missouri, Mississippi, Montana, Nevada, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Utah, Washington, and Wyoming) anticipated having to change state rules or policies as part of their transition to the new home and community-based settings rule. Thirty waivers in 13 states (California, Colorado, Indiana, Louisiana, Maryland, Michigan, Missouri, Montana, New Mexico, New York, Oregon, Washington, and Wyoming) had identified some settings that do not meet the new rules and consequently will need to be modified so that beneficiaries can continue to receive Medicaid-funded HCBS there. Additionally, two states (Oregon and Washington) identified some non-residential settings that cannot be modified to meet the new Medicaid Home and Community-Based Services Programs: 2013 Data Update 13 requirements, with the result that beneficiaries will be need to be relocated to continue receiving Medicaid- funded HCBS. The new rule presumes that certain settings are not community-based because they have institutional qualities, such as those in a facility that provides inpatient treatment, those on the grounds of or adjacent to a public institution, and those that have the effect of isolating individuals from the broader community. However, the rule permits the Secretary to overcome this presumption by applying heightened scrutiny based on information submitted by the state. Eleven states (California, Connecticut, Indiana, Kentucky, Louisiana, Michigan, Missouri, Montana, Nevada, Oregon, and Wyoming) planned to submit information asking the Secretary to determine that such a setting does not have the qualities of an institution and is home and community-based so that the state could continue to provide Medicaid-funded HCBS in those settings. Ten states (California, Colorado, Indiana, Kentucky, Maryland, Missouri, Nevada, Oregon, Washington, and Wyoming) identified settings that effectively isolate beneficiaries from the greater community and therefore are presumed institutional under the rule. As CMS's review of the states' transition plans proceeds, additional policy changes in this area may emerge. Unlike waivers, states are not permitted to maintain waiting lists or geographically limit the services provided through Medicaid home health and personal care state plan benefits. State plan services must be available to all beneficiaries as medically necessary. However, federal Medicaid rules allow states to use certain cost- containment strategies for state plan benefits. To understand how states controlled spending for home health and personal care services state plan benefits in 2015, all state Medicaid programs were asked about approved provider types, services provided within the scope of each benefit, the use of any expenditure or service caps, and the availability of self-direction within the programs. The following summary of the 2015 survey findings shows how states use cost control policies to limit access to Medicaid home health and personal care state plan services.25 To obtain a more comprehensive picture of the three main Medicaid HCBS programs, states were asked about the types of approved providers for state plan HCBS and the scope of benefits provided (no Tables shown). In addition to licensed home health agencies, 17 states (33%) allowed hospice agencies to provide home health state plan services, while Centers for Independent Living and independent providers were allowed to provide personal care state plan services in 14 states (41%) and 19 states (56%), respectively. In addition to skilled nursing services, therapy services, and home health aide services for assistance with ADLs, 14 states (27%) provided assistance with instrumental ADLs (e.g., medication management, meal preparation) as part of their home health state plan benefit. In addition, although therapy services are optional within the home health services state plan benefit, almost all states provide some form of therapy, such as physical, occupational, or speech. Even though case management is not required under the home health state plan benefit, four states (8%) provided this service. Among states with personal care state plan services, 30 states (88%) provided assistance with instrumental ADLs, while 14 states (41%) provided some sort of transportation services. Case management was offered in eight states (24%) within the personal care services state plan option. Medicaid Home and Community-Based Services Programs: 2013 Data Update 14 More than half of all states (59%, or 30 states) utilized either expenditure or service limits or both in their home health services state plan programs in 2015, while 59 percent of states with the optional personal care services state plan benefit used cost control limits. Among states offering the optional personal care services state plan benefit, 19 states used service limits while only one state used expenditure limits. Among the 30 states with cost controls in their home health services state plan benefit, Connecticut, Michigan and Oregon had a combination of expenditure and service limits while the rest had only one of these limits in place. Service limitations were the most popular form of cost control for home health state plan services, with 26 states (87% of cost control states) using such limits (Table 12). In 2015, only seven states allowed self-direction within their home health services state plan programs. In contrast, 71 percent of states (24 states) with the personal care services state plan option allowed self-direction (Table 12). The average reimbursement rate that states provided to home health agencies was $93.93 per home health visit in 2015, slightly higher than $92.69 in 2014. In states that paid registered nurses or home health aides directly or mandated their reimbursement rates, the average rate per visit was $87.26 and $52.19, respectively (Table 15). For the personal care services state plan option, the average rate paid to provider agencies was $18.82 per hour in 2015, a slight increase from $18.73 per hour in 2014. In states where personal care services providers were paid directly by the state or where reimbursement rates were determined by the state, the average reimbursement rate was $13.43 per hour in 2015 (Table 1526). Medicaid provider reimbursement rates are often set by state legislatures as part of the budget process. Over the past three decades, the increase in access to community-based alternatives to institutional care has resulted in rebalancing of national Medicaid LTSS dollars, while the size and scope of Medicaid HCBS programs continues to vary across states. Section 1915 (c) waivers still account for the majority (73%) of spending on LTSS provided in the community, and continued growth in waiver waiting list enrollment, to more than 640,000 persons nationally with waiting times of almost two and a half years, highlights the need for HCBS, especially for individuals with I/DD, seniors, and non-elderly people with physical disabilities. States continue to review and change policies in response to new regulatory requirements, including the DOL home care worker rules and CMS's rule defining the qualities of home and community-based settings. At the same time, competing pressures in state budgets may mean that states may face uncertainties about funding for Medicaid HCBS in the coming years, and states are continuing to utilize cost control measures within their Medicaid HCBS programs. In response to fiscal pressures and a desire to better coordinate beneficiaries' LTSS, states continue to incorporate HCBS into Medicaid managed care arrangements. In the coming years, states will be challenged to continue to expand access to high quality, person-centered HCBS in a cost-effective manner, and it will remain important to monitor the adoption of state plan options and other initiatives to expand Medicaid HCBS, differences in services and spending, and the impact of cost control policies on access and quality. Medicaid Home and Community-Based Services Programs: 2013 Data Update 15 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 6,365 8,243 8,915 8,032 7,912 7,859 8,136 8,437 8,862 8,983 9,291 3% AL 19,766 19,723 20,330 20,823 21,327 21,888 24,552 22,078 21,320 20,305 20,019 -1% AR 33,506 33,970 34,174 34,559 33,174 33,145 34,891 34,726 35,763 36,519 36,564 0% AZ 27,545 29,934 31,197 32,358 33,891 34,968 36,045 37,122 38,199 39,275 40,364 3% CA 446,510 454,476 482,776 493,315 516,338 599,526 605,489 586,696 594,425 554,567 440,841 -21% CO 33,615 34,270 31,264 36,721 38,637 40,455 42,927 44,185 46,078 47,763 49,755 4% CT 38,053 39,467 40,027 38,242 29,917 31,145 47,566 49,311 52,879 55,061 55,932 2% DC 5,081 5,574 6,818 7,579 9,027 9,541 9,952 10,678 11,404 12,268 12,432 1% DE 3,794 4,162 4,070 4,224 4,171 4,078 4,123 4,104 4,262 4,327 2,077 -52% FL 85,604 87,836 94,323 99,857 89,176 82,578 104,833 93,073 96,126 107,410 105,041 -2% GA 36,999 40,871 43,425 41,585 41,812 46,614 50,538 52,443 51,890 55,419 56,694 2% HI 6,277 4,643 5,663 6,060 6,502 7,088 4,197 4,305 4,454 4,583 4,691 2% IA 37,087 42,110 42,618 36,259 38,517 40,185 40,670 42,010 42,564 42,046 42,089 0% ID 13,021 15,827 16,552 17,004 17,976 18,784 17,528 17,244 16,828 21,364 18,435 -14% IL 73,070 77,419 81,714 85,935 85,354 93,287 100,021 104,701 111,852 117,982 125,386 6% IN 19,601 22,413 21,318 22,271 24,476 26,323 29,952 33,504 35,265 38,144 44,313 16% KS 25,338 27,767 29,213 30,211 30,752 33,423 33,916 33,631 33,591 32,251 32,349 0% KY 42,514 39,063 37,337 34,100 33,266 33,228 32,806 34,384 35,832 36,686 39,289 7% LA 18,258 24,126 26,001 27,758 30,970 36,172 40,520 44,231 46,015 41,877 47,772 14% MA 48,196 46,212 50,668 52,093 52,639 55,075 59,487 63,733 65,991 70,891 76,751 8% MD 20,215 19,478 23,662 23,705 23,360 24,505 29,434 30,346 31,156 32,332 33,554 4% ME 9,235 9,009 8,948 9,361 8,971 9,914 10,548 10,559 18,010 20,458 11,547 -44% MI 78,884 79,901 79,275 80,200 81,426 83,051 86,146 90,738 92,456 94,086 102,810 9% MN 51,577 56,005 59,325 78,449 84,517 90,225 94,841 99,009 89,920 103,125 103,268 0% MO 83,771 88,565 89,271 84,810 83,068 84,091 87,404 86,304 91,254 91,646 96,714 6% MS 23,613 23,885 23,584 22,166 22,524 22,924 24,482 25,714 27,045 30,553 25,240 -17% MT 6,525 7,303 7,566 7,650 7,890 8,105 8,327 8,616 8,820 9,505 9,285 -2% NC 84,254 95,880 110,891 117,467 115,123 115,793 120,312 116,892 104,570 116,075 107,911 -7% ND 4,126 5,159 5,511 6,401 6,487 6,515 6,473 5,824 6,087 6,286 6,925 10% NE 14,547 15,065 17,271 17,942 19,031 19,081 18,186 18,828 17,196 15,807 15,702 -1% NH 8,048 8,152 7,769 8,378 9,298 9,740 10,449 10,965 11,236 11,638 11,692 0% NJ 48,120 48,140 52,699 55,690 57,279 57,894 66,236 61,154 61,997 63,995 65,022 2% NM 15,121 15,934 16,274 17,508 19,812 21,083 21,304 22,011 23,246 23,388 26,642 14% NV 6,642 8,993 9,741 10,344 10,679 11,250 11,327 10,091 10,575 11,758 11,792 0% NY 250,697 271,682 271,886 281,821 277,626 277,555 280,552 281,990 280,418 281,006 281,283 0% OH 133,828 143,989 83,281 88,866 103,114 96,932 105,654 110,506 123,348 132,770 139,520 5% OK 28,685 27,556 31,255 33,538 36,434 39,720 39,047 37,891 36,957 36,960 35,306 -4% OR 43,361 42,487 43,196 43,607 44,437 44,688 47,284 49,270 51,109 52,071 46,196 -11% PA 48,173 53,897 59,938 76,891 78,202 84,782 90,912 98,588 86,152 91,778 92,225 0% RI 6,436 6,919 7,226 7,697 8,516 9,119 7,697 1,376 1,413 1,310 1,350 3% SC 27,766 24,793 24,249 22,638 24,492 25,173 25,141 23,876 23,345 23,718 25,360 7% SD 9,255 9,769 9,646 9,862 9,986 10,013 9,218 7,880 7,362 7,265 7,394 2% TN 12,573 17,735 19,317 19,871 20,292 23,519 25,089 25,255 20,034 18,879 19,009 1% TX 309,191 291,625 427,907 319,786 335,174 320,722 339,215 367,106 381,135 317,662 196,974 -38% UT 6,896 