Complex Needs, Complex Costs: Assessing Medicaid Payments on a Subset of Home- and Community-Based Services for Children by Level of Complexity in South Carolina.

OBJECTIVE

Describe Medicaid payments for a subset of home- and community-based services (HCBS) for continuously enrolled children by complexity level.

METHODS

A cohort study of 21,838 children in South Carolina (1,744,294 claims, 2019-2022). Outcomes include mean annual payments for selected HCBS (eg, home nursing, personal care, rehabilitation). Descriptive statistics, an adjusted gamma-distributed generalized linear model with a log link, and Tukey-adjusted post hoc tests examined associations between children's characteristics, payments, and the effect of South Carolina's Medically Complex Children's Waiver (MCCW) enrollment within each complexity level.

RESULTS

Payments increased with complexity (P<.001). Annually, children with C-CD had mean payments of $1496 (IQR: $296-$1733), followed by children with NC-CD (M=$426, IQR: $124-$428) and no CD (M=$265, IQR: $63-$261). Adjusted mean annual payments increased with complexity for children not enrolled in MCCW, from $273 (95% CI: [$256, $292]) for children with no CD, to $427 (95% CI: [$396, $460]) for children with NC-CD, and $1178 (95% CI: [$1071, $1296]) for children with C-CD (P<.001). Among those enrolled in MCCW, adjusted mean annual payments were $2571 (95% CI: [$1426, $4.637]) for children with no CD, $3335 (95% CI: [$1794, $6200]) for children with NC-CD, and $4460 (95% CI: [$3348, $5942]) for children with C-CD.

CONCLUSIONS

A small cohort of children enrolled in MCCW account for a high concentration of Medicaid payments, reflecting the resource-intensive nature of hospital-level care delivered at home. Health policymaking should consider that restricting HCBS and waiver access may exponentially increase long-term state spending through avoidable institutional care.