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Memo
Medicaid HCBS Waiver Expenditures, FY1995-2000
Medicaid HCBS Waiver Expenditures, FY 1995 through FY 2000
From: Steve Eiken and Brian Burwell, The MEDSTAT Group
Date: July 6, 2001
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The accompanying tables and graphs present data on Medicaid expenditures for 1915(c) Home and Community-Based Services waivers from FY 1995 through FY 2000. Our previous memos on Medicaid long term care spending have included information on aggregate state spending for HCBS waivers, but not detailed data on expenditures for individual waivers.[1] In addition, in this memo, we have classified each 1915(c) waiver by target population, and therefore can present information on the distribution of expenditures for HCBS services across long term care populations.
Table 1 presents data on HCBS waiver spending by target population from FY 1995 through FY 2000. Figure 1 presents the distribution of HCBS waiver expenditures by populations served in FY 2000. Figure 2 shows the growth in waiver spending by population served from FY 1995 through FY 2000.
As show in Figure 1, about three-fourths of waiver expenditures are used to purchase long term care supports for persons with mental retardation and other developmental disabilities. In FY 2000, about $9.3 billion of the total $12.4 billion spent for HCBS waiver services was targeted to persons with MR/DD. Thus, in FY 2000, states spent almost as much under Medicaid for HCBS services for persons with MR/DD as they spent for services in ICFs-MR, which totaled $9.9 billion. The high level of spending for MR/DD waivers is primarily a function of the higher per capita costs associated with providing supports to persons with MR/DD, since most persons with MR/DD who are provided long term supports through waiver programs receive supports on a 24-hour basis.
Almost all other waiver expenditures were for people with physical disabilities and elderly people with disabilities. Waivers serving one or both of these target populations spent $2.9 billion in FY 2000. Waivers for people with AIDS or AIDS-related conditions (ARC), technology-dependent people, and people with traumatic brain injuries (TBI) account for about 1.5% of all waiver spending, or about $190 million in FY 2000. As shown in Figure 2, waivers for persons with traumatic brain injuries have experienced relatively rapid growth over the last five years. There are also three small waiver programs which serve individuals with a primary diagnosis of mental illness, accounting for less than 0.2% of all HCBS waiver expenditures.
Information on the target populations served by each waiver program was drawn from internal HCFA reports that describe current waivers and 1915(c) Medicaid Home and Community Based Waiver Participants, Services, and Expenditures, 1992-1998 by Charlene Harrington, Helen Carrillo, Valerie Wellin, and Fanny Norwood, which can be obtained from the HCFA website ( http://www.hcfa.gov/medicaid/waiv9298.pdf). HCBS waiver expenditure data are drawn from HCFA 64 reports which states are required to submit on each individual waiver to receive Federal Financial Participation (FFP).
Table 2 presents data on HCBS waiver expenditures by state. Table 3 presents a comparison of state Medicaid waiver expenditures, as reported Table 2, with prior reports of aggregate spending for HCBS services, as presented in our annual Medicaid Long Term Care Expenditures memos. In general, Medicaid spending for HCBS waiver services, as reported in Table 2, is somewhat higher than reported in the Medicaid Long Term Care Expenditures memos because Table 2 includes prior period adjustments. States submit prior period adjustments to HCFA 64 reports to adjust claims submitted in their regular quarterly reports. In the case of HCBS waivers, this is usually due to an underreporting of payments made for HCBS services for a particular quarter. For example, a state MR/DD agency may make payments to HCBS waiver providers during a particular quarter which state Medicaid agencies may, however, fail to include on their quarterly HCFA 64 reports because information about these payments was not communicated between the state MR/DD agency and the State Medicaid agency on a timely basis.
Prior period adjustments are not included in the Medicaid Long Term Care Expenditures memos. The information in Table 2 includes prior period adjustments submitted before the end of FY 2000. In FY 1995 through FY 1997, most adjustments were submitted within two years of the initial HCFA 64 report. However, adjustments are occasionally submitted several years after the initial report. Therefore, the HCFA waiver expenditure data for FY 1999 and 2000 reported in Table 2 are likely to change with future adjustments.