8,942 8,903 8,790 15,510 13,043 16,144 13,555 12,295 11,418 11,947 5% Medicaid Home and Community-Based Services Programs: 2013 Data Update 16 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change VA 20,428 20,536 22,735 24,337 25,416 28,493 31,706 36,522 39,232 42,416 44,557 5% VT 8,373 9,070 9,559 5,958 5,705 6,224 6,224 6,247 5,943 5,555 5,564 0% WA 63,689 64,336 67,668 69,022 69,810 71,808 73,066 77,431 80,125 88,528 82,712 -7% WI 49,148 53,940 57,055 58,048 60,578 67,941 70,285 80,133 83,652 88,219 91,054 3% WV 15,664 15,388 14,916 16,524 16,335 17,659 19,180 19,365 19,755 19,992 21,195 6% WY 3,519 3,631 4,058 4,328 4,591 4,684 4,765 5,050 5,196 4,813 4,850 1% : Data may not sum to total due to rounding. Total Medicaid HCBS comprises Medicaid home health state plan services, Medicaid personal care state plan services, and Medicaid § 1915(c) HCBS waivers. Arizona did not operate any § 1915(c) waivers over the study period because all HCBS were provided through a § 1115 managed care waiver. Hawaii transitioned all non-Intellectual/Developmental Disabilities (I/DD) § 1915(c) waiver participants to a § 1115 waiver in 2009. Rhode Island terminated its § 1915(c) waivers in mid-2009 and provided services under a § 1115 waiver. Vermont terminated its § 1915(c) waivers in 2006 and provided services under a § 1115 waiver. : Kaiser Commission on Medicaid and the Uninsured (KCMU) and compilation of University of California, San Francisco (UCSF) analyses of Medicaid Home Health and Personal Care Services Policy Surveys and Centers for Medicare and Medicaid Services (CMS) Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 17 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 286 273 390 373 348 294 312 298 302 281 307 9% AL 6,576 6,345 6,757 6,389 6,513 6,743 9,635 7,013 6,622 5,527 5,231 -5% AR 6,772 6,642 6,788 6,505 6,065 5,763 6,251 6,167 6,363 6,352 6,387 1% AZ 27,545 29,934 31,197 32,358 33,891 34,968 36,045 37,122 38,199 39,275 40,364 3% CA 89,436 87,027 88,659 87,656 86,543 85,697 84,851 30,626 29,669 23,832 21,035 -12% CO 7,326 8,275 8,687 9,430 10,412 10,964 11,037 11,134 11,998 12,201 12,603 3% CT 20,933 21,446 21,753 22,217 14,394 15,157 26,519 27,474 30,070 31,484 31,676 1% DC 2,124 2,360 2,855 3,406 4,090 4,236 4,382 4,528 5,178 5,549 5,403 -3% DE 1,324 1,601 1,428 1,467 1,324 1,269 1,214 1,159 1,150 1,105 1,130 2% FL 17,476 19,962 21,192 21,149 19,092 17,023 15,819 14,671 12,226 11,042 10,562 -4% GA 10,913 13,102 14,014 8,731 6,411 6,033 5,655 5,277 4,899 4,521 4,631 2% HI 2,726 585 1,300 1,469 1,532 1,628 1,724 1,820 1,903 1,992 2,032 2% IA 20,548 23,346 24,558 12,835 13,039 13,230 12,699 13,922 13,766 13,016 13,189 1% ID 1,794 3,295 3,326 3,321 3,936 4,475 1,882 1,790 1,871 2,111 1,811 -14% IL 12,903 12,391 13,063 14,913 14,080 13,085 14,107 14,162 13,795 12,667 11,655 -8% IN 8,235 8,939 7,834 8,307 8,353 8,291 9,250 10,663 13,134 14,237 13,051 -8% KS 6,688 7,152 5,865 5,364 4,888 4,145 4,106 3,965 3,730 3,736 3,803 2% KY 24,636 23,702 22,415 19,261 18,528 18,146 16,572 15,976 15,864 14,986 15,036 0% LA 11,051 11,662 12,187 11,986 11,704 11,691 11,830 11,222 11,042 10,978 10,813 -2% MA 19,521 16,498 17,875 17,591 17,214 17,653 18,231 19,977 20,899 23,001 24,895 8% MD 3,598 1,245 4,393 4,176 3,312 3,709 3,977 4,067 4,244 4,233 4,108 -3% ME 3,140 2,875 2,986 3,695 3,091 2,866 2,634 2,611 7,831 11,606 2,537 -78% MI 8,301 7,080 6,573 6,551 5,996 5,896 5,796 6,395 6,044 5,253 13,764 162% MN 5,174 5,349 5,229 13,078 12,682 12,624 12,293 12,053 2,317 12,822 10,056 -22% MO 7,237 7,246 7,739 6,960 6,964 6,143 6,513 6,544 6,938 6,880 6,543 -5% MS 10,351 9,472 9,044 8,223 7,949 7,888 7,889 8,749 9,257 7,923 1,104 -86% MT 456 473 442 414 442 392 412 428 367 387 378 -2% NC 33,206 35,871 38,670 40,313 40,517 40,387 41,094 38,871 39,970 33,507 32,767 -2% ND 803 899 521 813 769 865 884 758 749 954 1,120 17% NE 5,602 5,532 7,539 7,700 8,184 7,678 5,808 6,305 4,307 3,123 2,671 -14% NH 2,300 2,389 2,841 2,694 2,698 2,540 2,798 3,056 3,314 3,572 3,546 -1% NJ 10,896 11,322 11,136 12,653 13,564 14,695 15,826 16,957 17,481 18,392 19,032 3% NM 609 391 431 447 429 396 326 273 249 523 581 11% NV 1,279 980 870 798 751 705 608 658 659 698 691 -1% NY 89,844 110,910 109,244 117,401 113,603 109,386 108,365 107,344 106,323 105,302 104,325 -1% OH 89,857 96,408 31,171 32,215 39,846 31,308 34,586 36,676 39,138 44,576 47,937 8% OK 3,006 3,841 5,129 5,233 5,918 5,001 5,147 5,750 5,298 5,528 5,058 -9% OR 1,165 1,010 819 3,341 4,609 3,012 3,341 2,970 3,062 3,191 414 -87% PA 8,071 9,171 9,359 23,716 24,521 25,775 27,461 28,705 14,656 13,777 7,692 -44% RI 1,365 1,588 1,658 1,546 1,566 1,436 1,406 1,376 1,413 1,310 1,350 3% SC 7,849 4,680 3,908 3,041 2,654 2,037 1,687 1,257 1,056 954 893 -6% SD 5,013 5,236 5,103 5,036 4,963 4,865 3,767 2,561 1,812 1,841 1,706 -7% TN 7,648 12,655 12,539 11,875 10,912 10,727 10,850 11,829 12,130 10,934 11,165 2% TX 186,870 170,881 187,099 192,421 209,679 198,832 210,046 230,619 235,475 199,567 133,544 -33% UT 1,488 2,214 2,121 1,976 10,013 6,866 9,842 7,236 5,649 4,392 4,479 2% Medicaid Home and Community-Based Services Programs: 2013 Data Update 18 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change VA 3,831 2,890 3,299 4,055 3,432 3,733 3,958 5,530 4,772 4,510 3,738 -17% VT 3,501 3,611 3,854 3,842 3,737 3,571 3,810 3,625 3,440 3,145 3,210 2% WA 3,231 2,858 3,597 3,703 3,317 3,282 3,239 3,356 3,129 2,750 3,668 33% WI 5,903 7,006 7,430 6,742 6,204 6,035 5,866 5,697 5,317 5,040 4,803 -5% WV 1,865 1,754 1,954 2,343 1,989 2,147 2,476 2,699 2,833 2,689 3,041 13% WY 559 536 565 567 610 555 569 583 597 611 602 -1% : Data may not sum to total due to rounding. : KCMU and UCSF analysis of Medicaid Home Health Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 19 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 2,742 4,679 4,960 3,904 3,705 3,520 3,538 3,556 3,574 3,598 3,657 2% AL - - - - - - - - - - - - AR 15,499 15,503 15,452 15,160 14,223 13,923 14,377 13,904 14,559 15,206 15,356 1% AZ - - - - - - - - - - - - CA 288,000 295,049 313,893 329,893 345,507 422,823 425,321 455,243 456,512 419,385 305,132 -27% CO - - - - - - - - - - - - CT - - - - - - - - - - - - DC 2,352 2,432 2,522 2,498 2,365 2,298 2,231 2,164 2,097 2,112 2,098 -1% DE 0 0 0 0 0 0 0 0 0 0 0 0% FL 14,659 14,718 13,980 12,253 357 403 944 1,235 1,744 11,115 12,364 11% GA - - - - - - - - - - - - HI - - - - - - - - - - - - IA - - - - - - - - - - - - ID 3,377 3,614 3,601 3,777 3,773 3,799 4,266 3,331 2,163 5,918 2,070 -65% IL - - - - - - - - - - - - IN - - - - - - - - - - - - KS - - - - 18 89 147 210 273 336 365 9% KY - - - - - - - - - - - - LA - 2 4,400 6,568 8,625 11,532 14,166 17,533 18,535 18,393 19,431 6% MA 10,570 11,716 13,767 14,200 15,109 16,900 18,200 19,828 21,566 22,853 24,292 6% MD 4,743 4,603 4,643 4,474 4,385 4,416 4,608 4,894 5,221 5,323 5,593 5% ME 1,899 1,950 1,901 1,632 1,716 1,704 2,128 2,245 4,474 3,016 3,088 2% MI 53,351 54,986 55,158 56,210 57,980 59,124 61,324 64,956 66,930 69,090 68,133 -1% MN 6,302 8,329 9,940 16,569 18,862 20,759 22,750 24,352 22,664 23,589 24,297 3% MO 44,835 49,295 49,481 47,435 46,969 49,333 52,732 51,115 55,473 55,665 58,960 6% MS - - - - - - - - - - - - MT 2,864 2,990 3,127 3,117 3,095 3,093 3,144 3,323 3,323 3,592 3,558 -1% NC 34,058 41,911 50,818 53,141 49,877 50,017 53,162 50,830 38,713 57,098 47,905 -16% ND 450 777 1,362 1,896 1,872 1,754 1,509 1,089 1,145 1,165 1,200 3% NE 1,301 1,356 1,549 1,680 1,723 1,832 2,412 2,349 2,266 1,991 2,325 17% NH 26 25 25 21 16 21 25 29 28 28 32 14% NJ 17,707 18,987 20,884 21,198 21,582 20,623 20,553 20,483 20,413 20,543 20,748 1% NM 8,960 9,525 9,614 10,477 11,769 12,365 13,443 14,520 15,598 15,872 16,013 1% NV 2,038 4,408 4,991 5,383 5,663 6,205 6,507 5,133 5,377 6,470 6,494 0% NY 83,846 85,613 84,270 82,801 80,099 78,494 75,158 71,693 68,228 66,198 64,032 -3% OH - - - - - - - - - - - - OK 7,000 4,342 5,505 4,077 3,700 3,327 3,475 3,885 3,836 3,998 3,858 -4% OR 2,376 4,495 5,086 3,746 3,609 3,389 3,077 3,228 3,130 3,226 700 -78% PA - - - - - - - - - - - - RI 0 0 0 0 0 0 0 0 0 0 0 0% SC - - - - - - - - - - - - SD 948 923 901 936 986 996 861 791 763 572 427 -25% TN - - - - - - - - - - - - TX 66,967 71,381 187,099 64,425 59,025 51,567 52,628 56,510 69,409 56,161 11,125 -80% UT 450 1,787 1,755 1,674 72 62 131 168 241 393 400 2% Medicaid Home and Community-Based Services Programs: 2013 Data Update 20 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change VA - - - - - - - - - - - - VT 1,222 1,543 1,896 2,116 1,968 2,653 2,414 2,622 2,503 2,410 2,354 -2% WA 21,436 22,390 22,738 23,988 25,152 27,075 25,689 27,303 27,989 26,979 25,684 -5% WI 10,474 11,123 12,540 13,255 13,653 14,032 14,411 14,790 15,169 15,548 15,654 1% WV 5,205 4,945 4,371 5,688 6,026 6,026 5,908 6,510 6,685 6,664 6,898 4% WY - - - - - - - - - - - - : Data may not sum to total due to rounding. Personal care services are an optional benefit. In 2013, 32 states reported personal care services participants. Delaware and Rhode Island were approved by CMS to offer personal care services but did not report participants during the period. A dash indicates that there was no operational personal care services program that year. : KCMU and UCSF analysis of Medicaid Personal Care Services Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 21 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 3,337 3,291 3,565 3,755 3,859 4,045 4,286 4,583 4,986 5,104 5,327 4% AL 13,190 13,378 13,573 14,434 14,814 15,145 14,917 15,065 14,698 14,778 14,788 0% AR 11,235 11,825 11,934 12,894 12,886 13,459 14,263 14,655 14,841 14,961 14,821 -1% AZ - - - - - - - - - - - - CA 69,074 72,400 80,224 75,766 84,288 91,006 95,317 100,827 108,244 111,350 114,674 3% CO 26,289 25,995 22,577 27,291 28,225 29,491 31,890 33,051 34,080 35,562 37,152 4% CT 17,120 18,021 18,274 16,025 15,523 15,988 21,047 21,837 22,809 23,577 24,256 3% DC 605 782 1,441 1,675 2,572 3,007 3,339 3,986 4,129 4,607 4,931 7% DE 2,470 2,561 2,642 2,757 2,847 2,809 2,909 2,945 3,112 3,222 947 -71% FL 53,469 53,156 59,151 66,455 69,727 65,152 88,070 77,167 82,156 85,253 82,115 -4% GA 26,086 27,769 29,411 32,854 35,401 40,581 44,883 47,166 46,991 50,898 52,063 2% HI 3,551 4,058 4,363 4,591 4,970 5,460 2,473 2,485 2,551 2,591 2,659 3% IA 16,539 18,764 18,060 23,424 25,478 26,955 27,971 28,088 28,798 29,030 28,900 0% ID 7,850 8,918 9,625 9,906 10,267 10,510 11,380 12,123 12,794 13,335 14,554 9% IL 60,167 65,028 68,651 71,022 71,274 80,202 85,914 90,539 98,057 105,315 113,731 8% IN 11,366 13,474 13,484 13,964 16,123 18,032 20,702 22,841 22,131 23,907 31,262 31% KS 18,650 20,615 23,348 24,847 25,846 29,189 29,663 29,456 29,588 28,179 28,181 0% KY 17,878 15,361 14,922 14,839 14,738 15,082 16,234 18,408 19,968 21,700 24,253 12% LA 7,207 12,462 9,414 9,204 10,641 12,949 14,524 15,476 16,438 12,506 17,528 40% MA 18,105 17,998 19,026 20,302 20,316 20,522 23,056 23,928 23,526 25,037 27,564 10% MD 11,874 13,630 14,626 15,055 15,663 16,380 20,849 21,385 21,691 22,776 23,853 5% ME 4,196 4,184 4,061 4,034 4,164 5,344 5,786 5,703 5,705 5,836 5,922 1% MI 17,232 17,835 17,544 17,439 17,450 18,031 19,026 19,387 19,482 19,743 20,913 6% MN 40,101 42,327 44,156 48,802 52,973 56,842 59,798 62,604 64,939 66,714 68,915 3% MO 31,699 32,024 32,051 30,415 29,135 28,615 28,159 28,645 28,843 29,101 31,211 7% MS 13,262 14,413 14,540 13,943 14,575 15,036 16,593 16,965 17,788 22,630 24,136 7% MT 3,205 3,840 3,997 4,119 4,353 4,620 4,771 4,865 5,130 5,526 5,349 -3% NC 16,990 18,098 21,403 24,013 24,729 25,389 26,056 27,191 25,887 25,470 27,239 7% ND 2,873 3,483 3,628 3,692 3,846 3,896 4,080 3,977 4,193 4,167 4,605 11% NE 7,644 8,177 8,183 8,562 9,124 9,571 9,966 10,174 10,623 10,693 10,706 0% NH 5,722 5,738 4,903 5,663 