State Medicaid home care policies: inside the black box

With Medicaid now the largest budget item for many states and the biggest payer of home and community-based services (HCBS), there is increasing interest in the policies used by states on their three main Medicaid HCBS programs: 1915(c) waivers, state plan personal care, and home health. This article presents an analysis of annual national surveys (2002-2004) of Medicaid HCBS programs that investigate the four main features over which states have discretion: (1) eligibility criteria, (2) services offered (including consumer direction), (3) discretionary cost controls (financial caps, service limits, and wait lists), and (4) workforce issues including the use of independent providers. The findings advance knowledge of state policy trends within each of the three programs and variations between them.