Ninety percent of aggregate expenditures reported in prior period adjustments were for HCBS waivers in California and New York. The majority of expenditures for California’s MR/DD waivers as well as its waiver for the elderly with disabilities were reported in prior period adjustment reports, so California’s HCBS expenditures in Table 2 are often double or triple the expenditures reported in the Medicaid Long Term Care Expenditures memos.
It is important to reiterate some caveats about HCFA 64 data. First, HCFA 64 data are by date of payment, not date of service. Thus, the data reported in Tables 1 and 2 reflect expenditures in regard to when payments are made to HCBS providers, not when HCBS services are used by consumers.
Second, HCFA 64 reports represent state claims to the Federal government of expenditures that states believe are eligible for Federal matching funds. As a result of its audit process, HCFA may disallow some of these claims as not eligible for Federal match. Third, HCFA 64 reports on HCBS waiver spending only represent Medicaid fee-for-service spending, not spending for services provided through capitated managed care programs. Arizona, Texas and Minnesota are three states which pay for HCBS services through capitated long term care programs.
We are very interested in hearing from state administrators of HCBS waiver programs about whether the data presented in this memorandum are consistent with internal state reports of HCBS waiver spending. If there are discrepancies between internal state reports and the data reported in Tables 1 and 2, please let us know. Contact either Steve Eiken at mailto: steve.eiken@medstat.com or Brian Burwell at mailto: brian.burwell@medstat.com.
We would like to thank Don Allen in HCFA’s Center for Medicaid and State Operations, Division of Financial Management and John Klemm in HCFA’s Office of the Actuary for their assistance in making these data available and for assisting us in their interpretation.
Download Excel Tables
[1] Burwell, B. Medicaid Long Term Care Expenditures in FY 2000, The MEDSTAT Group, May 7, 2001.
From: Steve Eiken and Brian Burwell, The MEDSTAT Group
Date: July 6, 2001
[ Up ]
--------------------------------------------------------------------------------
The accompanying tables and graphs present data on Medicaid expenditures for 1915(c) Home and Community-Based Services waivers from FY 1995 through FY 2000. Our previous memos on Medicaid long term care spending have included information on aggregate state spending for HCBS waivers, but not detailed data on expenditures for individual waivers.[1] In addition, in this memo, we have classified each 1915(c) waiver by target population, and therefore can present information on the distribution of expenditures for HCBS services across long term care populations.
Table 1 presents data on HCBS waiver spending by target population from FY 1995 through FY 2000. Figure 1 presents the distribution of HCBS waiver expenditures by populations served in FY 2000. Figure 2 shows the growth in waiver spending by population served from FY 1995 through FY 2000.
As show in Figure 1, about three-fourths of waiver expenditures are used to purchase long term care supports for persons with mental retardation and other developmental disabilities. In FY 2000, about $9.3 billion of the total $12.4 billion spent for HCBS waiver services was targeted to persons with MR/DD. Thus, in FY 2000, states spent almost as much under Medicaid for HCBS services for persons with MR/DD as they spent for services in ICFs-MR, which totaled $9.9 billion. The high level of spending for MR/DD waivers is primarily a function of the higher per capita costs associated with providing supports to persons with MR/DD, since most persons with MR/DD who are provided long term supports through waiver programs receive supports on a 24-hour basis.
Almost all other waiver expenditures were for people with physical disabilities and elderly people with disabilities. Waivers serving one or both of these target populations spent $2.9 billion in FY 2000. Waivers for people with AIDS or AIDS-related conditions (ARC), technology-dependent people, and people with traumatic brain injuries (TBI) account for about 1.5% of all waiver spending, or about $190 million in FY 2000. As shown in Figure 2, waivers for persons with traumatic brain injuries have experienced relatively rapid growth over the last five years. There are also three small waiver programs which serve individuals with a primary diagnosis of mental illness, accounting for less than 0.2% of all HCBS waiver expenditures.
