Medicaid HCBS Recipients Had High Excess Mortality Rates During Pandemic

Medicaid beneficiaries receiving home- and community-based services (HCBS) during the COVID-19 pandemic had higher excess mortality rates than community-dwelling beneficiaries and the general population, a Health Affairs study found.

Researchers gathered data from 14 health plans across 12 states to determine excess mortality among people receiving Medicaid long-term services and supports (LTSS) in the form of HCBS between March and December 2020.

Excess mortality rate was defined as the actual minus the expected mortality rate.

The study sample included 55,000 adults under 65, classified as younger adults, and 90,000 adults aged 65 and older, referred to as older adults.

Researchers found that the average monthly excess mortality rate for younger adults receiving HCBS (133 deaths per month per 100,000) was almost the same as the rate for nursing home residents in the same age group (143 deaths per month per 100,000).

The excess mortality rate for younger HCBS recipients was 7.4 times the rate for Medicaid beneficiaries in the community not receiving HCBS and 26.6 times that rate for the general population.

The average monthly excess mortality rate for older Medicaid HCBS recipients was also similar to the rate for nursing home residents in the same age group, the study noted.

The difference in excess mortality rates between older HCBS recipients and other beneficiaries their age was not as big as the difference between younger beneficiaries. However, the excess mortality rate for older beneficiaries receiving HCBS was still 3.5 times greater than the rate of non-HCBS beneficiaries and 5.7 times the rate for the general population.

Regardless of age group, the expected and actual mortality rates were also significantly greater for HCBS recipients than for non-HCBS community-dwelling Medicaid beneficiaries during the first 10 months of the pandemic.

“Many factors likely contributed to the high mortality rates of HCBS recipients, including individual risk factors, societal barriers, and indirect impacts,” the study stated.

For example, people receiving Medicaid HCBS have high rates of secondary health conditions that lead to a greater risk of contracting COVID-19 and experiencing worse outcomes. Additionally, some beneficiaries live in group settings or attend communal programs, which increases their exposure risk.

Exposure risks may also be greater for those who rely on daily in-person supports provided by caregivers who routinely enter their homes.

At the beginning of the pandemic, nursing homes were required by Congress to report mortality rates. More than 23 percent of all COVID-19-related deaths have been linked to people receiving LTSS in nursing homes and other long-term care facilities.

The mandatory reporting helped inform policy discussions and responses to the severe impact that COVID-19 had on these facilities.

However, reporting like this was not required for Medicaid HCBS recipients, despite the high number of beneficiaries receiving these services. In 2019, around 7.5 million Medicaid beneficiaries received HCBS compared to 1.6 million who resided in nursing homes and other facilities.

“Our study helps shine a light on a population that has largely been invisible in the public discourse and COVID-19 response,” researchers wrote. “Our findings highlight the vulnerability of the HCBS population during the pandemic.”

The pandemic highlighted the need to minimize reliance on nursing home care and expand access to HCBS and at-home caregiver support.

In June 2022, HHS and CMS helped expand access to these services by extending the timeframe for states to invest American Rescue Plan funds in HCBS. The American Rescue Plan offered states a temporary 10 percentage point increase to the federal medical assistance percentage (FMAP) for HCBS-related Medicaid spending.

Initially, states had three years to use the funds, from April 1, 2021, through March 31, 2024. Following the announcement from HHS and CMS, states can now use the funds through March 31, 2025.