6,584 7,179 7,626 7,880 7,894 8,038 8,114 1% NJ 19,517 17,831 20,679 21,839 22,133 22,576 29,857 23,714 24,103 25,060 25,242 1% NM 5,552 6,018 6,229 6,584 7,614 8,322 7,535 7,218 7,399 6,993 10,048 44% NV 3,325 3,605 3,880 4,163 4,265 4,340 4,212 4,300 4,539 4,590 4,607 0% NY 77,007 75,159 78,372 81,619 83,924 89,675 97,029 102,953 105,867 109,506 112,926 3% OH 43,971 47,581 52,110 56,651 63,268 65,624 71,068 73,830 84,210 88,194 91,583 4% OK 18,679 19,373 20,621 24,228 26,816 31,392 30,425 28,256 27,823 27,434 26,390 -4% OR 39,820 36,982 37,291 36,520 36,219 38,287 40,866 43,072 44,917 45,654 45,082 -1% PA 40,102 44,726 50,579 53,175 53,681 59,007 63,451 69,883 71,496 78,001 84,533 8% RI 5,071 5,331 5,568 6,151 6,950 7,683 6,291 - - - - - SC 19,917 20,113 20,341 19,597 21,838 23,136 23,454 22,619 22,289 22,764 24,467 7% SD 3,294 3,610 3,642 3,890 4,037 4,152 4,590 4,528 4,787 4,852 5,261 8% TN 4,925 5,080 6,778 7,996 9,380 12,792 14,239 13,426 7,904 7,945 7,844 -1% TX 55,354 49,363 53,709 62,940 66,470 70,323 76,541 79,977 76,251 61,934 52,305 -16% UT 4,958 4,941 5,027 5,140 5,425 6,115 6,171 6,151 6,405 6,633 7,068 7% Medicaid Home and Community-Based Services Programs: 2013 Data Update 22 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change VA 16,597 17,646 19,436 20,282 21,984 24,760 27,748 30,992 34,460 37,906 40,819 8% VT 3,650 3,916 3,809 - - - - - - - - - WA 39,022 39,088 41,333 41,331 41,341 41,451 44,138 46,772 49,007 58,799 53,360 -9% WI 32,771 35,811 37,085 38,051 40,721 47,874 50,008 59,646 63,166 67,631 70,597 4% WV 8,594 8,689 8,591 8,493 8,320 9,486 10,796 10,156 10,237 10,639 11,256 6% WY 2,960 3,095 3,493 3,761 3,981 4,129 4,196 4,467 4,599 4,202 4,248 1% : Data may not sum to total due to rounding. Arizona did not operate a § 1915(c) waiver over the study period because all HCBS were provided through a § 1115 managed care waiver. Hawaii transitioned all non-I/DD § 1915(c) waiver participants to a § 1115 waiver in 2009. Rhode Island terminated its § 1915(c) waivers in mid-2009 and provided services under a § 1115 waiver. Vermont terminated its § 1915(c) waivers in 2006 and provided services under a § 1115 waiver. A dash indicates that there was no operational § 1915(c) waiver that year. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 23 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 145,679 154,532 156,572 204,456 207,051 216,777 240,683 264,154 288,418 304,935 331,312 9% AL 212,282 237,214 273,707 297,316 333,373 360,800 401,074 404,282 413,801 421,686 452,002 7% AR 163,560 177,834 203,467 236,124 242,661 262,769 313,836 344,180 369,189 397,407 405,225 2% AZ 502,730 571,603 642,134 694,692 783,660 793,647 803,633 813,619 823,606 833,592 849,478 2% CA 3,598,498 4,024,636 4,415,656 4,994,201 5,865,291 6,347,460 7,006,430 6,537,005 6,998,970 5,593,850 5,681,174 2% CO 459,337 464,008 433,878 477,107 512,932 557,264 678,293 720,817 738,093 827,162 881,789 7% CT 669,221 677,714 701,999 341,269 340,732 376,033 1,019,813 1,045,839 1,121,845 1,199,212 1,229,427 3% DC 26,775 31,255 38,496 50,041 81,335 95,204 184,499 227,023 255,654 275,561 294,863 7% DE 63,121 67,341 74,056 86,786 99,991 108,474 115,687 114,767 114,267 116,651 102,213 -12% FL 813,749 919,013 1,001,617 1,111,757 1,220,846 1,301,098 1,008,925 1,390,426 1,552,103 1,736,585 1,712,743 -1% GA 339,544 377,603 397,916 449,990 427,570 517,181 655,220 819,154 800,488 914,391 978,729 7% HI 78,699 108,280 120,842 128,630 133,649 138,909 110,894 104,185 105,620 107,473 119,901 12% IA 251,675 285,540 352,321 410,094 453,768 495,130 533,901 565,564 577,916 616,267 671,830 9% ID 112,677 134,245 146,763 156,768 169,315 182,154 196,241 218,602 221,980 236,861 223,851 -5% IL 628,828 708,678 802,485 874,787 903,932 1,070,985 1,221,466 1,325,518 1,479,595 1,588,015 1,629,712 3% IN 372,148 471,504 488,513 496,083 556,511 641,574 729,215 784,163 793,087 845,048 998,531 18% KS 346,807 364,019 368,829 401,008 443,773 506,743 575,054 574,161 680,691 569,325 714,323 25% KY 249,306 245,138 277,332 263,695 334,418 347,118 370,523 417,182 482,639 552,634 636,841 15% LA 201,612 481,613 605,240 383,204 473,487 632,067 748,929 742,020 762,665 674,064 831,311 23% MA 816,117 884,525 951,013 1,034,885 1,024,243 1,130,156 1,284,262 1,339,689 1,401,148 1,634,704 1,793,693 10% MD 375,900 460,526 521,542 572,551 683,372 680,193 800,918 834,349 850,436 965,510 1,050,474 9% ME 217,868 240,961 242,990 265,977 283,299 342,198 354,103 359,843 381,136 378,806 373,225 -1% MI 583,489 656,393 663,682 667,403 713,414 749,468 786,316 820,079 853,013 899,103 991,141 10% MN 1,145,026 1,222,684 1,374,386 1,623,184 1,795,676 2,002,357 2,208,230 2,296,604 2,389,306 2,455,891 2,517,987 3% MO 570,761 580,071 616,843 653,403 729,314 806,630 895,232 844,619 1,000,729 1,080,007 1,192,728 10% MS 95,938 132,325 141,184 124,416 142,763 156,100 179,224 207,517 208,309 270,288 273,255 1% MT 88,122 97,642 105,414 112,248 117,504 137,808 151,663 165,514 168,920 174,068 176,851 2% NC 738,981 803,021 943,140 991,647 1,092,502 1,176,824 1,185,789 1,256,967 1,199,884 1,157,769 1,199,775 4% ND 60,711 71,566 75,531 82,644 88,506 98,072 109,865 126,233 147,512 165,652 179,640 8% NE 181,540 195,653 215,597 226,642 248,177 268,384 273,811 294,545 312,040 325,113 335,409 3% NH 153,386 157,916 163,275 171,188 185,352 202,118 236,010 251,221 251,077 259,119 273,132 5% NJ 741,790 743,903 804,134 809,575 840,544 866,594 1,012,815 1,082,551 1,132,610 1,256,614 1,324,450 5% NM 386,869 443,841 424,686 463,942 504,150 557,314 546,763 568,229 581,356 584,713 614,608 5% NV 61,186 87,594 95,280 126,347 142,596 152,703 155,126 158,699 164,673 168,259 166,613 -1% NY 5,221,679 6,383,266 7,008,325 7,761,946 8,454,236 9,041,475 9,441,876 9,713,233 9,684,139 9,712,552 9,451,904 -3% OH 890,302 979,106 1,026,817 1,245,787 1,546,853 1,569,361 1,752,152 1,907,247 2,180,451 2,255,206 2,348,916 4% OK 336,358 298,367 337,313 390,549 438,951 486,746 508,450 505,779 497,495 495,812 483,842 -2% OR 570,406 561,006 586,983 600,838 640,195 726,316 869,422 926,182 1,059,030 968,092 807,320 -17% PA 1,184,355 1,313,386 1,479,377 1,294,903 1,375,754 2,116,073 2,395,308 2,632,203 2,532,129 2,784,016 3,054,059 10% RI 234,785 242,921 243,359 260,635 293,257 304,493 144,212 2,579 2,461 2,544 2,694 6% SC 266,240 276,384 289,974 281,348 335,875 392,982 486,588 446,291 457,403 442,920 472,501 7% SD 72,998 85,156 79,489 89,901 97,242 104,222 109,714 115,070 119,357 120,566 126,374 5% TN 244,002 344,406 520,247 634,819 782,847 926,555 909,931 839,807 802,345 803,423 808,145 1% Medicaid Home and Community-Based Services Programs: 2013 Data Update 24 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change TX 1,286,404 1,725,338 1,957,450 2,066,581 2,036,889 2,278,729 2,638,822 2,879,440 3,074,590 2,426,576 2,099,185 -13% UT 114,232 125,793 130,506 134,753 147,776 190,113 214,327 214,589 217,419 220,326 238,949 8% VA 363,474 361,373 431,049 529,166 620,997 710,241 838,222 950,681 1,042,903 1,124,032 1,220,259 9% VT 125,870 142,778 141,610 24,210 22,501 23,152 25,853 27,838 29,063 35,070 35,006 0% WA 754,189 725,307 851,519 929,438 994,350 1,116,182 1,283,178 1,377,645 1,424,414 1,638,838 1,484,147 -9% WI 805,316 902,982 986,359 1,069,318 1,116,212 1,212,537 1,422,037 1,665,416 1,738,918 1,842,459 1,945,764 6% WV 215,466 239,217 264,715 269,684 302,372 332,385 356,346 381,931 392,163 483,087 598,123 24% WY 76,936 82,799 89,724 95,313 99,314 100,436 118,588 115,003 117,709 93,227 125,268 34% : Data may not sum to total due to rounding. Total Medicaid HCBS comprises Medicaid home health state plan services, Medicaid personal care state plan services and Medicaid § 1915(c) HCBS waivers. Arizona did not operate any § 1915(c) waivers over the study period because all HCBS were provided through a § 1115 managed care waiver. Hawaii transitioned all non- Intellectual/Developmental Disabilities (I/DD) § 1915(c) waiver participants to a § 1115 waiver in 2009. Rhode Island terminated its § 1915(c) waivers in mid-2009 and provided services under a § 1115 waiver. Vermont terminated its § 1915(c) waivers in 2006 and provided services under a § 1115 waiver. : KCMU and compilation of UCSF analyses of Medicaid Home Health and Personal Care Services Policy Surveys and CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 25 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 848 745 1,221 1,165 1,155 957 302 335 375 319 1,041 226% AL 9,200 11,500 16,000 16,500 20,800 25,000 32,320 29,248 28,884 23,404 21,069 -10% AR 9,850 12,640 13,140 13,199 11,702 10,370 14,160 15,958 16,609 16,771 17,237 3% AZ 502,730 571,603 642,134 694,692 783,660 793,647 803,633 813,619 823,606 833,592 849,478 2% CA 157,959 162,471 161,558 161,459 159,631 156,214 152,797 150,174 146,757 137,979 129,547 -6% CO 96,765 99,364 75,370 90,877 88,367 88,651 126,358 148,124 160,692 211,764 265,486 25% CT 179,555 173,256 178,419 194,780 144,862 148,520 231,265 223,456 250,615 251,585 255,585 2% DC 12,151 12,478 12,900 13,316 15,321 17,632 19,944 22,255 22,852 23,466 24,301 4% DE 3,485 3,578 3,699 4,270 5,085 5,070 5,055 5,040 5,154 5,270 5,364 2% FL 44,680 53,741 67,041 73,248 74,528 71,306 65,878 221,586 201,905 179,752 165,236 -8% GA 13,535 7,417 6,663 6,861 5,698 5,037 4,376 3,715 3,054 2,892 2,962 2% HI 2,706 822 2,052 2,660 2,963 3,169 3,374 3,580 3,824 4,050 4,135 2% IA 70,559 67,449 76,136 91,684 100,158 106,830 113,447 122,715 125,935 133,533 134,037 0% ID 3,447 6,362 6,773 7,504 7,248 7,487 4,048 3,943 4,479 4,844 3,844 -21% IL 39,242 36,424 35,983 33,744 35,358 32,318 42,320 48,491 53,345 51,604 52,198 1% IN 52,176 66,990 76,746 84,227 94,117 105,813 138,778 158,242 184,603 218,663 243,681 11% KS 40,788 40,333 16,570 16,360 14,790 12,085 12,854 10,882 9,620 9,830 9,451 -4% KY 58,124 54,134 52,479 56,169 63,172 49,893 41,885 40,880 38,652 35,099 36,084 3% LA 26,816 293,605 292,748 27,154 28,688 36,526 38,670 42,891 44,699 44,803 43,946 -2% MA 66,544 64,057 62,886 64,745 71,321 85,672 100,134 120,992 150,099 194,634 240,228 23% MD 2,633 2,523 2,691 2,591 2,044 2,327 2,361 2,798 3,061 2,943 2,986 1% ME 5,567 5,894 6,094 6,932 7,861 7,703 4,097 3,921 3,379 3,719 4,477 20% MI 4,776 4,825 4,515 4,738 4,163 4,037 3,911 5,081 4,977 4,342 13,340 207% MN 8,225 7,594 7,419 28,587 26,329 25,160 24,020 22,364 23,347 22,456 17,083 -24% MO 6,134 5,339 7,113 6,388 6,746 5,955 6,493 6,923 7,263 6,887 6,607 -4% MS 14,698 28,883 19,289 12,393 11,661 7,284 4,048 8,677 7,918 6,193 2,344 -62% MT 539 494 488 447 485 431 455 531 445 448 572 28% NC 94,913 97,659 111,310 116,214 119,785 131,309 144,747 149,348 141,831 55,269 56,355 2% ND 3,026 4,944 4,925 5,256 5,018 5,750 6,267 7,652 6,682 8,670 10,651 23% NE 20,658 19,721 32,005 32,985 34,753 38,132 24,832 25,838 19,199 17,425 12,100 -31% NH 3,028 3,205 3,884 3,205 3,884 2,980 3,490 4,001 4,511 5,022 5,133 2% NJ 36,608 37,591 38,865 42,634 45,367 49,037 52,707 56,376 57,649 58,950 60,452 3% NM 538 315 386 451 441 426 327 289 254 1,740 2,188 26% NV 6,136 2,218 4,325 2,180 3,394 3,347 3,155 5,113 7,513 11,034 13,015 18% NY 704,235 1,342,916 1,424,463 1,682,697 1,836,285 1,842,757 1,849,228 1,855,700 1,862,171 1,868,643 1,889,655 1% OH 114,663 132,313 83,193 98,579 151,244 149,864 182,308 214,740 250,636 294,259 365,252 24% OK 4,158 5,411 7,742 8,994 12,001 10,739 11,490 13,396 14,209 14,770 15,266 3% OR 1,006 1,033 1,068 544 475 1,055 544 663 490 607 552 -9% PA 37,159 45,277 52,370 139,112 159,887 187,338 216,248 224,029 88,310 90,462 39,894 -56% RI 3,114 3,632 3,755 3,427 3,266 3,037 2,808 2,579 2,461 2,544 2,694 6% SC 18,406 18,901 19,541 22,660 26,357 29,632 25,588 19,577 15,068 10,687 7,418 -31% SD 4,044 4,153 4,293 3,957 4,700 4,763 4,827 4,891 5,098 5,771 7,014 22% Medicaid Home and