What Comes Next? When and How Medicaid Home- and Community-Based Services End

As Medicaid long-term services and supports shift towards home-and-community-based settings (HCBS), it is important to understand trajectories of HCBS use among older adults, including duration and living circumstances at cessation, to inform decisions about whether state Medicaid programs can afford to sustain or expand HCBS benefits.

This study examined determinants of HCBS episode duration and how they vary by status at cessation (community discharge, nursing home, or deceased). We used Southern Community Cohort Study (SCCS) data linked with Medicaid and Medicare claims to follow a cohort of older adults who initiated Medicaid-funded HCBS in Southeastern states between 2006 and 2018. We calculated unadjusted incidence of cessation and modeled adjusted rate of cessation using Cox proportional hazard models to understand how demographic characteristics, Medicaid coverage, HCBS program, and health history related to cessation with community discharge, nursing home entry, and death.

Among older adults with 5 years of follow-up (n = 591), 25.2% ended HCBS with community discharge, 16.2% with nursing home entry, and 26.2% with death. The remaining 32.3% still used HCBS. Across the entire sample (n = 1304), female cohort members had significantly lower rates of HCBS cessation (HR: 0.7, 95% CI: 0.6, 0.8), while individuals who were older (HR: 1.1, 95% CI: 1.0, 1.1), had more health conditions (HR: 1.1, 95% CI: 1.0, 1.1), or prior nursing home use (HR: 1.3, 95% CI: 1.0, 1.5) had higher rates of HCBS cessation. Individuals initiating HCBS use and Medicaid coverage at the same time had a lower rate of community discharge (HR: 0.7, 95% CI: 0.5, 0.9) than HCBS users with established Medicaid coverage.

Extended duration of HCBS use was common across our sample, which may affect Medicaid's ability to fund HCBS programs. Policymakers should consider how care needs may vary when projecting how long older adults will access HCBS benefits.