Medicaid: HCBS and Eligibility Updates

I follow Medicaid but don’t often get many inquiries around Medicaid policy or requests for articles in this subject area. Medicaid, however, is very important for providers, especially post-acute and senior living, as it is typically, a significant if not majority payer.

During COVID and the public health emergency, Medicaid policy and CMS enacted requirements for states to keep Medicaid enrollees covered through the entirety of the public health emergency.  In December of 2022, the Omnibus spending bill disconnected the public health emergency from the continued enrollment provision allowing states to begin determining ongoing eligibility (for Medicaid) starting in April of 2023. All individuals enrolled in Medicaid will undergo an eligibility redetermination prior to June of 2024. Individuals that do not complete and return their enrollment data will lose their Medicaid benefits, meaning they could lose Medicaid-funded long-term care, cost-sharing or coverage of Medicare premiums (Medicaid covers Part B premiums for dually eligible participants). An excellent background piece on Medicaid and this issue of requalification is available here from LeadingAge: LeadingAge-Medicaid-Unwinding-2-22-23

In the Consolidated Appropriations Act of 2023 were provisions that allowed states to resume Medicaid eligibility terminations in April of 2023, along with data reporting requirements (as noted above). CMS has used this data or failure to report the data to determine whether states are improperly terminating individuals from Medicaid for administrative or paperwork reasons. In response, CMS released an interim final rule on December 4 defining CMS’ ability to enforce state compliance by imposing corrective action plans, levying fines, suspending disenrollments, or decreasing a states’ federal financial participation (FMAP).  The rule took effect yesterday.  It is available here: CMS State Reporting Rule on Medicaid Eligibility

Another Medicaid element that continues to show strain, pre and post pandemic, is known as HCBS waiver slots.  HCBS stands for Home and Community Based Services. The waiver concept is such that a Medicaid qualified individual would otherwise be at-risk of institutionalization unless a “slot” was available via and HCBS plan that provided personal care, assisted living services, or adult day care services that met the person’s needs without having to access institutional care (typically a nursing home).  Historically, Medicaid only covered services provided via a Medicaid institutional provider.

In a November article from the Kaiser Family Foundation, KFF looked at HCBS programs and specifically, how many people were using HCBS services and how many were waiting for service access. “The only HCBS that states are required to cover is home health, but states may choose to cover personal care and other services such as private duty nursing through the Medicaid state plan. Those benefits are generally available to all Medicaid enrollees who need them. States may use HCBS waivers to offer expanded personal care benefits or to provide additional services such as adult day care, supported employment, and non-medical transportation. Because waivers may only be offered to specific populations, states often provide specialized benefits through waivers that are specific to the population covered, such as providing supported employment only to people under age 65″.

Because states can limit waivers to targeted populations, waiting lists for services are common.  The difficulty in sorting actual numbers and identifying classes or sets of individuals needing service but not able to access service, is that each state maintains lists ranging from interested, to referred, to waiting.  All can mean the same thing, or each can have a different twist (e.g., referred meaning via an agency and interested meaning a person expressing a desire for more information or qualification). KFF estimates that over 4 million Medicaid participants use HCBS, and that the numbers of people using HCBS through the state plan are similar to the numbers using HCBS through waivers.

Per Kaiser, between 2016 and 2023 about .7 million people (700K) each year are on an HCBS waiting list.  The majority of this group are people with intellectual or developmental disabilities, comprising 88% of the waiting lists in states that do not screen for waiver eligibility, compared with 51% in states that determine waiver eligibility before placing someone on a waiting list.

People with intellectual/developmental disabilities comprise 72% of the total waiver waiting list population. Seniors and adults with physical disabilities account for one-quarter (25%), while the remaining share (3%) includes children who are medically fragile or technology dependent, people with traumatic brain or spinal cord injuries, people with mental illness, and people with HIV/AIDS. The folk on waiting lists for waivers tend to be considerably different than the general state Medicaid population and HCBS service users (personal care primarily).

The KFF article is available here: https://www.kff.org/medicaid/issue-brief/a-look-at-waiting-lists-for-medicaid-home-and-community-based-services-from-2016-to-2023/?utm_campaign=KFF-2023-Medicaid&utm_medium=email&_hsmi=284403982&_hsenc=p2ANqtz–nNSoA_lQ3D6y565q31ZGiPIJQTCA15k0NAD8n2JTA_j_HzDDmOFtZLPlWEF1r7IWeK_ux8DmCcaqXjK5OUY0dE9hHGg&utm_content=284403982&utm_source=hs_email