Community-Based Services Programs: 2013 Data Update 26 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change TN 33,818 69,346 136,076 195,439 278,452 318,237 244,845 207,652 211,821 202,985 204,496 1% TX 176,894 414,933 459,642 481,609 429,354 467,050 528,469 622,167 679,625 643,671 609,817 -5% UT 2,908 8,801 9,217 9,557 13,284 32,895 35,518 34,183 34,903 27,503 28,860 5% VA 4,434 3,053 4,556 5,019 4,787 5,842 6,228 7,166 7,935 7,920 6,533 -18% VT 7,972 7,652 7,633 7,798 5,668 6,313 6,576 6,302 6,877 13,295 15,971 20% WA 3,843 3,236 4,489 4,615 4,337 4,282 4,201 4,365 3,980 3,021 3,570 18% WI 18,232 18,722 19,356 18,653 18,133 17,633 17,134 16,635 17,082 17,541 16,450 -6% WV 2,594 2,663 2,754 3,513 3,066 3,372 3,886 4,348 4,752 4,784 5,258 10% WY 1,231 1,217 1,378 1,545 1,936 1,705 1,953 2,201 2,449 2,697 2,137 -21% : Data may not sum to total due to rounding. : KCMU and UCSF analysis of Medicaid Home Health Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 27 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 39,328 40,384 41,752 78,154 73,174 72,474 77,336 82,197 87,059 91,921 93,145 1% AL - - - - - - - - - - - - AR 52,311 53,920 61,134 59,892 57,422 55,633 70,117 71,263 78,580 84,946 90,143 6% AZ - - - - - - - - - - - - CA 2,300,000 2,605,215 2,857,270 3,403,108 4,013,108 4,326,503 4,865,302 4,325,761 4,349,211 2,270,395 2,960,322 30% CO - - - - - - - - - - - - CT - - - - - - - - - - - - DC 10,283 10,559 10,917 10,124 9,653 8,963 8,273 7,583 6,893 7,588 7,961 5% DE 0 0 0 0 0 0 0 0 0 0 0 0% FL 35,127 35,264 33,411 29,286 5,204 6,380 18,047 31,098 38,200 180,550 190,325 5% GA - - - - - - - - - - - - HI - - - - - - - - - - - - IA - - - - - - - - - - - - ID 26,886 24,453 27,298 28,549 30,161 30,732 24,765 15,906 15,999 20,778 6,949 -67% IL - - - - - - - - - - - - IN - - - - - - - - - - - - KS - - - - 56 1,247 2,375 3,398 4,421 5,444 5,903 8% KY - - - - - - - - - - - - LA - 1 33,519 72,267 121,164 194,116 242,683 237,587 190,140 185,443 227,137 22% MA 193,168 221,845 243,905 268,960 283,566 314,501 355,674 394,358 436,194 465,197 504,651 8% MD 20,739 20,490 20,595 21,475 22,904 23,899 25,201 26,535 29,990 31,062 40,474 30% ME 10,358 11,640 10,935 10,774 9,234 6,566 14,798 16,247 45,829 27,135 26,055 -4% MI 249,445 254,155 237,292 218,775 253,962 254,320 256,432 259,320 281,640 289,709 290,638 0% MN 116,529 121,767 180,596 281,732 304,956 346,854 396,486 400,763 422,260 438,478 444,657 1% MO 209,162 211,889 239,481 242,195 265,736 303,599 351,852 234,779 398,945 420,764 466,007 11% MS - - - - - - - - - - - - MT 21,300 21,900 24,958 25,306 26,037 28,778 36,937 45,316 43,305 43,177 42,698 -1% NC 190,808 221,039 286,653 311,069 301,391 316,782 346,151 320,902 249,918 229,763 330,717 44% ND 2,004 4,556 5,314 10,949 11,367 12,369 15,964 17,433 19,041 19,830 20,989 6% NE 8,116 8,463 9,784 10,539 11,269 13,653 13,359 13,401 12,474 12,351 14,233 15% NH 654 499 511 472 495 430 557 684 811 798 804 1% NJ 280,035 263,184 269,283 254,337 253,790 250,363 250,369 250,375 250,381 251,387 256,840 2% NM 159,392 180,888 150,526 167,269 190,766 203,666 223,786 243,906 264,026 267,982 276,023 3% NV 19,809 43,134 35,568 54,273 65,004 71,775 69,844 68,222 70,110 66,672 67,383 1% NY 1,796,653 1,930,721 2,045,068 2,244,915 2,324,483 2,342,911 2,220,834 2,140,557 2,060,281 2,051,086 2,068,407 1% OH - - - - - - - - - - - - OK 31,000 12,375 14,340 11,847 10,824 10,237 10,763 12,187 12,281 11,930 11,420 -4% OR 3,100 4,497 5,645 5,323 5,178 4,960 4,426 3,995 3,754 3,866 1,700 -56% PA - - - - - - - - - - - - RI 0 0 0 0 0 0 0 0 0 0 0 0% SC - - - - - - - - - - - - SD 1,321 1,337 1,337 1,570 1,694 1,763 1,501 1,201 1,173 822 619 -25% Medicaid Home and Community-Based Services Programs: 2013 Data Update 28 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change TN - - - - - - - - - - - - TX 374,444 417,973 459,642 481,520 449,989 422,475 479,569 414,168 551,443 304,501 91,104 -70% UT 847 1,272 1,082 1,204 319 356 363 675 796 1,352 1,784 32% VA - - - - - - - - - - - - VT 8,165 10,616 13,131 16,411 16,832 16,839 19,277 21,536 22,186 21,775 19,035 -13% WA 215,675 238,677 195,430 222,686 249,212 304,218 344,090 361,707 372,795 368,742 349,207 -5% WI 113,296 123,839 128,035 136,936 140,365 145,396 150,426 155,457 160,487 163,517 164,032 0% WV 26,850 27,571 28,505 27,037 36,793 37,800 37,676 41,253 43,273 51,696 61,700 19% WY - - - - - - - - - - - - : Data may not sum to total due to rounding. Personal care services are an optional benefit. In 2013, 32 states reported personal care services expenditures. Delaware and Rhode Island were approved by CMS to offer personal care services but did not report expenditures during the period. A dash indicates that there was no operational personal care services program that year. : KCMU and UCSF analysis of Medicaid Personal Care Services Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 29 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 105,503 113,402 113,599 125,137 132,721 143,346 163,045 181,622 200,984 212,695 237,126 11% AL 203,082 225,714 257,707 280,816 312,573 335,800 368,754 375,034 384,918 398,281 430,933 8% AR 101,399 111,273 129,193 163,033 173,537 196,766 229,559 256,959 274,000 295,690 297,845 1% AZ - - - - - - - - - - - - CA 1,140,539 1,256,950 1,396,828 1,429,634 1,692,552 1,864,743 1,988,332 2,061,069 2,503,002 3,185,476 2,591,306 -19% CO 362,572 364,644 358,508 386,230 424,565 468,613 551,935 572,693 577,400 615,398 616,303 0% CT 489,666 504,458 523,580 146,489 195,870 227,512 788,548 822,383 871,230 947,627 973,843 3% DC 4,340 8,218 14,678 26,601 56,360 68,608 156,282 197,185 225,909 244,508 262,601 7% DE 59,637 63,763 70,357 82,517 94,906 103,405 110,632 109,727 109,113 111,381 96,849 -13% FL 733,941 830,009 901,164 1,009,222 1,141,114 1,223,412 924,999 1,137,742 1,311,999 1,376,283 1,357,182 -1% GA 326,008 370,186 391,253 443,129 421,872 512,144 650,844 815,439 797,435 911,498 975,767 7% HI 75,994 107,459 118,789 125,971 130,686 135,740 107,520 100,605 101,796 103,423 115,766 12% IA 181,116 218,091 276,185 318,410 353,610 388,300 420,454 442,849 451,981 482,734 537,794 11% ID 82,344 103,431 112,692 120,714 131,905 143,935 167,428 198,753 201,503 211,240 213,057 1% IL 589,587 672,254 766,502 841,044 868,574 1,038,667 1,179,146 1,277,027 1,426,249 1,536,410 1,577,515 3% IN 319,972 404,514 411,766 411,856 462,394 535,762 590,437 625,921 608,485 626,384 754,849 21% KS 306,019 323,687 352,258 384,648 428,926 493,410 559,825 559,881 666,650 554,051 698,969 26% KY 191,182 191,004 224,853 207,525 271,246 297,226 328,638 376,303 443,987 517,535 600,757 16% LA 174,795 188,007 278,972 283,784 323,635 401,425 467,575 461,542 527,827 443,818 560,228 26% MA 556,405 598,623 644,222 701,180 669,355 729,983 828,454 824,339 814,855 974,873 1,048,814 8% MD 352,527 437,514 498,257 548,485 658,424 653,967 773,357 805,016 817,385 931,505 1,007,014 8% ME 201,944 223,427 225,961 248,270 266,204 327,929 335,208 339,675 331,928 347,952 342,693 -2% MI 329,268 397,413 421,876 443,889 455,289 491,111 525,973 555,677 566,396 605,052 687,163 14% MN 1,020,272 1,093,323 1,186,371 1,312,866 1,464,391 1,630,342 1,787,725 1,873,476 1,943,699 1,994,956 2,056,247 3% MO 355,464 362,843 370,250 404,820 456,831 497,076 536,887 602,917 594,521 652,357 720,114 10% MS 81,240 103,442 121,895 112,023 131,102 148,815 175,176 198,840 200,391 264,095 270,911 3% MT 66,284 75,248 79,969 86,495 90,983 108,599 114,271 119,668 125,171 130,443 133,580 2% NC 453,260 484,323 545,177 564,364 671,325 728,732 694,891 786,717 808,134 872,737 812,703 -7% ND 55,680 62,066 65,292 66,439 72,121 79,953 87,634 101,147 121,788 137,152 148,000 8% NE 152,766 167,469 173,808 183,117 202,155 216,599 235,620 255,306 280,367 295,337 309,075 5% NH 149,705 154,211 158,880 167,511 180,973 198,708 231,962 246,536 245,754 253,299 267,196 5% NJ 425,146 443,129 495,986 512,603 541,388 567,194 709,740 775,799 824,580 946,277 1,007,157 6% NM 226,940 262,637 273,775 296,222 312,943 353,222 322,651 324,034 317,075 314,992 336,397 7% NV 35,241 42,243 55,387 69,893 74,198 77,581 82,127 85,363 87,050 90,553 86,215 -5% NY 2,720,790 3,109,629 3,538,794 3,834,334 4,293,467 4,855,807 5,371,814 5,716,976 5,761,687 5,792,823 5,493,843 -5% OH 775,640 846,793 943,624 1,147,208 1,395,609 1,419,497 1,569,844 1,692,507 1,929,815 1,960,947 1,983,664 1% OK 301,201 280,582 315,231 369,707 416,125 465,770 486,196 480,197 471,006 469,112 457,156 -3% OR 566,300 555,476 580,270 594,972 634,543 720,301 864,453 921,524 1,054,787 963,620 805,068 -16% PA 1,147,196 1,268,109 1,427,006 1,155,791 1,215,867 1,928,735 2,179,060 2,408,175 2,443,818 2,693,554 3,014,165 12% RI 231,671 239,289 239,604 257,209 289,991 301,456 141,405 - - - - - SC 247,834 257,484 270,433 258,689 309,519 363,350 461,000 426,715 442,335 432,233 465,083 8% SD 67,633 79,667 73,859 84,374 90,849 97,696 103,386 108,979 113,085 113,974 118,741 4% Medicaid Home and Community-Based Services Programs: 2013 Data Update 30 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change TN 210,184 275,060 384,171 439,380 504,395 608,317 665,087 632,155 590,524 600,438 603,649 1% TX 735,065 892,433 1,038,166 1,103,452 1,157,546 1,389,204 1,630,785 1,843,104 1,843,521 1,478,404 1,398,264 -5% UT 110,477 115,720 120,207 123,992 134,173 156,863 178,446 179,731 181,720 191,471 208,305 9% VA 359,040 358,320 426,493 524,147 616,209 704,399 831,993 943,515 1,034,968 1,116,112 1,213,726 9% VT 109,732 124,510 120,845 - - - - - - - - - WA 534,670 483,394 651,600 702,137 740,802 807,682 934,887 1,011,573 1,047,640 1,267,075 1,131,370 -11% WI 673,788 760,421 838,968 913,729 957,714 1,049,507 1,254,477 1,493,325 1,561,349 1,661,401 1,765,281 6% WV 186,022 208,982 233,456 239,133 262,513 291,214 314,784 336,330 344,138 426,607 531,165 25% WY 75,705 81,582 88,346 93,768 97,378 98,731 116,635 112,802 115,260 90,530 123,132 36% : Data may not sum to total due to rounding. Arizona did not operate a § 1915(c) waiver over the study period because all HCBS were provided through a § 1115 managed care waiver. Hawaii transitioned all non-I/DD § 1915(c) waiver participants to a § 1115 waiver in 2009. Rhode Island terminated its § 1915(c) waivers in mid-2009 and provided services under a § 1115 waiver. Vermont terminated its § 1915(c) waivers in 2006 and provided services under a § 1115 waiver. A dash indicates that there was no operational § 1915(c) program that year. