1. A National Analysis Of Medicaid Home And Community Based Services (HCBS) Waivers For People With Intellectual And Developmental Disabilities
Carli Friedman, PhD
Postdoctoral Research Associate
University of Illinois at Chicago

2. Introduction
$47.77 billion
66%

3. HCBS 1915(c) waivers Developed in 1981 as an alternative to ICF/IIDs
Allow community-based service programs tailored to certain populations (e.g., IDD)
Funding surpassed ICF/IID in 2000
Largest provider of long term supports and services (LTSS) for people with IDD
FY 2010: $23.5 billion for 515,000 people (Rizzolo, Friedman, Lulinski-Norris, & Braddock, 2013)

4. Changes since 2010 Recovery from the Great Recession (2007 – 2009)
HCBS 1915(c) final settings rule
Established ‘outcome-oriented’ definition of home and community based settings
Person centered planning
Flexibility to combine waiver target groups (e.g., older adults and people with physical disabilities)
Transition plans

5. Purpose
Update to Rizzolo, Friedman, Lulinski-Norris, & Braddock’s (2013) FY 2010 analysis
Examine projected spending allocations and state priorities FY 2015
Examine updated HCBS IDD waiver taxonomy

7. Findings
111 HCBS 1915(c) waivers for people with IDD from 46 states and DC

8. Total Unduplicated Participants
Range = 15 to 110,000
M = 5,673
F(2, 108) = 4.45, p = .014.

9. Total Projected Spending
$25.6 billion in FY 2015
Range $28,793 to $2.8 billion
M = $230.3 million per waiver

10. Spending Per Capita

12. Fiscal effort

14. Average spending per participant
M = $39,989
Range: $576 to $146,502

15. Average spending per participant
F(2, 108) = 6.27, p = .003
F(2, 108) = 3.58, p = .031

16. Comprehensive vs Support Waivers
t(20) = -5.15, p < .001

17. Service Taxonomy

18. SPENDING BY CATEGORY (FY 2015) Total proposed spending (in millions)
Service
Total proposed spending (in millions) %
Residential habilitation
$10,815.6
42.3%
Supports to live in one’s own home
$5,239.6
20.5%
Day habilitation
$4,210.0
16.5%
Health and professional services
$1,130.9
4.4%
Clinical and therapeutic services
$758.0
3.0%
Nursing and home health
$336.6
1.3%
Dental
$36.3
0.1%
Crisis
$30.6
Supported employment
$669.3
2.6%
Care coordination
$618.7
2.4%
Respite
$589.6
2.3%
Transportation
$541.2
2.1%
Family services
$520.3
2.0%
Family supports
$475.6
1.9%
Family training & counseling
$14.1
0.06%
Community transition supports
$451.7
1.8%
Prevocational
$448.6
Specialized medical equipment and assistive technology
$210.1
0.8%
Adult day health
$59.6
0.2%
Financial support services
$48.0
Individual goods and services
$10.6
0.04%
Self advocacy training
$1.57
0.006%
Education
$0.43
0.002%
Recreation and leisure
$0.14
0.0005%

20. Frequency of Service Categories

21. Discussion
In FY 2015, waivers provided 2,850+ services to approximately 630,000 people with IDD.
Over $25.6 billion was projected for HCBS waivers in FY 2015
On average waivers projected spending $39,989 per participant in a year in FY 2015.
Services with the most funding:
residential habilitation
supports to live in one’s own home
day habilitation

22. Discussion: Differences across groups
waivers for people with ID projected spending more on the average participant in a year than waivers for people with ASD
waivers for both children and adults had higher total projected spending and average spending per participant than waivers for children

23. Discussion: FY 2010 vs FY 2015
10% growth
5% growth
5% reduction

24. FY 2010 vs FY 2015: State Level Changes
Total projected spending = shifts to 1115 & expansion of HCBS waivers?
New York dropping 99% between FY 2010 and FY 2015
Expansion in Washington, New Mexico, Nebraska, Connecticut
Average spending per participant = shifts between comprehensive and support waivers?
Tennessee grew 68% ($14,989 to $77,384)
Oregon reduced by 61% ($24,618 to $5,921)

25. FY 2010 vs FY 2015: Service Category Priorities
Largest growth:
Community transition supports
Adult day health
Individual goods and services
Health and professional services
Largest drop:
Recreation and Leisure
Education

26. FY 2010 vs FY 2015: Service Category Priorities
Shift away from facility based supports to homes and non-facility based settings
↓ Residential habilitation
↑ Supports for living in one’s own home

27. Limitations Four unavailable waivers
New Mexico’s Mi Via-ICF/MR waiver
New York’s OPWDD Comprehensive waiver
Utah’s Autism waiver
Washington’s Individual and Family Services waiver
Waivers are based on state projections, not utilization

28. Conclusion HCBS 1915c waivers are recovering from the Great Recession
Large discrepancies across states and waivers
As states reevaluate their IDD programs in response to the final settings rule, findings should be used to determine areas of need & how to best capitalize on limited funding available
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