Medicaid Home and Community-Based Services Data, 2009

Terence Ng and Charlene Harrington. Updated March, 2013

Introduction to Medicaid

What is Medicaid?

Good health is important to everyone. If you can't afford to pay for medical care right now, Medicaid can make it possible for you to get the care that you need.

Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that are recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.

Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services.

Medicaid is regulated by the Center for Medicaid and Medicare Services (CMS).

Difference between Medicaid and Medicare?

Although sounding similar, Medicaid and Medicare programs are very different. Medicare is a Federal run health insurance program for people over 65, people with a disability and people of all ages with end stage renal disease. Medicare does not cover any kind of custodial care.

Medicaid is funded jointly by the Federal Government and the individual states. Medicaid is an assistance program, with strict eligibily requirements, the main one being low income, a criterion which plays no role in determining Medicare coverage. Medicaid covers a wider range of health care services than Medicare.

Put simply, Medicare is designed to help with long-term care of the elderly and Medicaid covers healthcare costs for the poor. Coverage under both programs is possible which is sometimes referered to as dual eligibility.

Eligibility

Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age, whether you are pregnant, have a disability, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group. There are special rules for those who live in nursing homes and for children with disabilities living at home.

Your child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not (however, there is a 5-year limit that applies to lawful permanent residents). Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.

In general, you should apply for Medicaid if your income is low and you match one of the descriptions of the eligibility groups. (Even if you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for Medicaid and have a qualified caseworker in your state evaluate your situation.)

To help you see if you may be eligible for a variety of governmental programs, you may access the GovBenefits and BenefitsCheckUp websites.

When does Eligibility Start?

Coverage may start retroactive to any or all of the 3 months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most States have additional "State-only" programs to provide medical assistance for specified poor persons who do not qualify for the Medicaid program. No Federal funds are provided for State-only programs.

What is Not Covered?

Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds. As noted earlier, categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the Temporary Assistance for Needy Families (TANF) program or from the Supplemental Security Income (SSI) program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses.

Medicaid home and community-based service (HCBS) programs

In 2009, the federal-state Medicaid program paid for 45 percent of the total national long-term services and supports expenditures. This part of the website introduces a series of tables that present the latest available (2009) state-by-state, participant and expenditure data for the three main Medicaid home and community-based service (HCBS) programs, and for total Medicaid long–term services and supports.

Medicaid HCBS Programs

The three main Medicaid (HCBS) programs are:

• 1915(c) Home and Community-Based Services waivers

  Since 1981, states have used authority under Section 1915(c) of the Social Security Act to request a waiver of certain federal Medicaid requirements (including state-wide program coverage) to establish HCBS 'waiver' programs. These programs attract federal-matched funds and allow states to provide a wide range of HCBS to participants who would otherwise be in an institution, including: optional Medicaid benefits (e.g., personal assistance), and services not otherwise authorized by federal Medicaid statute (e.g., home modifications). Every state and DC has waivers except for Arizona and Vermont, which provide Medicaid long-term care through 1115 demonstration waivers. In mid–2009, Rhode Island transitioned its HCBS waiver participants into a 1115 managed care waiver.

• State Plan Personal Care

  Since 1975, states have had the option of offering personal care services (PCS) as a Medicaid benefit. States have considerable discretion in defining PCS but programs typically involve non-medical assistance with activities of daily living (e.g., bathing and eating) for participants with disabilities and chronic conditions. States are known to vary in the amount and scope of services provided (e.g., only some states provide PCS outside the participant's residence). Unlike waivers, if PCS is offered as a state plan benefit, it must be made available statewide, to all categorically eligible persons. In 2009, 34 states offered the Medicaid Personal Care Services benefit but Rhode Island and Delaware reported no participants.

• Home Health

  For Medicaid participants other than those eligible for institutional care, Medicaid home health nursing services are optional. States can vary the amount, scope and duration of benefits offered so long as they remain sufficient to reasonably achieve their purpose and remain the same for all eligibility groups. All states offer the Medicaid Home Health benefit.

For an explanation as to what a Medicaid waiver is please read the introduction to Medicaid waivers.

The only two mandated Medicaid long-term services and supports benefits are institutional care and home health services for participants eligible for institutional care. Medicaid regulations do, however, allow states to use combinations of three programs to provide HCBS either directly, or through a variety of contractual arrangements: 1915(c) HCBS waivers, Home Health, and State Plan Personal Care Services.

The waiver data are taken from the Form 372 reports that states submit annually to Centers for Medicare and Medicaid Services (CMS). The home health and state plan personal care data are collected annually by PAS Center researchers using a survey of state officials. In addition, the total long-term services and supports tables also shows the percentage of Medicaid long-term services and supports participants being served in home and community-based services.¹

1. Percentage data obtained partly from Eiken, S., Sredl, S., Burwell, B. &. Gold, L. (2011). Medicaid Expenditures for Long-Term Services and Supports: 2011 Update. MA: Thomson Reuters