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 31 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 22,888 18,747 17,563 25,455 26,169 27,583 29,582 31,309 32,545 33,947 35,659 5% AL 10,740 12,027 13,463 14,278 15,632 16,484 16,336 18,312 19,409 20,767 22,579 9% AR 4,882 5,235 5,954 6,832 7,315 7,928 8,995 9,911 10,323 10,882 11,083 2% AZ 18,251 19,096 20,583 21,469 23,123 22,696 22,295 21,918 21,561 21,224 21,045 -1% CA 8,059 8,856 9,146 10,124 11,359 10,587 11,572 11,142 11,774 10,087 12,887 28% CO 13,665 13,540 13,878 12,993 13,276 13,775 15,801 16,314 16,018 17,318 17,723 2% CT 17,587 17,172 17,538 8,924 11,389 12,074 21,440 21,209 21,215 21,780 21,981 1% DC 5,270 5,607 5,646 6,603 9,010 9,978 18,539 21,261 22,418 22,463 23,718 6% DE 16,637 16,180 18,196 20,546 23,973 26,600 28,059 27,965 26,814 26,957 49,212 83% FL 9,506 10,463 10,619 11,133 13,690 15,756 9,624 14,939 16,147 16,168 16,305 1% GA 9,177 9,239 9,163 10,821 10,226 11,095 12,965 15,620 15,427 16,500 17,263 5% HI 12,538 23,321 21,339 21,226 20,555 19,599 26,422 24,201 23,715 23,449 25,560 9% IA 6,786 6,781 8,267 11,310 11,781 12,321 13,128 13,463 13,578 14,657 15,962 9% ID 8,653 8,482 8,867 9,219 9,419 9,697 11,196 12,677 13,191 11,087 12,143 10% IL 8,606 9,154 9,821 10,180 10,590 11,481 12,212 12,660 13,228 13,460 12,998 -3% IN 18,986 21,037 22,916 22,275 22,737 24,373 24,346 23,405 22,489 22,154 22,534 2% KS 13,687 13,110 12,625 13,274 14,431 15,161 16,955 17,072 20,264 17,653 22,082 25% KY 5,864 6,275 7,428 7,733 10,053 10,447 11,294 12,133 13,469 15,064 16,209 8% LA 11,042 19,962 23,278 13,805 15,289 17,474 18,483 16,776 16,574 16,096 17,402 8% MA 16,933 19,141 18,769 19,866 19,458 20,520 21,589 21,020 21,232 23,059 23,370 1% MD 18,595 23,643 22,041 24,153 29,254 27,757 27,211 27,495 27,296 29,862 31,307 5% ME 23,592 26,747 27,156 28,413 31,579 34,517 33,571 34,079 21,162 18,516 32,322 75% MI 7,397 8,215 8,372 8,322 8,761 9,024 9,128 9,038 9,226 9,556 9,641 1% MN 22,200 21,832 23,167 20,691 21,246 22,193 23,283 23,196 26,571 23,815 24,383 2% MO 6,813 6,550 6,910 7,704 8,780 9,592 10,242 9,787 10,966 11,785 12,333 5% MS 4,063 5,540 5,986 5,613 6,338 6,809 7,321 8,070 7,702 8,847 10,826 22% MT 13,505 13,370 13,933 14,673 14,893 17,003 18,213 19,210 19,152 18,313 19,047 4% NC 8,771 8,375 8,505 8,442 9,490 10,163 9,856 10,753 11,474 9,974 11,118 11% ND 14,714 13,872 13,705 12,911 13,644 15,053 16,973 21,675 24,234 26,351 25,941 -2% NE 12,480 12,987 12,483 12,632 13,041 14,066 15,056 15,644 18,146 20,568 21,361 4% NH 19,059 19,371 21,016 20,433 19,934 20,751 22,587 22,911 22,346 22,264 23,361 5% NJ 15,415 15,453 15,259 14,537 14,675 14,969 15,291 17,702 18,269 19,636 20,369 4% NM 25,585 27,855 26,096 26,499 25,447 26,434 25,665 25,816 25,009 25,001 23,069 -8% NV 9,212 9,740 9,781 12,214 13,353 13,574 13,695 15,727 15,572 14,310 14,129 -1% NY 20,829 23,495 25,777 27,542 30,452 32,575 33,655 34,445 34,535 34,564 33,603 -3% OH 6,653 6,800 12,330 14,019 15,001 16,190 16,584 17,259 17,677 16,986 16,836 -1% OK 11,726 10,828 10,792 11,645 12,048 12,254 13,021 13,348 13,461 13,415 13,704 2% OR 13,155 13,204 13,589 13,778 14,407 16,253 18,387 18,798 20,721 18,592 17,476 -6% PA 24,585 24,368 24,682 16,841 17,592 24,959 26,348 26,699 29,391 30,334 33,115 9% RI 36,480 35,109 33,678 33,862 34,436 33,392 18,736 1,874 1,741 1,943 1,996 3% SC 9,589 11,148 11,958 12,428 13,714 15,611 19,354 18,692 19,593 18,675 18,632 0% SD 7,887 8,717 8,241 9,116 9,738 10,409 11,902 14,603 16,213 16,596 17,091 3% TN 19,407 19,420 26,932 31,947 38,580 39,396 36,268 33,253 40,049 42,556 42,514 0% TX 4,161 5,916 4,574 6,462 6,077 7,105 7,779 7,844 8,067 7,639 10,657 40% UT 16,565 14,068 14,659 15,330 9,528 14,576 13,276 15,831 17,684 19,296 20,001 4% VA 17,793 17,597 18,960 21,743 24,433 24,927 26,437 26,030 26,583 26,500 27,386 3% VT 15,033 15,742 14,814 4,063 3,944 3,720 4,154 4,456 4,890 6,313 6,292 0% WA 11,842 11,274 12,584 13,466 14,244 15,544 17,562 17,792 17,777 18,512 17,944 -3% WI 16,386 16,740 17,288 18,421 18,426 17,847 20,232 20,783 20,788 20,885 21,369 2% WV 13,755 15,546 17,747 16,321 18,511 18,822 18,579 19,723 19,851 24,164 28,220 17% WY 21,863 22,803 22,110 22,022 21,632 21,445 24,887 22,773 22,654 19,370 25,828 33% : Total Medicaid HCBS comprises Medicaid home health state plan services, Medicaid personal care state plan services, and Medicaid § 1915(c) waivers. Arizona did not operate a § 1915(c) waiver over the study period because all HCBS were provided through a § 1115 managed care waiver. Hawaii transitioned all non-I/DD § 1915(c) waiver participants to a § 1115 waiver in 2009. Rhode Island terminated its § 1915(c) waivers in mid-2009 and provided services under a § 1115 waiver. Vermont terminated its § 1915(c) waivers in 2006 and provided services under a § 1115 waiver. : KCMU and compilation of UCSF analyses of Medicaid Home Health and Personal Care Services Policy Surveys and CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 32 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 2,965 2,730 3,131 3,124 3,319 3,256 967 1,124 1,242 1,137 3,389 198% AL 1,399 1,812 2,368 2,583 3,194 3,708 3,354 4,171 4,362 4,235 4,028 -5% AR 1,455 1,903 1,936 2,029 1,929 1,799 2,265 2,588 2,610 2,640 2,699 2% AZ 18,251 19,096 20,583 21,469 23,123 22,696 22,295 21,918 21,561 21,224 21,045 -1% CA 1,766 1,867 1,822 1,842 1,845 1,823 1,801 4,903 4,946 5,790 6,159 6% CO 13,208 12,008 8,676 9,637 8,487 8,086 11,449 13,304 13,393 17,356 21,065 21% CT 8,578 8,079 8,202 8,767 10,064 9,799 8,721 8,133 8,334 7,991 8,069 1% DC 5,721 5,287 4,518 3,910 3,746 4,163 4,551 4,915 4,413 4,229 4,498 6% DE 2,632 2,235 2,591 2,910 3,840 3,995 4,164 4,348 4,483 4,768 4,747 0% FL 2,557 2,692 3,163 3,463 3,904 4,189 4,165 15,104 16,514 16,279 15,644 -4% GA 1,240 566 475 786 889 835 774 704 623 640 640 0% HI 993 1,404 1,579 1,811 1,934 1,946 1,957 1,967 2,010 2,033 2,035 0% IA 3,434 2,889 3,100 7,143 7,681 8,075 8,934 8,814 9,148 10,259 10,163 -1% ID 1,921 1,931 2,036 2,260 1,842 1,673 2,151 2,203 2,394 2,295 2,123 -7% IL 3,041 2,940 2,755 2,263 2,511 2,470 3,000 3,424 3,867 4,074 4,479 10% IN 6,336 7,494 9,797 10,139 11,267 12,762 15,003 14,840 14,055 15,359 18,671 22% KS 6,099 5,639 2,825 3,050 3,026 2,916 3,131 2,745 2,579 2,631 2,485 -6% KY 2,359 2,284 2,341 2,916 3,410 2,750 2,527 2,559 2,436 2,342 2,400 2% LA 2,427 25,176 24,021 2,265 2,451 3,124 3,269 3,822 4,048 4,081 4,064 0% MA 3,409 3,883 3,518 3,681 4,143 4,853 5,493 6,057 7,182 8,462 9,650 14% MD 732 2,026 613 620 617 627 594 688 721 695 727 5% ME 1,773 2,050 2,041 1,876 2,543 2,688 1,555 1,502 432 320 1,765 451% MI 575 681 687 723 694 685 675 795 823 827 969 17% MN 1,590 1,420 1,419 2,186 2,076 1,993 1,954 1,855 10,076 1,751 1,699 -3% MO 848 737 919 918 969 969 997 1,058 1,047 1,001 1,010 1% MS 1,420 3,049 2,133 1,507 1,467 923 513 992 855 782 2,124 172% MT 1,181 1,044 1,103 1,079 1,096 1,101 1,105 1,240 1,211 1,158 1,512 31% NC 2,858 2,723 2,878 2,883 2,956 3,251 3,522 3,842 3,548 1,649 1,720 4% ND 3,769 5,500 9,453 6,464 6,526 6,648 7,089 10,095 8,922 9,088 9,510 5% NE 3,688 3,565 4,245 4,284 4,246 4,966 4,275 4,098 4,458 5,579 4,530 -19% NH 1,316 1,342 1,367 1,190 1,440 1,173 1,247 1,309 1,361 1,406 1,447 3% NJ 3,360 3,320 3,490 3,369 3,345 3,337 3,330 3,325 3,298 3,205 3,176 -1% NM 883 805 895 1,009 1,028 1,077 1,003 1,058 1,022 3,326 3,765 13% NV 4,797 2,263 4,971 2,732 4,519 4,748 5,189 7,771 11,400 15,808 18,835 19% NY 7,838 12,108 13,039 14,333 16,164 16,846 17,065 17,287 17,514 17,746 18,113 2% OH 1,276 1,372 2,669 3,060 3,796 4,787 5,271 5,855 6,404 6,601 7,619 15% OK 1,383 1,409 1,509 1,719 2,028 2,147 2,232 2,330 2,682 2,672 3,018 13% OR 864 1,023 1,304 163 103 350 163 223 160 190 1,332 601% PA 4,604 4,937 5,596 5,866 6,520 7,268 7,875 7,805 6,026 6,566 5,186 -21% RI 2,281 2,287 2,265 2,216 2,085 2,115 1,997 1,874 1,741 1,943 1,996 3% SC 2,345 4,039 5,000 7,451 9,931 14,547 15,168 15,574 14,269 11,202 8,307 -26% SD 807 793 841 786 947 979 1,281 1,910 2,814 3,135 4,111 31% TN 4,422 5,480 10,852 16,458 25,518 29,667 22,566 17,554 17,463 18,565 18,316 -1% TX 947 2,428 2,457 2,503 2,048 2,349 2,516 2,698 2,886 3,225 4,566 42% UT 1,955 3,975 4,345 4,836 1,327 4,791 3,609 4,724 6,179 6,262 6,443 3% VA 1,157 1,056 1,381 1,238 1,395 1,565 1,574 1,296 1,663 1,756 1,748 0% VT 2,277 2,119 1,981 2,030 1,517 1,768 1,726 1,738 1,999 4,227 4,975 18% WA 1,190 1,132 1,248 1,246 1,307 1,305 1,297 1,301 1,272 1,099 973 -11% WI 3,089 2,672 2,605 2,767 2,923 2,922 2,921 2,920 3,213 3,481 3,425 -2% WV 1,391 1,518 1,409 1,500 1,542 1,570 1,570 1,611 1,677 1,779 1,729 -3% WY 2,203 2,270 2,438 2,725 3,173 3,072 3,432 3,775 4,102 4,414 3,549 -20% : KCMU and UCSF analysis of Medicaid Home Health Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 33 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 14,343 8,631 8,418 20,019 19,750 20,589 21,859 23,115 24,359 25,548 25,470 0% AL - - - - - - - - - - - - AR 3,375 3,478 3,956 3,951 4,037 3,996 4,877 5,125 5,397 5,586 5,870 5% AZ - - - - - - - - - - - - CA 7,986 8,830 9,103 10,316 11,615 10,232 11,439 9,502 9,527 5,414 9,702 79% CO - - - - - - - - - - - - CT - - - - - - - - - - - - DC 4,372 4,342 4,329 4,053 4,082 3,900 3,708 3,504 3,287 3,593 3,794 6% DE 0 0 0 0 0 0 0 0 0 0 0 0% FL 2,396 2,396 2,390 2,390 14,578 15,830 19,118 25,180 21,904 16,244 15,393 -5% GA - - - - - - - - - - - - HI - - - - - - - - - - - - IA - - - - - - - - - - - - ID 7,962 6,766 7,581 7,559 7,994 8,089 5,805 4,775 7,396 3,511 3,357 -4% IL - - - - - - - - - - - - IN - - - - - - - - - - - - KS - - - - 3,118 14,011 16,156 16,180 16,193 16,201 16,174 0% KY - - - - - - - - - - - - LA - 666 7,618 11,003 14,048 16,833 17,131 13,551 10,258 10,082 11,689 16% MA 18,275 18,935 17,717 18,941 18,768 18,610 19,543 19,889 20,226 20,356 20,774 2% MD 4,373 4,451 4,436 4,800 5,223 5,412 5,469 5,422 5,744 5,835 7,236 24% ME 5,454 5,969 5,752 6,602 5,381 3,853 6,954 7,237 10,243 8,997 8,437 -6% MI 4,676 4,622 4,302 3,892 4,380 4,301 4,182 3,992 4,208 4,193 4,266 2% MN 18,491 14,620 18,169 17,004 16,168 16,709 17,428 16,457 18,631 18,588 18,301 -2% MO 4,665 4,298 4,840 5,106 5,658 6,154 6,672 4,593 7,192 7,559 7,904 5% MS - - - - - - - - - - - - MT 7,437 7,324 7,981 8,119 8,413 9,304 11,748 13,637 13,032 12,020 12,001 0% NC 5,602 5,274 5,641 5,854 6,043 6,333 6,511 6,313 6,456 4,024 6,904 72% ND 4,454 5,863 3,902 5,775 6,072 7,052 10,579 16,009 16,630 17,022 17,491 3% NE 6,238 6,241 6,317 6,273 6,541 7,453 5,539 5,705 5,505 6,204 6,122 -1% NH 25,137 19,956 20,438 22,486 30,934 20,496 22,293 23,594 28,969 28,509 25,114 -12% NJ 15,815 13,861 12,894 11,998 11,759 12,140 12,182 12,224 12,266 12,237 12,379 1% NM 17,789 18,991 15,657 15,965 16,209 16,471 16,648 16,798 16,927 16,884 17,237 2% NV 9,720 9,785 7,126 10,082 11,479 11,567 10,734 13,291 13,039 10,305 10,376 1% NY 21,428 22,552 24,268 27,112 29,020 29,848 29,549 29,857 30,197 30,984 32,303 4% OH - - - - - - - - - - - - OK 4,429 2,850 2,605 2,906 2,925 3,077 3,097 3,137 3,201 2,984 2,960 -1% OR 1,305 1,000 1,110 1,421 1,435 1,463 1,438 1,237 1,199 1,198 2,429 103% PA - - - - - - - - - - - - RI 0 0 0 0 0 0 0 0 0 0 0 0% SC - - - - - - - - - - - - SD 1,393 1,448 1,484 1,677 1,718 1,770 1,744 1,518 1,538 1,436 1,450 1% TN - - - - - - - - - - - - TX 5,591 5,856 2,457 7,474 7,624 8,193 9,112 7,329 7,945 5,422 8,189 51% UT 1,881 712 617 719 4,428 5,735 2,772 4,020 3,304 3,439 4,460 30% VA - - - - - - - - - - - - VT 6,682 6,880 6,926 7,756 8,553 6,347 7,985 8,214 8,864 9,035 8,086 -11% WA 10,061 10,660 8,595 9,283 9,908 11,236 13,394 13,248 13,319 13,668 13,596 -1% WI 10,817 11,134 10,210 10,331 10,281 10,362 10,438 10,511 10,580 10,517 10,479 0% WV 5,159 5,576 6,521 4,753 6,106 6,273 6,377 6,337 6,473 7,758 8,945 15% WY - - - - - - - - - - - - : Personal care state plan services are an optional benefit. In 2013, 32 states reported personal care services expenditures. Delaware and Rhode Island were approved by CMS to offer personal care services but did not report expenditures during the period. A dash indicates that there was no operational personal care services program that year. : KCMU and UCSF analysis of Medicaid Personal Care Services Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 34 12-13 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % change AK 31,616 34,458 31,865 33,325 34,393 35,438 38,041 39,629 40,310 41,674 44,514 7% AL 15,397 16,872 18,987 19,455 21,100 22,172 24,720 24,894 26,188 26,950 29,141 8% AR 9,025 9,410 10,826 12,644 13,467 14,620 16,095 17,534 18,462 19,764 20,096 2% AZ - - - - - - - - - - - - CA 16,512 17,361 17,412 18,869 20,081 20,490 20,860 20,442 23,124 28,608 22,597 -21% CO 13,792 14,027 15,879 14,152 15,042 15,890 17,307 17,328 16,943 17,305 16,589 -4% CT 28,602 27,993 28,652 9,141 12,618 14,230 37,466 37,660 38,197 40,193 40,149 0% DC 7,174 10,509 10,186 15,881 21,913 22,813 46,805 49,469 54,713 53,072 53,255 0% DE 24,144 24,898 26,630 29,930 33,335 36,812 38,031 37,259 35,062 34,569 102,270 196% FL 13,726 15,615 15,235 15,187 16,365 18,778 10,503 14,744 15,970 16,144 16,528 2% GA 12,498 