Generosity of States' Medicaid Home and Community-Based Programs for Youths With Complex Mental Health Needs

Medicaid's Home and Community-Based Services (HCBS) waiver programs, authorized by section 1915(c) of the Social Security Act, are widely used to finance care for individuals experiencing complex health needs. Programs for youths experiencing complex behavioral health needs are less numerous and comprehensive than are programs for other populations, and little is known about variations in coverage and benefits across states. This study aimed to quantify and compare the benefits of different states' HCBS waiver programs for youths experiencing behavioral health needs.

States' initial, renewal, and amendment applications (2006-2022) for HCBS waiver programs for youths experiencing behavioral health needs were collected from states and the Centers for Medicare and Medicaid Services. Data collected included the following elements that were used to construct the Generosity Index-a monthly measure of program generosity-for each state: annual costs per person, maximum number of participants, cost limits, age ranges related to eligibility, services covered, service limits, geographic exclusions, allowances for participant-directed care, and authorizations for family members to provide care.

Consistent with studies examining section 1915(c) waiver programs for youths with other types of complex health needs, characteristics of programs for youths experiencing behavioral health needs varied substantially across states and evolved over time. Wisconsin consistently provided the most generous benefits and coverage (index score=1.64 in 2022), whereas substantial declines in program generosity were observed at certain times in Wyoming and Kansas.

Heterogeneity among mental health waiver programs for youths must be accounted for in assessing the impacts of waiver policies.