HCBS Claims Analysis Chartbook: A Final Report December 15, 2017 An overview

Research Questions: 1. What are the characteristics of FFS Medicaid beneficiaries who use HCBS, for example age, gender, race/ethnicity, dual eligibility, basis of Medicaid eligibility, and major health conditions? 2. What are their HCBS use patterns, as defined by the service categories in the HCBS taxonomy, overall and for each LTSS population group? Which services are most and least frequently used? How do the patterns vary by state and over time? 3. How much is spent on HCBS in total and by type of HCBS, as defined by the service categories in the HCBS taxonomy? How is total HCBS spending distributed across 1915(c) waivers, HCBS state plan benefits, managed care (if available), and other Medicaid authorities (if it is possible to distinguish them)? How does spending vary by each LTSS population group? How do spending patterns vary by state and over time?

The Population Least one FFS 1915(c) waiver service claim or one state plan service claim with a valid FFS community-based longterm care flag during the study years. HCBS state plan services: personal care private duty nursing adult day care home health care residential care rehabilitation for aged or disabled enrollees targeted case management for aged or disabled enrollees Transportation Hospice durable medical equipment. Target groups: aged and disabled Aged physically disabled people with brain injuries people with HIV/AIDS intellectually disabled/ developmentally disabled people with mental illness/serious emotional disturbance technology dependent/medically fragile individuals with autism/autism spectrum disorder unspecified or unknown populations.

The Population - continued Excluded HCBS spending for HCBS users enrolled in managed LTSS (MLTSS) plans Colorado, Idaho, Kansas, Maine, and Rhode Island—incomplete MAX file Arizona - operated MLTSS (1) statewide, (2) for all LTSS users, and (3) in all four study years (no other state met all three of these criteria) Vermont - does not operate any 1915(c) waivers Beneficiaries missing or undefined demographic information whose date of death occurred before the study year whose claims did not indicate that they were true HCBS users

Interesting facts Not all data is the same - 2010-2012 included 44 states & 2013 included only 25 states Top 3 states – highest percentage use of 1915 waivers 1. Hawaii 2. New Mexico 3. Pennsylvania Top 3 states - highest percentage use of state plans 1. Michigan 2. California 3. Nevada

Median and Average Costs The median FFS Medicaid HCBS expenditures per HCBS Twenty-three states - less than $1,000. Range - under $100 in Alabama to $20,132 in Tennessee Average per participant spending on HCBS state plan services $4,330 in 2010 $4,254 in 2011 $4,253 in 2012 Average cost in HCBS 1915 waiver services per participant $26,444 in 2010 $26,419 in 2011 $26,083 in 2012

Non-LTSS spending for HCBS Users Inpatient hospital services -85 to 86% across years. $19.3 to $21.6 billion a year Outpatient hospital services- roughly 14 % of hospital spending. Prescription drugs made up the largest share of non-hospital services.

Characteristics of FFS Medicaid beneficiaries who use HCBS Eligible for Medicaid based on blindness/disability (64 to 65 percent) Not dually eligible for Medicare (40 to 44 percent) ages 19 to 64 years (52 to 53 percent) female (58 percent) white non-Hispanic (50 to 52 percent)

Prevalence & Cost of Chronic Conditions In 2012, the five most common conditions Diabetes – 21% Depression – 16.6 % Hyperlipidemia – 11.8% Chronic Obstructive Pulmonary Disease (COPD) – 11.5% Ischemic Heart Disease – 10.9% In 2012, average costs per HCBS user with any health conditions - $22,324 3 conditions had average costs over $50,000 per HCB user intellectual disabilities and related conditions mobility impairments epilepsy

HCBS service use Round-the-clock services, home-based services, and day services comprised about 80 percent or more of total Medicaid HCBS FFS expenditures for high-cost HCBS waiver users Round-the clock (56.1 percent) and day services (52.0 percent) were the most commonly used taxonomy services. No HCBS taxonomy category was universally reported by all states for the high-cost HCBS population The highest average spending per person in 2012 round-the-clock services ($93,635) home-based services ($48,510).

FINDINGS ON TOTAL HCBS USERS AND SPENDING From 2010 to 2012, the 44 states - approximately 6 million individual HCBS users each year In 2012, approximately 1.3 million HCBS users had 1915(c) waiver claims in the 44 study states - 86.8% of the 1.5 million HCBS users in all 50 states and the District of Columbia reported as receiving 1915(c) waiver services In 2012, the 44 study states reported $58.1 billion on Medicaid HCBS claims- 83.5% of total HCBS expenditures by all states

Limitations of the Study MAX data do not include all types of Medicaid expenditures Data quality and completeness vary by state. State plan services are not sorted by HCBS taxonomy.

Future Research Study populations in isolation that are common across states so you can make better comparisons. More detailed subgroup analysis Expand analyses to managed care expenditures, or expand the application of the HCBS taxonomy to state plan services