13,331 13,303 13,488 11,917 12,620 14,501 17,289 16,970 17,908 18,742 5% HI 21,401 26,481 27,226 27,439 26,295 24,862 43,477 40,485 39,904 39,916 43,537 9% IA 10,951 11,623 15,293 13,593 13,879 14,405 15,032 15,766 15,695 16,629 18,609 12% ID 10,490 11,598 11,708 12,186 12,848 13,695 14,712 16,395 15,750 15,841 14,639 -8% IL 9,799 10,338 11,165 11,842 12,186 12,951 13,725 14,105 14,545 14,589 13,871 -5% IN 28,152 30,022 30,537 29,494 28,679 29,712 28,521 27,403 27,495 26,201 24,146 -8% KS 16,409 15,702 15,087 15,481 16,595 16,904 18,873 19,007 22,531 19,662 24,803 26% KY 10,694 12,434 15,069 13,985 18,405 19,707 20,244 20,442 22,235 23,850 24,770 4% LA 24,254 15,086 29,634 30,833 30,414 31,000 32,193 29,823 32,110 35,488 31,962 -10% MA 30,732 33,261 33,860 34,537 32,947 35,571 35,932 34,451 34,636 38,937 38,050 -2% MD 29,689 32,099 34,067 36,432 42,036 39,925 37,093 37,644 37,683 40,899 42,218 3% ME 48,128 53,400 55,642 61,544 63,930 61,364 57,934 59,561 58,182 59,622 57,868 -3% MI 19,108 22,283 24,047 25,454 26,091 27,237 27,645 28,662 29,073 30,646 32,858 7% MN 25,443 25,830 26,868 26,902 27,644 28,682 29,896 29,926 29,931 29,903 29,837 0% MO 11,214 11,330 11,552 13,310 15,680 17,371 19,066 21,048 20,612 22,417 23,072 3% MS 6,126 7,177 8,383 8,034 8,995 9,897 10,557 11,721 11,266 11,670 11,224 -4% MT 20,681 19,596 20,007 20,999 20,901 23,506 23,951 24,598 24,400 23,605 24,973 6% NC 26,678 26,761 25,472 23,502 27,147 28,703 26,669 28,933 31,218 34,266 29,836 -13% ND 19,380 17,820 17,997 17,995 18,752 20,522 21,479 25,433 29,046 32,911 32,139 -2% NE 19,985 20,480 21,240 21,387 22,156 22,631 23,642 25,094 26,392 27,620 28,869 5% NH 26,162 26,874 32,405 29,579 27,485 27,678 30,417 31,286 31,132 31,511 32,930 5% NJ 21,783 24,852 23,985 23,472 24,461 25,124 23,771 32,715 34,211 37,761 39,900 6% NM 40,875 43,642 43,952 44,991 41,101 42,444 42,820 44,893 42,854 45,044 33,479 -26% NV 10,599 11,718 14,275 16,789 17,397 17,876 19,498 19,852 19,178 19,728 18,714 -5% NY 35,332 41,374 45,154 46,978 51,159 54,149 55,363 55,530 54,424 52,900 48,650 -8% OH 17,640 17,797 18,108 20,250 22,059 21,631 22,089 22,924 22,917 22,234 21,660 -3% OK 16,125 14,483 15,287 15,259 15,518 14,837 15,980 16,994 16,929 17,100 17,323 1% OR 14,221 15,020 15,561 16,292 17,520 18,813 21,153 21,395 23,483 21,107 17,858 -15% PA 28,607 28,353 28,213 21,736 22,650 32,687 34,342 34,460 34,181 34,532 35,657 3% RI 45,686 44,886 43,032 41,816 41,726 39,238 22,477 - - - - - SC 12,443 12,802 13,295 13,200 14,173 15,705 19,656 18,865 19,845 18,988 19,009 0% SD 20,532 22,069 20,283 21,689 22,504 23,530 22,524 24,068 23,623 23,492 22,570 -4% TN 42,677 54,146 56,679 54,951 53,775 47,554 46,709 47,084 74,712 75,574 76,957 2% TX 13,279 18,079 19,329 17,532 17,415 19,755 21,306 23,045 24,177 23,871 26,733 12% UT 22,283 23,420 23,912 24,123 24,732 25,652 28,917 29,220 28,372 28,866 29,472 2% VA 21,633 20,306 21,943 25,843 28,030 28,449 29,984 30,444 30,034 29,444 29,734 1% VT 30,064 31,795 31,726 - - - - - - - - - WA 13,702 12,367 15,765 16,988 17,919 19,485 21,181 21,628 21,377 21,549 21,203 -2% WI 20,560 21,234 22,623 24,013 23,519 21,922 25,086 25,036 24,718 24,566 25,005 2% WV 21,646 24,051 27,175 28,157 31,552 30,699 29,157 33,116 33,617 40,100 47,190 18% WY 25,576 26,359 25,292 24,932 24,461 23,914 27,797 25,252 25,062 21,545 28,986 35% : Arizona did not operate a § 1915(c) waiver over the study period because all HCBS were provided through a § 1115 managed care waiver. Hawaii transitioned all non-I/DD § 1915(c) waiver participants to a § 1115 waiver in 2009. Rhode Island terminated its § 1915(c) waivers in mid- 2009 and provided services under a § 1115 waiver. Vermont terminated its § 1915(c) waivers in 2006 and provided services under a § 1115 waiver. A dash indicates that there was no operational § 1915(c) waiver program that year. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 35 I/DD 614,360 625,976 2% $29,106,060 $29,198,146 0% $47,376 $46,644 -2% Aged 189,894 210,421 11% $2,181,026 $2,505,382 15% $11,485 $11,907 4% (≥ 65) Aged/Disabled 528,132 540,362 2% $6,301,799 $6,316,263 0% $11,932 $11,689 -2% Physically 87,017 88,949 2% $1,818,976 $1,897,906 4% $20,904 $21,337 2% Disabled Children 46,274 48,933 6% $681,245 $753,277 11% $14,722 $15,394 5% HIV/AIDS 13,538 12,287 -9% $52,226 $50,029 -4% $3,858 $4,072 6% Mental Health 4,061 4,243 4% $50,502 $38,230 -24% $12,436 $9,010 -28% TBI/SCI 17,066 17,134 0% $652,482 $685,349 5% $38,233 $39,999 5% : Data may not sum to total due to rounding. I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 36 AK 4 1,701 1,832 - 1,501 293 - - - 5,327 AL 6 5,538 - 8,535 530 - 185 - - 14,788 AR 4 4,151 6,805 988 2,810 67 - - - 14,821 CA 8 96,369 - 13,361 2,882 112 1,950 - - 114,674 CO 11 7,849 - 23,706 - 1,986 - 3,286 325 37,152 CT 8 9,334 - 13,284 996 48 - 166 428 24,256 DC 2 1,806 - 3,125 - - - - - 4,931 DE 1 947 - - - - - - - 947 FL 13 24,826 32,008 17,767 122 5 7,012 - 375 82,115 GA 5 12,425 - 38,013 - 489 - - 1,136 52,063 HI 1 2,659 - - - - - - - 2,659 IA 7 12,263 10,521 - 3,621 1,107 36 - 1,352 28,900 ID 4 3,373 - 9,926 - 1,255 - - - 14,554 IL 9 18,537 56,643 9,281 21,081 2,333 1,495 - 4,361 113,731 IN 4 15,797 - 15,265 - - - - 200 31,262 KS 7 8,872 6,801 - 6,215 5,613 - - 680 28,181 KY 6 12,867 - 10,906 62 - - - 418 24,253 LA 6 10,372 - 5,837 - 1,319 - - - 17,528 MA 8 11,873 15,321 - - 172 - - 198 27,564 MD 9 13,503 3,684 4,695 732 1,111 - 69 59 23,853 ME 4 4,244 - 1,519 159 - - - - 5,922 MI 4 8,321 - 11,846 - 746 - - - 20,913 MN 5 16,285 31,278 - 19,872 - - - 1,480 68,915 MO 10 12,265 - 17,067 1,653 153 73 - - 31,211 MS 6 2,009 - 18,267 2,522 - - 505 833 24,136 MT 6 2,639 - 2,384 - 116 - 210 - 5,349 NC 4 13,014 - 12,542 - 1,683 - - - 27,239 ND 6 4,170 - 396 - 39 - - - 4,605 NE 5 4,475 - 5,883 - 327 - - 21 10,706 NH 4 4,488 3,425 - - - - - 201 8,114 NJ 5 10,912 - 13,456 292 - 240 - 342 25,242 NM 6 4,259 - 5,634 - 148 7 - - 10,048 NV 4 1,751 2,236 37 583 - - - - 4,607 NY 9 71,738 - 29,890 - 8,388 - - 2,910 112,926 OH 9 32,706 - 46,248 12,629 - - - - 91,583 OK 5 4,965 41 20,970 127 287 - - - 26,390 OR 6 15,135 - 29,659 - 288 - - - 45,082 PA 9 29,845 37,706 - 9,848 6,231 297 - 606 84,533 SC 6 6,803 - 15,464 52 426 986 - 736 24,467 SD 4 3,519 1,607 - 135 - - - - 5,261 TN 3 7,844 - - - - - - - 7,844 TX 7 31,376 - 14,480 - 6,449 - - - 52,305 UT 7 4,486 513 1,436 128 399 - - 106 7,068 VA 7 10,282 - 30,134 397 - 6 - - 40,819 WA 6 12,347 - 40,930 - 83 - - - 53,360 WI 11 25,152 - 38,827 - 6,435 - 7 176 70,597 WV 2 4,492 - 6,757 - - - - 7 11,256 WY 6 1,392 - 1,847 - 825 - - 184 4,248 : Data may not sum to total due to rounding. I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. A dash indicates no § 1915(c) waiver was offered for that target enrollment group. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 37 AK 4 126,580 49,035 - 48,462 13,049 - - - 237,126 AL 6 306,192 - 116,898 6,408 - 1,435 - - 430,933 AR 4 181,882 59,314 14,772 41,788 89 - - - 297,845 CA 7 2,378,950 - 83,334 119,665 386 8,971 - - 2,591,306 CO 11 321,817 - 236,713 - 16,235 - 28,256 13,282 616,303 CT 8 722,261 - 182,220 26,364 - - 2,845 40,154 973,843 DC 2 180,135 - 82,466 - - - - - 262,601 DE 3 96,849 - - - - - - - 96,849 FL 15 901,603 320,587 112,697 633 24 10,569 - 11,069 1,357,182 GA 5 503,574 - 413,246 - 16,579 - - 42,369 975,767 HI 1 115,766 - - - - - - - 115,766 IA 7 394,937 76,980 - 25,497 9,366 335 - 30,679 537,794 ID 4 130,241 - 75,416 - 7,400 - - - 213,057 IL 9 589,123 427,421 138,463 287,940 43,254 18,602 - 72,711 1,577,515 IN 5 584,462 - 164,383 - - - - 6,004 754,849 KS 7 358,300 71,326 - 156,975 89,657 - - 22,710 698,969 KY 6 474,626 - 84,403 5,139 - - - 36,589 600,757 LA 5 427,384 - 118,968 - 13,875 - - - 560,228 MA 8 909,040 123,547 - - 2,655 - - 13,572 1,048,814 MD 8 729,869 123,770 80,159 35,698 31,689 - 90 5,741 1,007,014 ME 4 309,604 - 27,926 5,163 - - - - 342,693 MI 4 501,688 - 168,762 - 16,713 - - - 687,163 MN 5 1,032,258 380,135 - 546,686 - - - 97,167 2,056,247 MO 9 599,575 - 94,179 22,921 1,513 1,926 - - 720,114 MS 6 49,592 - 152,074 47,096 - - 3,365 18,785 270,911 MT 6 90,653 - 37,453 - 1,857 - 3,617 - 133,580 NC 4 563,856 - 186,394 - 62,453 - - - 812,703 ND 5 142,543 - 5,107 - 349 - - - 148,000 NE 5 217,784 - 70,770 - 19,825 - - 696 309,075 NH 4 206,924 41,237 - - - - - 19,035 267,196 NJ 5 723,646 - 232,490 21,371 - 568 - 29,083 1,007,157 NM 6 286,334 - 48,096 - 1,675 293 - - 336,397 NV 4 73,246 9,340 275 3,354 - - - - 86,215 NY 9 5,146,108 - 64,025 - 153,594 - - 130,116 5,493,843 OH 8 1,301,277 - 435,133 247,254 - - - - 1,983,664 OK 5 273,025 312 179,222 2,239 2,358 - - - 457,156 OR 6 610,949 - 192,906 - 1,213 - - - 805,068 PA 9 1,921,815 807,315 - 206,636 29,230 2,919 - 46,250 3,014,165 SC 6 286,502 - 137,554 1,757 5,903 4,402 - 28,965 465,083 SD 4 103,195 10,856 - 4,689 - - - - 118,741 TN 3 603,649 - - - - - - - 603,649 TX 7 1,126,706 - 174,047 - 97,512 - - - 1,398,264 UT 6 164,892 4,206 28,824 2,135 4,918 - - 3,329 208,305 VA 7 639,956 - 541,726 32,035 - 9 - - 1,213,726 WA 9 549,379 - 579,669 - 2,322 - - - 1,131,370 WI 11 789,161 - 874,035 - 93,663 - 57 8,365 1,765,281 WV 2 365,285 - 165,784 - - - - 96 531,165 WY 6 84,953 - 15,677 - 13,921 - - 8,581 123,132 : Data may not sum to total due to rounding. I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. A dash indicates no § 1915(c) waiver was offered for that target enrollment group. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 38 AK 4 74,415 26,766 - 32,286 44,535 - - - 44,514 AL 6 55,289 - 13,696 12,091 - 7,759 - - 29,141 AR 4 43,816 8,716 14,951 14,871 1,326 - - - 20,096 CA 7 24,686 - 6,237 41,522 3,445 4,601 - - 22,597 CO 11 41,001 - 9,985 - 8,175 - 8,599 40,868 16,589 CT 8 77,380 - 13,717 26,470 - - 17,137 93,817 40,149 DC 2 99,743 - 26,389 - - - - - 53,255 DE 3 102,270 - - - - - - - 102,270 FL 15 36,317 10,016 6,343 5,191 4,709 1,507 - 29,517 16,528 GA 5 40,529 - 10,871 - 33,903 - - 37,296 18,742 HI 1 43,537 - - - - - - - 43,537 IA 7 32,206 7,317 - 7,041 8,461 9,303 - 22,692 18,609 ID 4 38,613 - 7,598 - 5,896 - - - 14,639 IL 9 31,781 7,546 14,919 13,659 18,540 12,443 - 16,673 13,871 IN 5 36,998 - 10,769 - - - - 30,021 24,146 KS 7 40,385 10,488 - 25,258 15,973 - - 33,397 24,803 KY 6 36,887 - 7,739 82,883 - - - 87,535 24,770 LA 5 41,206 - 20,382 - 10,519 - - - 31,962 MA 8 76,564 8,064 - - 15,434 - - 68,546 38,050 MD 8 54,052 33,597 17,073 48,767 28,523 - 1,302 97,302 42,218 ME 4 72,951 - 18,384 32,471 - - - - 57,868 MI 4 60,292 - 14,246 - 22,404 - - - 32,858 MN 5 63,387 12,153 - 27,510 - - - 65,654 29,837 MO 9 48,885 - 5,518 13,866 9,890 26,389 - - 23,072 MS 6 24,685 - 8,325 18,674 - - 6,663 22,551 11,224 MT 6 34,351 - 15,710 - 16,013 - 17,224 - 24,973 NC 4 43,327 - 14,862 - 37,108 - - - 29,836 ND 5 34,183 - 12,897 - 8,956 - - - 32,139 NE 5 48,667 - 12,030 - 60,626 - - 33,143 28,869 NH 4 46,106 12,040 - - - - - 94,700 32,930 NJ 5 66,317 - 17,278 73,189 - 2,365 - 85,038 39,900 NM 6 67,230 - 8,537 - 11,317 41,802 - - 33,479 NV 4 41,831 4,177 7,428 5,753 - - - - 18,714 NY 9 71,735 - 2,142 - 18,311 - - 44,714 48,650 OH 8 39,787 - 9,409 19,578 - - - - 21,660 OK 5 54,990 7,616 8,547 17,627 8,217 - - - 17,323 OR 6 40,367 - 6,504 - 4,211 - - - 17,858 PA 9 64,393 21,411 - 20,982 4,691 9,829 - 76,320 35,657 SC 6 42,114 - 8,895 33,797 13,857 4,464 - 39,355 19,009 SD 4 29,325 6,756 - 34,736 - - - - 22,570 TN 3 76,957 - - - - - - - 76,957 TX 7 35,910 - 12,020 - 15,120 - - - 26,733 UT 6 36,757 8,199 20,072 16,681 12,326 - - 31,409 29,472 VA 7 62,240 - 17,977 80,692 - 1,451 - - 29,734 WA 9 44,495 - 14,162 - 27,972 - - - 21,203 WI 11 31,376 - 22,511 - 14,555 - 8,147 47,531 25,005 WV 2 81,319 - 24,535 - - - - 13,674 47,190 WY 6 61,029 - 8,488 - 16,874 - - 46,634 28,986 I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. A dash indicates no § 1915(c) waiver was offered for that target enrollment group. