Long-Term Services and Supports (LTSS): Medicaid s Role and Options for States

Long-Term Services and Supports (LTSS): Medicaid s Role and Options for States Erica L. Reaves, Policy Analyst State Variation in Long-Term Services and Supports: Location, Location, Location National Health Policy Forum Friday, July 19, 2013

Figure 1 The National LTSS Landscape, 2013 and Beyond Aging of America: The 85 and over age cohort is at highest risk for needing longterm services and supports (LTSS), and the number of individuals in this age cohort is expected to increase by almost 70 percent over the next two decades. 1 Growth in Demand for Person-Centered LTSS: Over 10 million Americans of all ages may require daily assistance with self-care tasks, with some individuals needing more extensive, institution-based services as a result of chronic conditions and/or severe functional and/or cognitive impairments. 2 Widespread Use of Informal Supports and Limited Access to Adequate, Affordable Housing: Family caregivers play a significant role in reducing unmet need among individuals who desire to remain in the community. 3 Access to suitable community-based housing is limited. 1 A. Houser et al. (2012). Across the States 2012: Profiles of Long-Term Services and Supports. AARP Public Policy Institute. Available at: http://www.aarp.org/home-garden/livable-communities/info-09-2012/across-the-states-2012-profiles-of-longterm-services-supports-aarp-ppi-ltc.html. 2 S. Kaye et al. (2010). Long-Term Care: Who Gets It, Who Provides It, Who Pays, And How Much? Health Affairs, 29:1, 11-21. 3 L. Feinberg. (2011). Valuing the Invaluable: The Growing Contributions and Costs of Family Caregiving, 2011 Update, available at http://www.aarp.org/relationships/caregiving/info-07-2011/valuing-the-invaluable.html.

Figure 2 The National LTSS Landscape, 2013 and Beyond, continued Few Can Afford LTSS Expenses: In the absence of affordable options to finance current and/or future care needs, low-income people with LTSS needs will continue to rely on Medicaid to cover their expenses for institutional and home and community-based LTSS. States Have Considerable Flexibility in Using Medicaid Funding to Provide LTSS and Financial and Functional Eligibility Criteria Differ Among States: States provide a range of LTSS under various Medicaid authorities and can customize benefits to meet the care needs of particular beneficiary populations. The Affordable Care Act (ACA) Gives States New and Expanded HCBS Opportunities: To date, all but three states are pursuing at least one ACA option to expand access to Medicaid HCBS; over half are pursing three or more options. 4 4 M. O Malley Watts, M. Musumeci, and E. Reaves, How is the Affordable Care Act Leading to Changes in Medicaid Long-Term Services and Supports (LTSS) Today? State Adoption of Six LTSS Options, The Henry J. Kaiser Family Foundation, April 2013, available at: http://www.kff.org/medicaid/issue-brief/how-is-the-affordable-care-actleading-to-changes-in-medicaid-long-term-services-and-supports-ltss-today-state-adoption-of-six-ltss-options.

Figure 3 Medicaid is the primary payer for LTSS Medicare Post-Acute Care 21% Other Private and Public 18% Medicaid 40% Private Insurance 7% Out-of-Pocket 15% Total National LTSS Spending, 2011 = $357 billion NOTE: Total LTSS expenditures include spending on residential care facilities, nursing homes, home health services, and home and community-based waiver services. Expenditures also include spending on ambulance providers. All home and community-based waiver services are attributed to Medicaid. SOURCE: KCMU estimates based on CMS National Health Expenditure Accounts data for 2011.