Information on the target populations served by each waiver program was drawn from internal HCFA reports that describe current waivers and 1915(c) Medicaid Home and Community Based Waiver Participants, Services, and Expenditures, 1992-1998 by Charlene Harrington, Helen Carrillo, Valerie Wellin, and Fanny Norwood, which can be obtained from the HCFA website ( http://www.hcfa.gov/medicaid/waiv9298.pdf). HCBS waiver expenditure data are drawn from HCFA 64 reports which states are required to submit on each individual waiver to receive Federal Financial Participation (FFP).
Table 2 presents data on HCBS waiver expenditures by state. Table 3 presents a comparison of state Medicaid waiver expenditures, as reported Table 2, with prior reports of aggregate spending for HCBS services, as presented in our annual Medicaid Long Term Care Expenditures memos. In general, Medicaid spending for HCBS waiver services, as reported in Table 2, is somewhat higher than reported in the Medicaid Long Term Care Expenditures memos because Table 2 includes prior period adjustments. States submit prior period adjustments to HCFA 64 reports to adjust claims submitted in their regular quarterly reports. In the case of HCBS waivers, this is usually due to an underreporting of payments made for HCBS services for a particular quarter. For example, a state MR/DD agency may make payments to HCBS waiver providers during a particular quarter which state Medicaid agencies may, however, fail to include on their quarterly HCFA 64 reports because information about these payments was not communicated between the state MR/DD agency and the State Medicaid agency on a timely basis.
Prior period adjustments are not included in the Medicaid Long Term Care Expenditures memos. The information in Table 2 includes prior period adjustments submitted before the end of FY 2000. In FY 1995 through FY 1997, most adjustments were submitted within two years of the initial HCFA 64 report. However, adjustments are occasionally submitted several years after the initial report. Therefore, the HCFA waiver expenditure data for FY 1999 and 2000 reported in Table 2 are likely to change with future adjustments.
Ninety percent of aggregate expenditures reported in prior period adjustments were for HCBS waivers in California and New York. The majority of expenditures for California’s MR/DD waivers as well as its waiver for the elderly with disabilities were reported in prior period adjustment reports, so California’s HCBS expenditures in Table 2 are often double or triple the expenditures reported in the Medicaid Long Term Care Expenditures memos.
It is important to reiterate some caveats about HCFA 64 data. First, HCFA 64 data are by date of payment, not date of service. Thus, the data reported in Tables 1 and 2 reflect expenditures in regard to when payments are made to HCBS providers, not when HCBS services are used by consumers.
Second, HCFA 64 reports represent state claims to the Federal government of expenditures that states believe are eligible for Federal matching funds. As a result of its audit process, HCFA may disallow some of these claims as not eligible for Federal match. Third, HCFA 64 reports on HCBS waiver spending only represent Medicaid fee-for-service spending, not spending for services provided through capitated managed care programs. Arizona, Texas and Minnesota are three states which pay for HCBS services through capitated long term care programs.
We are very interested in hearing from state administrators of HCBS waiver programs about whether the data presented in this memorandum are consistent with internal state reports of HCBS waiver spending. If there are discrepancies between internal state reports and the data reported in Tables 1 and 2, please let us know. Contact either Steve Eiken at mailto: steve.eiken@medstat.com or Brian Burwell at mailto: brian.burwell@medstat.com.
We would like to thank Don Allen in HCFA’s Center for Medicaid and State Operations, Division of Financial Management and John Klemm in HCFA’s Office of the Actuary for their assistance in making these data available and for assisting us in their interpretation.
Download Excel Tables
[1] Burwell, B. Medicaid Long Term Care Expenditures in FY 2000, The MEDSTAT Group, May 7, 2001.
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