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of CMS Form 372 Medicaid Home and Community-Based Services Programs: 2013 Data Update 39 AK 5,125 3,125 3,801 451 - 5,389 AL 9,321 7,902 7,451 1,604 - 21,356 AR 6,831 9,324 324 532 936 19,654 CA 16,936 44,570 62,935 17,953 35,596 71,642 CO 1,238 19,323 19,010 3,083 4,936 46,727 CT 13,226 5,609 13,325 1,440 639 36,799 DC 2,672 1,603 1,540 264 - 3,262 DE 1,544 1,364 1,650 251 1,236 869 FL 89,021 42,139 25,430 15,403 22,401 111,897 GA 12,001 19,654 9,011 412 24,031 25,189 HI - 2,401 2,340 54 - 365 IA 19,877 25,965 13,289 1,118 10,361 55,400 ID 1,263 2,030 6,473 4,672 4,467 15,228 IL 6,493 29,267 29,709 9,055 9,281 89,793 IN 19,013 11,320 32,460 13,024 1,051 31,204 KS 3,564 29,012 11,362 596 - 24,598 KY 36,198 17,066 12,257 8,366 6,231 15,707 LA 8,957 7,901 6,011 106 113 12,907 MA - 9,210 12,054 602 2,240 26,079 MD 12,122 7,012 21,009 2,604 2,353 11,870 ME 1,645 5,952 4,535 118 - 4,846 MI - 9,023 394 2,364 4,650 36,084 MN 41,397 20,687 24,903 751 5,136 69,014 MO 168 12,870 8,502 1,929 296 30,346 MS 20,475 20,710 3,886 108 683 29,058 MT 3,031 2,400 4,865 749 67 9,339 NC 14,601 39,013 8,312 943 35 18,315 ND 503 850 3,153 32 154 5,636 NE - 1,228 7,667 122 2,613 6,222 NH 2,901 6,501 2,135 2,640 901 5,694 NJ 24,601 20,945 9,354 832 3,901 8,654 NM 5,647 4,108 4,048 15,827 2,642 6,015 NV 2,901 323 3,602 765 693 5,124 NY 12,551 25,525 107,982 3,456 1,987 73,124 OH 7 75,623 31,392 6,595 6,714 156,394 OK 25,013 23,640 7,936 25,875 1,540 59,701 OR 21,929 15,020 5,570 510 27,507 18,473 PA 77,296 65,013 49,147 8,753 901 93,154 SC 16,802 16,001 7,694 765 10 49,012 SD 3,519 590 5,491 4,560 1,210 6,321 TN 6,890 6,901 9,032 6,901 1,002 9,321 TX 4,955 26,451 21,367 49,924 16,010 80,962 UT 6,588 3,168 5,203 3,479 3,369 9,915 VA 16,057 65,000 8,386 1,469 56 4,725 WA - 46,901 2,650 8,560 23,214 52,364 WI 29,032 48,601 8,102 5,001 10,654 36,402 WV 10,301 4,877 9,540 15,974 - 18,032 WY 4,676 2,879 3,015 1,415 228 4,134 : Data may not sum to total due to rounding. "Other Services" include assistance with chores, meals, transportation, etc. A dash indicates that the service was not offered in a § 1915(c) waiver. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 40 , AK 13,201 54,680 125,650 3,569 - 40,025 AL 30,265 43,213 282,855 36,501 - 38,099 AR 8,324 224,033 3,015 268 15,301 46,904 CA 41,603 194,931 831,310 210,520 1,110,836 202,107 CO 1,017 196,106 304,122 8,344 46,114 60,601 CT 18,302 112,324 631,581 2,501 10,503 198,632 DC 3,965 109,216 65,042 1,365 - 83,012 DE 2,663 17,654 20,322 41 55,037 1,132 FL 90,363 306,555 468,846 69,457 180,325 241,635 GA 29,046 95,365 26,085 6,980 412,302 405,988 HI - 68,901 38,964 2,365 - 5,535 IA 19,120 85,444 56,755 3,469 298,333 74,673 ID 1,022 8,438 133,745 1,826 45,301 22,726 IL 8,538 405,924 547,010 13,249 138,463 464,330 IN 12,368 89,675 436,549 36,450 23,655 156,152 KS 610 276,733 289,954 2,013 - 129,659 KY 47,557 158,333 105,363 51,403 209,391 28,708 LA 12,652 115,415 41,142 8,681 884 381,454 MA - 68,902 751,012 410 36,548 191,942 MD 18,101 113,941 760,985 6,407 75,521 32,060 ME 1,222 266,708 57,961 127 - 16,675 MI - 59,012 2,365 10,325 37,950 577,510 MN 68,904 256,987 965,702 2,904 365,770 395,981 MO 230 402,481 195,201 14,780 9,375 98,047 MS 34,954 127,388 37,094 238 8,184 63,052 MT 8,287 14,699 94,426 1,851 1,160 13,158 NC 26,324 504,327 209,402 33,402 12,894 26,355 ND 425 15,022 119,386 54 477 12,635 NE - 1,664 210,988 1,855 36,574 57,995 NH 10,366 159,645 56,970 5,960 10,241 24,014 NJ 33,698 821,589 18,966 26,870 90,355 15,679 NM 18,046 124,812 37,771 22,237 123,684 9,848 NV 1,795 1,896 68,567 6,570 6,296 1,091 NY 55,687 209,242 5,133,215 7,773 3,560 84,366 OH 4 1,331,628 248,903 34,255 99,081 269,793 OK 68,401 201,549 123,257 9,962 23,996 29,991 OR 11,675 108,818 59,134 744 611,587 13,109 PA 121,809 894,637 1,705,170 105,563 9,402 177,584 SC 137,357 129,458 165,287 1,407 - 31,575 SD 8,983 15,887 83,587 8,309 - 1,975 TN 18,980 468,041 99,655 5,012 3,650 8,310 TX 9,794 256,432 230,485 53,452 443,951 404,151 UT 14,287 11,596 123,870 6,750 41,282 10,519 VA 6,840 1,042,546 111,153 43,292 584 9,310 WA - 917,660 9,911 929 183,037 19,833 WI 56,970 1,187,473 95,048 39,702 289,548 96,541 WV 20,367 23,678 263,401 23,970 - 199,748 WY 11,311 18,678 80,362 3,863 2,239 6,678 : Data may not sum to total due to rounding. "Other Services" include assistance with chores, meals, transportation, etc. A dash indicates that the service was not offered in a § 1915(c) waiver. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 41 AK 2,576 17,498 33,057 7,915 - 7,427 AL 3,247 5,469 37,962 22,756 - 1,784 AR 1,219 24,028 9,306 504 16,347 2,386 CA 2,456 4,374 13,209 11,726 31,207 2,821 CO 821 10,149 15,998 2,707 9,342 1,297 CT 1,384 20,026 47,398 1,737 16,437 5,398 DC 1,484 68,133 42,235 5,171 - 25,448 DE 1,725 12,943 12,316 165 44,528 1,303 FL 1,015 7,275 18,437 4,509 8,050 2,159 GA 2,420 4,852 2,895 16,943 17,157 16,118 HI - 28,697 16,651 43,805 - 15,164 IA 962 3,291 4,271 3,103 28,794 1,348 ID 809 4,157 20,662 391 10,141 1,492 IL 1,315 13,870 18,412 1,463 14,919 5,171 IN 651 7,922 13,449 2,799 22,507 5,004 KS 171 9,539 25,520 3,378 - 5,271 KY 1,314 9,278 8,596 6,144 33,605 1,828 LA 1,413 14,608 6,844 81,892 7,820 29,554 MA - 7,481 62,304 681 16,316 7,360 MD 1,493 16,249 36,222 2,461 32,096 2,701 ME 743 44,810 12,781 1,076 - 3,441 MI - 6,540 6,003 4,368 8,161 16,005 MN 1,664 12,423 38,779 3,866 71,217 5,738 MO 1,366 31,273 22,959 7,662 31,674 3,231 MS 1,707 6,151 9,546 2,208 11,982 2,170 MT 2,734 6,124 19,409 2,471 17,315 1,409 NC 1,803 12,927 25,193 35,421 368,391 1,439 ND 846 17,673 37,864 1,678 3,097 2,242 NE - 1,355 27,519 15,205 13,997 9,321 NH 3,573 24,557 26,684 2,258 11,366 4,217 NJ 1,370 39,226 2,028 32,296 23,162 1,812 NM 3,196 30,383 9,331 1,405 46,815 1,637 NV 619 5,870 19,036 8,589 9,085 213 NY 4,437 8,198 47,538 2,249 1,791 1,154 OH 529 17,609 7,929 5,194 14,757 1,725 OK 2,735 8,526 15,531 385 15,582 502 OR 532 7,245 10,617 1,459 22,234 710 PA 1,576 13,761 34,695 12,060 10,435 1,906 SC 8,175 8,091 21,483 1,839 - 644 SD 2,553 26,927 15,222 1,822 - 312 TN 2,755 67,822 11,034 726 3,643 892 TX 1,977 9,695 10,787 1,071 27,730 4,992 UT 2,169 3,660 23,807 1,940 12,254 1,061 VA 426 16,039 13,255 29,471 10,422 1,970 WA - 19,566 3,740 108 7,885 379 WI 1,962 24,433 11,731 7,939 27,177 2,652 WV 1,977 4,855 27,610 1,501 - 11,077 WY 2,419 6,488 26,654 2,730 9,821 1,615 : "Other Services" include assistance with chores, meals, transportation, etc. A dash indicates that the service was not offered in a § 1915(c) waiver. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of CMS Form 372. Medicaid Home and Community-Based Services Programs: 2013 Data Update 42 AK 300% 300% - 300% 300% - - - AL 300% - 300% 300% - 300% - - AR 300% 300% - 300% 300% - - - CA 100% - 100% 100% 100% 100% - - CO 300% - 300% - 300% 300% 300% 300% CT 300% - 300% 300% 300% - 300% 300% DC 300% - 300% - - - - - DE 250% - - - - - - - FL 300% - 300% 300% 300% 300% - 300% GA 300% - 300% - 300% - - 300% HI 100% - - - - - - - IA 300% 300% - 300% 300% 300% - 300% ID 300% - 300% - 300% - - - IL 100% 100% 100% 100% 100% 100% - 100% IN 300% - 300% - - - 100% 300% KS 300% 300% - 300% 300% - - 300% KY 300% - 300% 300% - - - 300% LA 300% - 300% - 300% - - - MA 300% 300% - - 100% - - 300% MD 300% 300% 100% 300% 300% - - 300% ME 300% - 300% - - - - 300% MI 100% - 300% - 300% - - - MN 300% 300% - 300% - - - 300% MO 100% - 100% 100% 100% 100% - - MS 300% - 300% 300% - - 300% 300% MT 100% - 100% - 100% - 100% - NC 100% - 100% - 100% - - - ND 100% - 100% 100% 100% - - - NE 100% - 100% - - - - 100% NH 100% 100% - - - - - 100% NJ 300% - 300% - - 300% - 300% NM 300% - 300% - 300% 300% - - NV 300% 300% - 300% - - - - NY 100% - 100% - 100% - - 100% OH 300% - 300% - - - - - OK 300% 300% 300% - - - - - OR 300% - 300% - 300% - - - PA 300% 300% - - - 300% - 300% SC 300% - 300% 300% 300% 300% - 300% SD 300% 300% - - - - - - TN 300% - 300% - - - - - TX 300% - - - 300% - - - UT 300% 300% 300% 300% 300% - - 300% VA 300% - 300% 300% - - - - WA 300% - 300% - 300% - - - WI 300% - 300% - 300% - - 300% WV 300% - 300% - - - - 300% WY 300% - 300% - 300% - - 300% : I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. In 2015, 300 percent of the SSI FBR was $2,199 per month. Arizona, Rhode Island, and Vermont are excluded from the table because the states did not operate any § 1915(c) waivers in 2015 (all HCBS were provided through a § 1115 waiver). A dash indicates that there was no operational § 1915(c) waiver for the target enrollment group. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of Medicaid § 1915(c) Waiver Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 43 AK CN, MN - Y CN, MN - Y S - AL CN, MN S - N/A N/A N/A C, S Y AR CN, MN S - CN S Y S Y AZ CN C - N/A N/A N/A N/A N/A CA CN, MN S Y CN, MN S Y C, S, G Y CO CN, MN - Y N/A N/A N/A C, G Y CT CN, MN C, S - N/A N/A N/A C Y DC CN, MN S - CN S - S - DE CN S - CN, MN - - - - FL CN, MN C - CN, MN S Y C Y GA CN, MN S - N/A N/A N/A - - HI CN, MN - - N/A N/A N/A - Y IA CN, MN S - N/A N/A N/A C, S Y ID CN S - CN, MN, MB S Y C Y IL CN - - N/A N/A N/A C Y IN CN, MN - - N/A N/A N/A C Y KS CN, MN - - CN, MN - Y S Y KY CN, MN S - N/A N/A N/A C, S Y LA CN, MN - Y CN, MN S Y C, S Y MA CN, MN S - CN, MN - Y C Y MD CN, MN - - CN, MN, MB - Y C, S Y ME CN, MN - Y CN, MN S - C, S Y MI CN, MN, MB C, S - CN, MN - - S, G Y MN CN, MN, MB S - CN, MN,I, MB S Y C Y MO CN S - CN C Y C Y MS CN, MN S - N/A N/A N/A S Y MT CN, MN - - CN, MN, MB S Y C, S, G Y NC CN, MN - - CN, MN S - C, S, G Y ND CN, MN C - CN, MN S Y C Y NE CN, MN C - CN, MN, MB S Y S Y NH CN, MN - - CN, MN - Y - - NJ CN, MN - - CN, MN S Y C, S Y NM CN - - CN - - - Y NV CN S - CN S Y C, G Y NY CN, MN S - CN, MN - Y S Y OH CN, MB S - N/A N/A N/A C, S Y OK CN S - CN - - C, S Y OR CN C, S - CN S Y C Y PA CN, MN, MB S - N/A N/A N/A C, S Y RI CN, MN S - CN, MN - - N/A N/A SC CN S - N/A N/A N/A C, S Y SD CN - Y CN S Y C, S Y TN CN, MN S - N/A N/A N/A C, S Y TX CN, MN - Y CN, MN S Y C, S, G Y UT CN, MN - - CN, MN,I, MB - Y - Y VA CN, MN S - N/A N/A N/A S Y VT CN, MN - - CN, MN - Y N/A N/A WA CN, MN S - CN S Y C, S, G Y WI CN, MN - - CN, MN - - G Y WV CN, MN - - CN, MN S - S Y WY CN - - N/A N/A N/A C, S Y : CN – Categorically Needy; MN – Medically Needy; I – Special Income Rules; MB-Medicaid Buy-In; C – Cost Limits; S – Service/Hourly Limits; G – Geographical Limits; Y – Yes, self-direction is required or allowed. Financial eligibility criteria for § 1915(c) waivers are presented in Table 11. N/A are states with no financial eligibility for personal care services or no § 1915(c) waivers. : KCMU and UCSF analyses of Medicaid § 1915(c) Waiver, Home Health, and Personal Care Services Policy Surveys. Medicaid Home and Community-Based Services Programs: 2013 Data Update 44 103 18 54 24 51 11 5 27 293 56 4 19 12 23 1 1 15 131 428,151 27,731 117,693 11,744 51,606 65 28 3,823 640,841 (67%) (4%) (18%) (2%) (8%) (<1%) (<1%) (1%) 34 3 14 7 18 1 1 10 88 (61%) (75%) (74%) (58%) (78%) (100%) (100%) (67%) (67%) 39 3 16 8 12 1 1 12 92 (70%) (75%) (84%) (67%) (52%) (100%) (100%) (67%) (70%) 52 4 18 11 20 1 1 13 120 (93%) (100%) (95%) 92%) (87%) (100%) (100%) (87%) (92%) I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. : KCMU and UCSF analysis of Medicaid § 1915(c) Waiver Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 45 AK 935 0 - 0 0 - - - 935 AL Unknown - 2,651 132 - 0 - - 2,783 AR 2,840 0 - 0 53 - - - 2,893 CA 0 - 1,707 1,800 20 65 - - 3,592 CO 3,564 - 0 - 624 0 0 30 4,218 CT 1,009 - 0 812 646 - 0 42 2,509 DC 0 - 0 - - - - - 0 DE 0 - - - - - - - 0 FL 21,000 - 62,068 