Figure 4 Overview of Medicaid LTSS Authority Provision Mandatory or Optional FMAP Time Limitation Nursing facility Mandatory Regular No Intermediate care facility for people with intellectual/developmental disabilities Optional Regular No Home health services Mandatory Regular No State Plan Services: Personal care Optional Regular No Community First Choice state plan option ( 1915(k)) Optional Enhanced 6% No Health home state plan option Optional Enhanced 90% for first 2 years A state can get more than one period of enhanced FMAP, but can only claim the enhanced FMAP for a total of eight quarters for one enrollee HCBS state plan option ( 1915(i)) Optional Regular If a state targets the benefit(s), approval periods are for 5 years, with the option to renew with CMS approval for additional 5-year periods Waivers: Section 1915(c) Optional Regular Section 1115 Optional Regular Section 1915(c) waivers are approved initially for a 3-year period and renewed for 5-year periods In general, Section 1115 demonstrations are approved for a 5-year period and can be renewed, typically for an additional 3 years Money Follows the Person Optional Enhanced Demonstration grant through September 2016 Other HCBS Programs: Balancing Incentive Program Optional Enhanced 2% or 5% State plan option or waiver from Oct. 2011 through Sept. 2015 for states that devoted less than half of Medicaid LTC expenditures to HCBS as of 2009

Figure 5 Medicaid LTSS Users Accounted for Nearly Half of Medicaid Spending, 2010 Enrollees Expenditures 94% 57% Individuals Who Used No LTSS Individuals Who Used Institutional LTSS 2% 4% 22% 21% Total Series = 66 million 1 Total Series = $369 2billion 43% Individuals Who Used Community-Based LTSS NOTE: Individuals who used both institutional and community-based services in the same year are classified as using institutional services in this figure. SOURCE: KCMU and Urban Institute estimates based on data from FY 2010 Medicaid Statistical Information System (MSIS). Because 2010 data was unavailable, 2009 data was used for Colorado, Idaho, Missouri, and West Virginia.

Figure 6 Growth in Medicaid LTSS Expenditures, 2002-2011 (in billions) $101 $93 32% 37% $111 41% $115 42% $123 $125 45% 45% Home and Community-Based LTSS Institution-Based LTSS 68% 63% 59% 58% 55% 55% 2002 2004 2006 2008 2010 2011 NOTE: Home and community-based care includes state plan home health, state plan personal care services and 1915(c) HCBS waivers. Institutional care includes intermediate care facilities for individuals with intellectual/developmental disabilities, nursing facilities, and mental health facilities. SOURCE: KCMU and Urban Institute analysis of CMS-64 data.

Figure 7 Medicaid Spending by LTSS Users, 2010 Physician, Lab, X-ray, Outpatient/Clinic, and Other Acute Services, 9% Drugs, 4% Rehab, Therapy, and Other Supportive Services, 3% Inpatient, 7% Mixed LTSS, 4% Institutional LTSS, 45% Community-Based LTSS, 32% Total Medicaid Spending by LTSS Users, 2010 = $159 billion NOTE: Community-based services include 1915(c) home and community-based waiver services, state plan home health services, and state plan personal care services. SOURCE: KCMU and Urban Institute estimates based on MSIS and CMS-64 2010 data. Because 2010 data was unavailable, 2009 MSIS data was used for Colorado, Idaho, Missouri, and West Virginia. Spending for these states was then adjusted to 2010 CMS-64 spending levels.

Figure 8 Medicaid Enrollees Who Used LTSS, 2010 Non-Disabled Adults, 1% Enrollment Expenditures Children, 5% Non-Disabled Children, 3% Adults, 1% Elderly, 51% Ind. with Disabilities Under Age 65, 43% Elderly, 42% Ind. with Disabilities Under Age 65, 54% Total = 3.8 million Total = $159 billion SOURCE: KCMU and Urban Institute estimates based on data from FY 2010 Medicaid Statistical Information System (MSIS). Because 2010 data was unavailable, 2009 data was used for Colorado, Idaho, Missouri, and West Virginia.

Figure 9 Distribution of Medicaid Beneficiaries Who Use LTSS, by Dual Eligibility Status, 2010 Enrollment Expenditures Non-Dual, 31% Non-Dual, 36 % Dual, 69 % Dual, 64 % Total = 3.8 million Total = $159 billion SOURCE: KCMU and Urban Institute estimates based on data from FY 2010 Medicaid Statistical Information System (MSIS). Because 2010 data was unavailable, 2009 data was used for Colorado, Idaho, Missouri, and West Virginia.

