Examining Cross-State Differences in Self Directed Services Provided Through 1915(c) Waivers for Older Adults

Area of Science:

• Gerontology
• Health Services Research
• Public Policy

Background:

• Self-Direction empowers older adults with choice and control over long-term services and supports.
• State-level policies dictate Self-Direction characteristics, influencing program accessibility and utilization.

Purpose of the Study:

• To identify cross-state variations in Self-Direction models within Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers for older adults.
• To analyze how state-specific design elements affect Self-Direction implementation and participant experience.

Main Methods:

• Mixed-method approach combining Framework Analysis and descriptive statistics.
• Analysis of 60 fiscal year 2023 Medicaid HCBS 1915(c) waivers serving older adults.
• Qualitative categorization based on program values, capacity determination, and participant authority.

Main Results:

• Significant cross-state differences observed in Self-Direction program design.
• High variation exists in goals, projected spending, and the number of eligible waiver services for Self-Direction.
• State of residence substantially influences older adults' access to and experience with Self-Direction.

Conclusions:

• Medicaid HCBS 1915(c) waivers exhibit considerable design heterogeneity regarding Self-Direction.
• State policies play a critical role in shaping the effectiveness and accessibility of Self-Direction for older adults.
• States can leverage cross-waiver insights to refine and improve their Self-Direction program designs.