0 1 0 - 296 83,365 GA 11,365 - 701 - 0 - - 135 12,201 HI 0 - - - - - - - 0 IA 0 0 - 5,013 2,356 0 - 1,136 8,505 ID 0 - 0 - 0 - - - 0 IL 17,501 0 0 0 13,972 0 0 0 31,473 IN 1,870 - 0 - - - - 44 1,914 KS 3,392 0 - 1,237 268 - - 0 4,897 KY 5,764 - 0 0 - - - 532 6,296 LA 17,083 - 37,267 - 8,478 - - - 62,828 MA 0 0 - - 0 - - 0 0 MD 12,975 27,000 - 1,401 4,468 - - 0 45,844 ME 0 - 0 - - - - 0 0 MI 0 - 0 - 0 - - - 0 MN 3,654 0 - 801 - - - 459 4,914 MO 0 - 0 0 0 0 - - 0 MS 1,801 - 4,639 576 - - 0 19 7,035 MT 982 - 471 - 102 - 28 - 1,583 NC 17,800 - 2,936 - 0 - - - 20,736 ND 0 - 0 0 0 - - - 0 NE 1,368 - 0 - - - - 0 1,368 NH 0 0 - - - - - 0 0 NJ 0 - 0 - - 0 - 59 59 NM 0 - 5,365 - 36 0 - - 5,401 NV 712 530 - 73 - - - - 1,315 NY 0 - 0 - Unknown - - 0 0 OH 62,118 - 0 - - - - - 62,118 OK 7,213 0 12 - - - - - 7,225 OR 0 - 0 - 0 - - - 0 PA 18,295 0 - - - 0 - 0 18,295 SC 1,654 - 0 0 436 0 - 265 2,355 SD 34 0 - - - - - - 34 TN 7,564 - 0 - - - - - 7,564 TX 186,627 - - - 17,923 - - - 204,550 UT 1,869 201 0 31 54 - - 86 2,241 VA 16,583 - 0 0 - - - - 16,583 WA 0 - 0 - 0 - - - 0 WI 801 - 711 - 2,140 - - 681 4,333 WV 396 - 1,816 - - - - 0 2,212 WY 317 - 0 - 29 - - 39 385 : Data may not sum to total due to rounding. I/DD – Intellectual/Developmental Disability; TBI/SCI – Traumatic Brain Injury/Spinal Cord Injury. "Unknown" indicates that there was a waiting list but the number of persons on list is unknown. A dash indicates that there was no operational § 1915(c) waiver for the target enrollment group. Arizona, Rhode Island, and Vermont do not have § 1915(c) waivers. : KCMU and UCSF analysis of Medicaid § 1915(c) Waiver Policy Survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 46 AK 169.36 - - 22.78 12.00 AL 27.00/hour - - Not offered Not offered AR - 145.02 66.63 - 14.00 AZ - - 9.15/hour Not offered Not offered CA - 74.86 45.75 20.85 10.10 CO - 93.38 33.21/hour Not offered Not offered CT 95.20/hour - 24.64/hour Not offered Not offered DC 76.00 62.00 17.90/hour 17.80 14.50 DE - 139.45/hour 30.80/hour 19.80 - FL 31.04 31.04 17.46 15.00 15.00 GA 61.32 61.32 61.32 Not offered Not offered HI - - - Not offered Not offered IA - 107.44 48.68 Not offered Not offered ID 15.76/hour 40.76/hour 143.51 15.76 - IL 72.00 - - Not offered Not offered IN 29.62/day 42.04 18.31/hour Not offered Not offered KS - 50.00 40.50 13.25 13.25 KY - 88.16 34.13 Not offered Not offered LA 44.19 65.22 23.16 11.40 - MA - 86.99 24.40/hour - 14.72 MD - 120.76 59.99 16.48 35.34/day ME 16.55/hour - - 26.00 - MI - 80.98 51.72 14.00 9.50 MN 53.75 32.52/hour 54.29 16.32 16.00 MO 77.16 77.16 77.16 17.88 15.56 MS 75.85 - - Not offered Not offered MT 74.74 74.74 33.37 19.42 - NC 103.33 109.60 47.28 13.88 - ND 118.63 53/hour - 27.16 19.76 NE 487.83/day 37.90/hour 21.36/hour 8.00 8.68 NH - 87.36/hour 23.56/hour 17.84 - NJ - 117.21/hour 25.87/hour 16.00 - NM 331.57 - - 13.16 9.65 NV 52.56/hour - - 17.00 - NY - 113.12/hour 29.76/hour 20.19 - OH 18.00/hour 22.76/hour 12.00/hour Not offered Not offered OK 47.49 65.38 29.60 15.68 - OR - 191.06 54.94 - 13.75 PA 88 - - Not offered Not offered RI 64.50 64.50 - 19.46 - SC - 72.65 39.13 Not offered Not offered SD - 76.10/hour 32.24/hour 20.64 - TN - - - Not offered Not offered TX 200.00 98.92 46.09 11.50 - UT - - 67.28 16.00 - VA - 185.94 73.28 Not offered Not offered VT - - - - - WA 43.83 45.06 45.32 23.00 - WI - 32.66/hour 39.71 63.36 - WV - - - 15.00 15.00 WY 52.00 - - Not offered Not offered : 1The reimbursement rate for home health services is per visit unless otherwise noted. 2The reimbursement rate for personal care services is per hour unless otherwise noted. : KCMU and UCSF analyses of Medicaid Home Health and Personal Care Services Policy Surveys. Medicaid Home and Community-Based Services Programs: 2013 Data Update 47 1 Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by- topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf. 2 Id. 3 Id. 4 Olmstead v. L.C., 527 U.S. 581 (1999), available at http://www.law.cornell.edu/supct/html/98-536.ZS.html; see also Kaiser Commission on Medicaid and the Uninsured, Olmstead's Role in Community Integration for People with Disabilities Under Medicaid: 15 Years after the Supreme Court's Olmstead Decision (Washington, DC: Kaiser Family Foundation, June 2014), http://kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years- after-the-supreme-courts-olmstead-decision/. 5 Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by- topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf. 6 MFP funding expires in September 2016. For more information, see Kaiser Commission on Medicaid and the Uninsured, Money Follows the Person: A 2015 State Survey of Transitions, Services, and Costs (Washington, DC: Kaiser Family Foundation, October 2015), http://kff.org/medicaid/report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/. 7 Delaware and Rhode Island had CMS approval to offer personal care state plan services but did not report any participants in their programs. 8 Kaiser Commission on Medicaid and the Uninsured, Implementing the ACA: Medicaid Spending & Enrollment Growth for FY 2014 and FY 2015 (Washington, DC: Kaiser Family Foundation, October 2014), http://kff.org/medicaid/report-section/implementing-the- aca-medicaid-spending-enrollment-growth-issue-brief. 9 Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip-program-information/by- topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf. 10 For background about § 1115 waivers, see Kaiser Commission on Medicaid and the Uninsured, Five Key Questions and Answers About Section 1115 Medicaid Demonstration Waivers (Washington, DC: Kaiser Family Foundation, June 2011), http://kff.org/health- reform/issue-brief/five-key-questions-and-answers-about-section/. 11 42 U.S.C. § 1315(a). 12 Self-direction of personal care services is available to states under the § 1915 (j) option, which allows states to offer self-direction provided that states offer personal care services as an optional state plan benefit or through a § 1915 (c) waiver. 42 U.S.C. § 1396n(j)(4)(A); 42 C.F.R. § 441.452(a). 13 Vermont's model is unique in that the state serves as the managed care entity. 14 Other states implement capitated Medicaid managed LTSS programs through combination § 1915 (b)/(c) waivers. Section 1915 (b) waivers allow states to offer Medicaid services in a managed care model or otherwise limit a beneficiary's choice of providers. 15 Expenditure data from Steve Eiken, Kate Sredl, Brian Burwell, and Paul Saucier, Medicaid Expenditures for Long Term Services and Supports (LTSS) in FY 2014, (Bethesda, MD: Truven Health Analytics, April 2016), https://www.medicaid.gov/medicaid-chip- program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-2014.pdf; participant data from Rhode Island Executive Office of Health and Human Services, Quarterly Operation Report: Rhode Island Global Consumer Choice Compact 1115 Waiver Demonstration, January 1, 2013 – March 31, 2013, (Providence, RI: Rhode Island Executive Office of Health and Human Services, September 2013), http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/Quarterly%20Global%20Wavier%20Report%20January%20- %20March%20%202013_1.pdf; State of Vermont Agency of Human Services, Global Commitment to Health, Quarterly Report (Waterbury, VT: State of Vermont Agency of Human Services, November 2013), available at http://dvha.vermont.gov/global- commitment-to-health/gc-ffy13-qtr-4-report.pdf. Arizona participation counts as reported by state officials to KCMU and UCSF, 2016. 16 Minnesota has a Section 1115 waiver that offers some fee-for-service HCBS, including Section 1915 (i) and Community First Choice services. Kansas has a joint Section 1115/Section 1915 (c) waiver. New Jersey's Section 1115 waiver was approved in 2012, but enrollment was not effective until July, 2014. 17 Kaiser Commission on Medicaid and the Uninsured, Key Themes in Capitated Medicaid Managed Long-Term Services and Supports Waivers (Washington, DC: Kaiser Family Foundation, November 2014), http://kff.org/medicaid/issue-brief/key-themes-in- capitated-medicaid-managed-long-term-services-and-supports-waivers/. Medicaid Home and Community-Based Services Programs: 2013 Data Update 48 18 U.S. Dep't of Labor, Information on the Final Rule: Application of the Fair Labor Standards Act to Domestic Service, http://www.dol.gov/whd/homecare/finalrule.htm. While the new rules were to be effective in January, 2015, enforcement was delayed, and they were challenged in litigation. In August, 2015, the D.C. Circuit Court of Appeals upheld the regulations. Home Care Assoc. of America v. Weil, No. 15-5018 (D.C. Cir. Aug. 21, 2015), http://www.dol.gov/whd/homecare/0821appealdecision.pdf. DOL has revised its time-limited non-enforcement policy, with no actions to enforce the new rules until 30 days after the D.C. Circuit Court's decision became final, and discretion in enforcement actions considering good faith efforts to comply with the new rule through December 2015. U.S. Dep't of Labor, We Count on Home Care, Time-Limited Non-Enforcement Policy, http://www.dol.gov/whd/homecare/non- enforcement_policy.htm; see also 80 Fed. Reg. 55029 (Sept. 14, 2015), http://www.gpo.gov/fdsys/pkg/FR-2015-09-14/pdf/2015- 23092.pdf; U.S. Dep't of Justice, Civil Rights Division and U.S. Dep't of Health & Human Servs., Office for Civil Rights, Dear Colleague letter (Dec. 15, 2014), http://www.ada.gov/olmstead/documents/doj_hhs_letter.pdf. 19 78 Fed. Reg. 60453-60557 (Oct. 1, 2013), http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=27104. 20 CMS Informational Bulletin, Self-Direction Program Options for Medicaid Payments in the Implementation of the Fair Labor Standards Act Regulation Changes (July 3, 2014), http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-03- 2014.pdf. 21 Id. 22 42 C.F.R. § 441.301 (c)(4)-(6). The settings rules also apply to Section 1915 (i) and Community First Choice services. CMS also has indicated it will include these requirements in the special terms and conditions of § 1115 demonstrations that include individuals receiving HCBS. CMS, Questions and Answers – 1915 (i) State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, Setting Requirements for Community First Choice, and 1915 (c) Home and Community-Based Services Waivers - CMS 2249-F and 2296-F, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long- Term-Services-and-Supports/Home-and-Community-Based-Services/Downloads/Final-Q-and-A.pdf. 23 Disabled and Elderly Health Programs Group, Centers for Medicare & Medicaid Services, Final Rule Medicaid HCBS, (Baltimore, MD: Centers for Medicare & Medicaid Services, January 16, 2014), https://www.medicaid.gov/medicaid-chip-program- information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/final-rule-slides- 01292014.pdf. 24 "Statewide Transition Plans," Medicaid.gov, CMS, accessed October 4, 2016, https://www.medicaid.gov/medicaid-chip-program- information/by-topics/long-term-services-and-supports/home-and-community-based-services/statewide-transition-plans.html. 25 Although Rhode Island and Delaware did not report participants or expenditures for personal care state plan services in 2015, their policy survey responses are included. 26 Reimbursement rates for services provided under § 1915 (c) waivers are not included in the policy survey. Medicaid Home and Community-Based Services Programs: 2013 Data Update 49 the henry j. kaiser family foundation Headquarters 2400 Sand Hill Road Menlo Park, CA 94025 Phone 650-854-9400 Barbara Jordan Conference Center 1330 G Street, NW Washington, DC 20005 Phone 202-347-5270 This publication (#8800-02) is available on the Kaiser Family Foundation's website at www.kff.org. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is