Figure 10 Medicaid Spending Per Enrollee, by Beneficiary Population, 2010 $16,292 LTSS Acute Care $12,995 $3,636 $10,087 $9,359 Elderly $6,205 Ind. with Disabilities Under Age 65 $XX,XXX $XX,XXX $3,039 $3,027 $12 Non-Disabled Adults $2,378 $XX,XXX $2,315 $63 Children Total: 6.2M 9.6M 17.9M 32.2M NOTE: Spending per enrollee figures are for all Medicaid enrollees, not just LTSS users. SOURCE: KCMU and Urban Institute estimates based on data from FY 2010 Medicaid Statistical Information System (MSIS). Because 2010 data was unavailable, 2009 data was used for Colorado, Idaho, Missouri, and West Virginia.

Figure 11 Distribution of Enrollment and Spending Among Medicaid LTSS Beneficiaries, by Population, 2009 Institutional Services Community- Based Services All LTSS Enrollees 37% 63% 52% 52% 48% 48% Elderly LTSS Enrollees 72% 28% LTSS Enrollees with Disabilities Under Age 65 21% 79% 37% 63% Total: Enrollment Expenditures Enrollment Expenditures Enrollment Expenditures 3.8M $156B 1.9M $68B 1.6M $83B NOTE: Note: Individuals who used both institutional and community-based services in the same year are classified as using institutional services in these tables. SOURCE: KCMU and Urban Institute estimates based on data from FY 2009 MSIS. Because 2009 data was unavailable, 2008 data was used for Pennsylvania, Utah, and Wisconsin.

Figure 12 Medicaid Home and Community-Based Services (HCBS) Participants and Expenditures, by Program, 2009 State Plan Home Health Services 975,929 Total = 3.25 million 30% Total = $50 billion 11% 22% $5.3 billion $11.0 billion State Plan Personal Care Services 912,076 28% Section 1915(c) Waiver Services 1,366,337 42% 67% $33.7 billion Participants Expenditures SOURCE: KCMU and University of California at San Francisco (UCSF) analysis of 2009 CMS 372 data and program surveys.

Figure 13 Growth in Medicaid HCBS Participants, by Program, 2000-2009 Home Health Services Personal Care Services Section 1915(c) HCBS Waiver in thousands 2.1M 2.1M 704 705 578 582 2.4M 766 683 2.5M 2.6M 851 877 716 755 2.8M 2.8M 2.9M 864 879 923 912 808 816 3.1M 922 896 3.3M 976 912 770 841 924 983 1,015 1,066 1,116 1,171 1,247 1,366 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 % Change: +4% +12% +7% +4% +7% -1% +4% +5% +6% NOTE: Figures updated annually and may not correspond with previous reports. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys.

Figure 14 Growth in Medicaid HCBS Expenditures, by Program, 2000-2009 Home Health Services Personal Care Services Section 1915(c) HCBS Waiver $50B in billions $22.1B $19.4B $2.5 $2.3 $5.3 $4.6 $12.6 $12.6 $32.1B $28.3B $4.1 $25.1B $2.8 $2.7 $5.5 $6.5 $7.1 $14.3 $16.9 $18.9 $38.4B $35.3B $4.4 $4.4 $8.6 $7.7 $20.5 $23.2 $42B $4.6 $9.4 $27.6 $45.1B $5.1 $10.0 $30.0 $5.3 $11.0 $33.7 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 % Change: +14% +14% +13% +14% +10% +9% +9% +7% +11% NOTE: Figures updated annually and may not correspond with previous reports. SOURCES: KCMU and UCSF analysis of CMS Form 372 data and program surveys.

