A Plate with word Medicaid and a stethoscope.
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“Far more people” received home- and community-based services such as those provided in some assisted living communities and other settings than institutional services such as those provided in nursing homes and elsewhere in 2021, according to recently published data about long-term services and supports from the Centers for Medicare & Medicaid Services.

HCBS expenditures also accounted for a higher proportion of LTSS spending than institutional services in 2021, the most recent year covered several publications on Medicaid LTSS users and expenditures that CMS released this summer with assistance from research and data analytics consultancy Mathematica.

States used a combination of programs and state plan options to deliver LTSS, the report authors noted, with state plan home health services being the most common among HCBS users, Section 1915(c) waiver program services being the largest HCBS expense category, and nursing facilities accounting for most institutional users and expenses. 

Fewer users received LTSS through fee-for-service programs than managed care in 2021 (4 million and 5.2 million, respectively), but the majority of LTSS expenses were for services delivered through FFS ($112.7 billion, or 62%), CMS said. “These trends suggest that although the use of managed care to deliver LTSS has increased considerably over time, FFS is still a substantial delivery model for LTSS,” according to one of the reports.

The number of Medicaid program beneficiaries receiving LTSS decreased slightly from 2019 to 2021, but spending increased each year during that time, according to the agency.

Nationally, the number of Medicaid LTSS users (including those receiving HCBS, including assisted living residents) dropped from 8,919,776 in 2019 to 8,836,143 in 2020 to 8,652,049 users in 2021, CMS said. 

Medicaid LTSS and HCBS spending totaled $169.2 billion in 2019 and $181.9 billion in 2021. In 2019, HCBS accounted for $97.1 billion (57.4%) of the total and institutional services (such as those provided in nursing homes) accounted for $72.1 billion (42.6%). In 2021, HCBS expenditures accounted for $115 billion (63.2%) of the total and institutional services accounted for $67 billion (36.8%).

According to the data for the most recent year discussed:

  • 86.2% of LTSS users received HCBS in 2021.
  • 63.2% of LTSS expenditures were for HCBS in 2021.
  • Total spending per LTSS user and per HCBS user rose between 2020 and 2021 to $21,024 and $15,407 respectively.

CMS noted that at the state level, the types of services, populations covered and delivery models differ greatly based on states’ Medicaid program structures. The states with the highest percentage of HCBS use among LTSS users in 2021 were Oregon, Wisconsin, New Mexico, Minnesota, Hawaii, Alaska, Pennsylvania , Michigan, Ohio, Nevada, Colorado, West Virginia and Georgia. States with the lowest percentage of HCBS use among LTSS users in 2021 were Kentucky, Arkansas, Louisiana, Maine, South Dakota, Oklahoma, Indiana, California, Utah, Nebraska, Mississippi, Missouri and Florida.

Nationwide, 7,461,364 people received HCBS in 2021 through a variety of Medicaid HCBS waiver programs and state plan options. The largest share of HCBS users received state plan home health services (30.9%), state plan rehabilitative services (29.0%), state plan case management services (23.3%) and Section 1915(c) waiver program services such as those used for assisted living (23.0%).

HCBS expenditures totaled $115 billion nationwide in 2021, with the largest share for people receiving Section 1915(c) waiver program services ($55.3 billion, or 48.1%)

Section 1915(c) waiver program users demographically were very similar to HCBS users overall, according to CMS, although Section 1915(c) waiver program users more often were dually eligible for both Medicaid and Medicare (59% compared with 32% of all HCBS users) and white non-Hispanic (62% compared with 52% of all HCBS users).

Of the 1,715,504 Section 1915(c) waiver program participants in 2021:

  • 33% were aged 65 or more years, and 53% were aged 21 to 64.
  • 52% were female, and 48% were male.
  • 79% were urban, 20% were rural and 1% were unknown.
  • 94% spoke English as their primary language, and 6% spoke Spanish.
  • 62% were white, non-Hispanic; 20% were Black, non-Hispanic; 11% were Hispanic, any race; 5% were Asian/Pacific Islander, non-Hispanic; 1% was American Indian or Alaska Native, non-Hispanic; and 1% was multiracial, non-Hispanic.

Read more in the CMS publications: