You have to compete with Medicare and Medicaid when you are offering clients long-term care insurance (LTCI) and other long-term care (LTC) and post-retirement health planning products and services.

Victoria Peebles and Alex Bohl, consultants at Mathematica Policy Research, have tried to map out one vast, confusing zoo of Medicaid LTC services: services coming from state Medicaid programs’ “home-and community-based services” (HCBS) waiver divisions.

In theory, Medicare pays for some home care. Medicaid pays only for nursing home care for the very poor or for people who qualify as what a state defines as “very poor” (wink wink) for Medicaid nursing home benefits planning purposes. In 1981, Congress changed that understanding by adding Section 1915(c) to the Social Security Act (SSA). SSA Section 1915 gave states the freedom to apply the use of federal money to make creative new efforts to reduce the cost of Medicaid LTC services and improve people’s quality of life by using Medicaid LTC money to pay for home care, adult daycare services, and other types of LTC services delivered outside of a nursing home.

One problem is that states have been so creative with HCBS waiver money that they have developed completely separate languages for describing the HCBS services they provide. Peebles and Bohl focused on developing a “taxonomy” for describing the services. A byproduct of that work is a peek at where the HCBS money is actually going in 28 states that could provide the data the consultants wanted in a format they could handle.

Here’s a look at what the states in the study are spending on five types of HCBS benefits.

Confusion

1. Case management

What percentage of HCBS users get it: 44%

How many states pay for it? 27

Average state spending on the service: $2,527

 

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Home modifications

2. Equipment, technology and modifications

What percentage of HCBS users get it: 28%

How many states pay for it? 28

Average state spending on the service: $887

 

Image: Tyrone White modifies a home for a woman with Parkinson’s disease in Baltimore. (AP photo/Patrick Semansky)

Home health aide

3. Caregiver support

What percentage of HCBS users get it: 15%

How many states pay for it? 27

Average state spending on service per user: $4,124

 

Image: A home health aide helps a woman in Ohio.

Cooking

4. Home-delivered meals

What percentage of HCBS users get it: 11%

How many states pay for it? 22

Average state spending on service per user: $1,241

 

Image: A cook in a Medicaid community services operation in Jackson, Miss., prepares dessert. (AP photo/Rogelio V. Solis)

Brain

5. Mental health services

What percentage of HCBS users get it: 11%

How many states pay for it? 25

Average state spending on service per user: $8,451

 

See also: Older adults face gaps in mental health care