Figure 15 Medicaid 1915(c) HCBS Waiver Waiting Lists, by Enrollment Group, 2002-2011 Other Groups Elderly/Disabled Groups I/DD Group 6% 5% 3% 1% 1% 41% 42% 43% 51% 53% 53% 47% 45% 53% 53% 6% 6% 30% 10% 26% 29% 68% 64% 61% 7% 9% 31% 28% 63% 62% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total: 192,447 180,347 206,427 260,916 280,176 331,689 393,096 365,553 428,571 511,174 NOTE: Elderly/Disabled comprises the following enrollment groups: aged, aged/disabled, and physically disabled. Other comprises the following enrollment groups: children, individuals with HIV/AIDS, individuals with mental health needs, and individuals with traumatic brain and spinal cord injuries. Percentages may not sum to 100 due to rounding. SOURCE: T. Ng et al., December 2012, available at: http://www.kff.org/medicaid/report/medicaid-homeand-community-based-service-programs/.

Figure 16 States Participation in Six Key Medicaid LTSS Options Provided or Enhanced by the Affordable Care Act NOTE: Number of states that are participating, used to participate, or have plans to participate in FY 2013 or FY 2014 as of July 2013. SOURCE: M. O Malley Watts, M. Musumeci, and E. Reaves, How is the Affordable Care Act Leading to Changes in Medicaid Long-Term Services and Supports (LTSS) Today? State Adoption of Six LTSS Options, The Henry J. Kaiser Family Foundation, April 2013, available at: http://www.kff.org/medicaid/issuebrief/how-is-the-affordable-care-act-leading-to-changes-in-medicaid-long-term-services-and-supportsltss-today-state-adoption-of-six-ltss-options/; updated July 2013. 46 29 26 18 14 10 Money Follows the Person Demonstration Health Homes State Plan Option Financial Alignment Demos for Dually Eligible Beneficiaries Balancing Incentive Program HCBS State Plan Option Community First Choice State Plan Option

Figure 17 Capitated Medicaid Managed LTSS: An Emerging Trend CMS reports that more than half the states are expected to be operating capitated Medicaid managed LTSS programs by January 2014, including: Expansion of current Medicaid capitated managed LTSS programs under 1115 or 1915(b)/(c) 19 states with waivers implemented or approved as of 2012 (AZ, CA, DE, FL, HI, KS, MA, MI, MN, NH, NJ, NM, NY, NC, PA, TN, TX, WA, and WI) Establishment of new Medicaid capitated managed LTSS programs under 1115 or 1915(b)/(c) 3 states with proposals pending (CA, IL, and NV) Implementation of Medicare/Medicaid financial alignment demonstrations for dual eligible beneficiaries under 1115A combined with 1115 or 1915(b)/(c) 5 states with capitated proposals approved (CA, IL, MA, OH, and VA); 10 states with capitated proposals pending (HI, ID, MI, NY, OK, RI, SC, TX, VT, and WA) SOURCES: P. Saucier, J. Kasten, B. Burwell, and L. Gold, The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update, July 2012, available at: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery- Systems/Downloads/MLTSSP_White_paper_combined.pdf; M. Musumeci, Financial Alignment Demonstrations for Dual Eligible Beneficiaries Compared: California, Illinois, Massachusetts, Ohio, and Washington, The Henry J. Kaiser Family Foundation s Commission on Medicaid and the Uninsured, May 2013, available at http://www.kff.org/medicaid/issue-brief/illinois-massachusetts-ohio-and-washington-financial-alignmentdemonstrations-for-dual-eligible-beneficiaries-compared/.

Figure 18 Contact Information Erica L. Reaves, Policy Analyst The Henry J. Kaiser Family Foundation Kaiser Commission on Medicaid and the Uninsured 1330 G Street, NW Washington, DC 20005 EricaR@kff.org 202.654.1373 Visit our new, improved site: www.kff.org twitter.com/kaiserfamfound facebook.com/kaiserfamilyfoundation

Figure 19 APPENDIX: Medicaid Long-Term Services and Supports Provisions

Figure 20 Medicaid State Plan Institutional Services Provision Description Mandatory or Optional FMAP Self-Direction Time Limitation Must require daily care provided in facility Nursing Facility Services Financial eligibility at state option up to 300% SSI federal benefit rate ($2,130/month for an individual in 2013) Mandatory Regular N/A No Intermediate Care Facility Services for People with Intellectual/Developmental Disabilities Must require health or rehabilitative services provided in facility Optional Regular N/A No

