Recipients of Home and Community-Based Services in California
(2012, June). Recipients of Home and Community-Based Services in California Long Beach, CA: The SCAN Foundation & the California Department of Health Care Services.
Home and community-based services (HCBS) refer to a broad range of health and social services needed by people with limited capacity for self-care. They are intended to help recipients with disabilities remain either at home or in other community-based settings while maintaining or restoring an individual's highest level of functioning and independence possible. HCBS are intended to delay, and sometimes even prevent, entry into high-cost nursing facilities and other institutional facilities.
The need for HCBS affects persons of all ages, including those with limitations in activities of daily living (ADLs), such as bathing and dressing; instrumental activities of daily living (IADLs), such as preparing meals and shopping; and cognitive impairments and/or breathing limitations. The need for HCBS is defined, in part, by a dependence on others for an extended period of time. Individuals with HCBS needs often rely on family members and other informal caregivers for assistance. Given the high cost of care, however, many turn to publicly funded programs for coverage of paid care.
Medicaid is the largest public payer of HCBS in the country. This is primarily because federal and state governments, the two sources of funding for Medicaid, have devoted significant efforts over the past several decades to expanding Medicaid's offering of HCBS for persons with disabilities and to reducing reliance on institutional care. For FY 2010, Medicaid spent $63 billion on HCBS, or 16% of its total spending on Medicaid benefits.
Many Medicaid recipients of HCBS are also enrolled in Medicare. These individuals have traditionally been referred to dual eligibles. The Medicare-Medicaid Coordination Office of the Centers for Medicare and Medicaid Services (CMS) has begun referring to dual eligibles as Medicare-Medicaid enrollees (MMEs). Hereafter in this report, we will follow CMS' example.
MMEs tend to qualify for Medicare by being at least 65 years-old, or under age 65 and receiving Social Security Disability Insurance benefits. Medicare covers certain preventive, primary, acute, behavioral and post-acute services. For MMEs, Medicare covers services provided by physicians, acute care hospitals, skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and hospice, among others. It does not cover custodial care in nursing facilities or the HCBS services provided under Medicaid, such as personal care services, homemaker services, and adult day health. Medicaid's HCBS and other services wrap around Medicare's benefits. In other words, Medicare pays first for Medicare-covered benefits. For those Medicare-covered benefits that are also covered by Medicaid (e.g., hospital care, physician care, home health), Medicaid pays last. Medicaid also covers relevant Medicare co-pays, deductibles, and/or coinsurance.
Medi-Cal, California's Medicaid program, is the largest Medicaid program in the nation. In fiscal year (FY) 2008, California covered 10.6 million individuals under Medi-Cal. Of these, 478,381 received HCBS at some point during the calendar year (CY). This report describes Medi-Cal's recipients of five major HCBS: home health, in-home supportive services, adult day health, targeted case management, and HCBS waivers, in CY 2008.
Data for this report were collected by the California Medicaid Research Institute (CAMRI) under contract with the California Department of Health Care Services (DHCS), and with co-funding from The SCAN Foundation. For this project, CAMRI developed an integrated and longitudinal database containing claims and assessment data from Medi-Cal, Medicare, and other state data files. For additional information about CAMRI’s process for acquiring, linking and cleaning these data as well as the challenges faced, see "Studying Recipients of Long-Term Services and Supports: A Case Study in Assembling Medicaid and Medicare Claims and Assessment Data in California."