Medicaid Long Term Services and Supports Annual Expenditures Report: Federal Fiscal Year 2019
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Key Findings
- National Medicaid LTSS expenditures totaled $162.1 billion in FY 2019, with HCBS accounting for $95.0 billion (58.6 percent) and institutional services accounting for $67.1 billion (41.4 percent).
- The share of LTSS out of total Medicaid expenditures declined from 47 percent in FY 1988 to 34 percent in FY 2019. There are several factors behind this decline, including state LTSS system rebalancing initiatives that promote the increased use of more cost-effective HCBS and increased spending for Medicaid populations that do not use LTSS.
- The percentage of HCBS expenditures of total Medicaid LTSS expenditures has steadily increased over the last three decades, but it has slowed in recent years. The national total surpassed the longstanding benchmark of 50 percent of LTSS expenditures in FY 2013 and has remained higher than 50 percent since then, reaching 58.6 percent in FY 2019.
- The absolute amount spent on MLTSS programs increased more than sevenfold in the past two decades, climbing from $6.7 billion in FY 2008 to $47.5 billion in FY 2019. This growth reflects more states using MLTSS, rising from 8 in FY 2006 to 25 states in FY 2019, and more people receiving LTSS though these programs.
Long-term services and supports (LTSS) encompass a wide range of medical and nonmedical services and supports for people with physical, intellectual, mental, or other disabilities or conditions. These can include institutional care, such as that provided in nursing facilities, intermediate care facilities for individuals with intellectual or developmental disabilities (ICF/IDD), and mental health facilities, and home and community-based services (HCBS), such as personal care and home health, among other services. Medicaid is the primary payer of LTSS, covering slightly more than half of all spending for such services and supports in the United States (Centers for Medicare & Medicaid Services n.d.; O’Malley Watts et al. 2020). Over the past several decades, federal and state initiatives and consumer preferences have led to shifts in Medicaid LTSS expenditure patterns across settings and service types, including increases in HCBS expenditures.
This report is the latest in a series of reports, sponsored by Centers for Medicare & Medicaid Services (CMS), on Medicaid LTSS expenditures. It contains detailed information about Medicaid LTSS expenditures for federal fiscal year (FY) 2019 (October 1, 2018, to September 30, 2019) at the national and state levels by service category, type of LTSS (institutional and HCBS), and payment models. Because this period occurred just before the onset of the COVID-19 Public Health Emergency (PHE) in early 2020, the data in this report can serve as a reference to monitor potential shifts in Medicaid LTSS expenditure patterns as states seek to provide alternatives to institutional care and take advantage of new federal funding opportunities to expand access to HCBS. The accompanying Excel attachments contain LTSS service category expenditures, state data tables, managed LTSS expenditures, and additional non-LTSS expenditures for several relevant categories. The report is based on data from several sources, including Medicaid CMS-64 expenditure reports, state-reported managed LTSS (MLTSS) expenditures, Money Follows the Person (MFP) worksheets for proposed budgets, CMS 372 report data for section 1915(c) waiver programs, and U.S. Census data.
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