Figure 21 Medicaid State Plan Home and Community-Based Services (HCBS) Provision Description Mandatory or Optional FMAP Self- Direction Time Limitation Home Health Services Part-time or intermittent nursing services; home health aide services; medical supplies, equipment and appliances suitable for use in the home; and at state option, physical therapy, occupational therapy, and speech pathology and audiology services Mandatory Regular N/A No Personal Care Services Assistance with activities of daily living (e.g., bathing, dressing) and instrumental activities of daily living (e.g., preparing meals) Optional Regular Permitted No Community First Choice State Plan Option ( 1915(k)) Home and community-based attendant services and supports for beneficiaries who would otherwise require institutional care; financial eligibility up to 150% FPL ($1,436/month for an individual in 2013) or up to state limit for nursing facility services if higher Optional 6% enhanced Required No Health Home State Plan Option Services include: comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, patient & family support, referral to community & social support services To be eligible, individuals must: have at least two chronic conditions; or have one chronic condition and are at risk for a second; or have one serious and persistent mental health condition Optional Enhanced 90% for first two years; planning funds up to $500,000 available Permitted If a state targets the benefit(s), approval periods are for 5 years, with the option to renew with CMS approval for additional 5-year periods Geographic targeting permitted Services include: case management, homemaker/home health aide/personal care services, adult day health, habilitation, respite, day treatment/partial hospitalization, psychosocial rehabilitation, chronic mental health clinic services, other services approved by Secretary (same as 1915(c) HCBS waiver) To be eligible, individuals must: HCBS State Plan Option ( 1915(i)) meet financial eligibility criteria (individuals are covered up to 150% FPL, or $1,436/month for an individual in 2013); states have the option to expand up to 300% SSI FBR ($2,130/month for an individual in 2013) if eligible for HCBS through a waiver meet needs-based criteria less stringent than institutional care Optional Regular Permitted If a state targets the benefit(s), approval periods are for 5 years, with the option to renew with CMS approval for additional 5-year periods Enrollment caps not permitted Statewideness required Population targeting permitted

Figure 22 Medicaid HCBS Waivers Provision Description Mandatory or Optional FMAP Self-Direction Time Limitation Services include: case management, homemaker/home health aide/personal care services, adult day health, habilitation, respite, day treatment/partial hospitalization, psychosocial rehabilitation, chronic mental health clinic services, other services approved by Secretary Beneficiaries must otherwise require institutional care 1915(c) Secretary can waive regular program income and resource limits Optional Regular Permitted Section 1915(c) waivers are approved initially for a 3-year period and renewed for 5-year periods Cost neutrality required Enrollment caps permitted Statewideness not required Population targeting permitted 1115 Secretary can waive certain Medicaid requirements and allow states to use Medicaid funds in ways that are not otherwise allowable under federal rules for experimental, pilot, or demonstration projects that in the Secretary s view are likely to assist in promoting program objectives Optional Regular Permitted Budget neutrality required through longstanding administrative policy In general, Section 1115 demonstrations are approved for a 5-year period and can be renewed, typically for an additional 3 years

Figure 23 Other Medicaid HCBS Authorities Provision Description Mandatory or Optional FMAP Self- Direction Time Limitation Money Follows the Person HCBS for beneficiaries who transition from institution to community setting Includes supplemental services not otherwise matchable to facilitate transition Optional Enhanced for 12 months for state plan or waiver HCBS Permitted Demonstration Grant through Sept. 2016 Balancing Incentive Program New or expanded HCBS for beneficiaries with incomes up to 300% SSI FBR ($2,130/month for an individual in 2013) Must develop no wrong door/single entry point system, conflict-free case management services, and core standardized assessment Optional Enhanced 2% or 5% Permitted State plan option or waiver from Oct. 2011 through Sept. 2015 for states that devoted less than half of Medicaid LTC expenditures to HCBS as of 2009