Trends in the Use of and Spending for Home and Community-Based Services as a Share of Total LTSS Use and Spending in Medicaid, 2019–2021

Over the last several decades, states have sought to rebalance their Medicaid LTSS systems by increasing access to HCBS and reducing reliance on institutional care. Progress toward rebalancing Medicaid LTSS systems away from institutional services and toward greater use of HCBS can be measured nationally and for individual states based on both the share of total Medicaid LTSS users receiving HCBS and the share of total Medicaid LTSS spending devoted to HCBS. These measures are commonly referred to as LTSS user and expenditure rebalancing ratios. We analyzed national and state trends in Medicaid LTSS user and expenditure rebalancing ratios for 2019–2021, based on data from the Transformed Medicaid Statistical Information System Analytic Files (TAF). We also examined national rebalancing ratios by select characteristics, including age, sex, dual-eligibility status, urban or rural residence, primary spoken language, and race and ethnicity, for 2019–2021. We found that 86.2 percent of LTSS users received HCBS in 2021 and 63.2 percent of LTSS expenditures were for HCBS in 2021. Both rebalancing ratios varied the most by age group with those ages 0–20 with the highest rebalancing ratios and those ages 65 and over with the lowest.