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The Affordable Care Act included the opportunity for states to increase spending on Medicaid home and community-based services (HCBS) for older adults and persons with disabilities through the Balancing Incentive Program (BIP). This study utilized comparative case studies to identify the factors that facilitated or impeded states’ implementation of BIP. Findings indicate factors that facilitated the implementation of BIP were communication with the federal government and its contractor, merging BIP with existing HCBS programs, and enhanced federal revenue. On the other hand, the short duration of BIP, state procurement and contracting processes, and the need to incorporate feedback from non-governmental stakeholders and determining how to spend the enhanced revenue proved challenging for some states. This research suggests ways federal and state officials can implement new initiatives to achieve greater rebalancing of Medicaid long-term services and supports for older adults.

Community First Choice is a program within the Affordable Care Act that encourages states to expand Medicaid home and community-based services (HCBS). Specifically, this Medicaid state plan benefit provides states with an additional 6% federal match to promote greater rebalancing of long-term services and supports. Through Community First Choice, states can offer services that assist with activities of daily living, instrumental activities of daily living, and health-related tasks. The program is optional for states, and, to date, eight states have pursued Community First Choice. The purpose of this study is to understand the barriers and facilitators to implementing Community First Choice in two states. Data was collected through semi-structured interviews with individuals involved in HCBS policy nationally and in Maryland and Texas, including government bureaucrats, consumer advocates, and provider representatives. The results suggest that communication with the Centers for Medicare and Medicaid Services, the enhanced federal match, and leveraging existing HCBS infrastructure facilitated implementation. Maryland and Texas encountered challenges implementing Community First Choice because of constraints posed by existing HCBS programs, ambitious timelines, limited staff resources, and insufficient engagement with external stakeholders. The findings suggest that implementing Community First Choice is a large undertaking, and states should ensure they have enough time and sufficient staffing for the implementation process. States should also understand how implementing Community First Choice will impact existing HCBS offerings and how leveraging HCBS infrastructure can facilitate implementation. The lessons from implementing Community First Choice can be informative to other states pursuing or contemplating this program.

Objectives The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states’ participation in this program. Methods Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors was considered representing states’ economic, political, and programmatic conditions. Results The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP. Discussion The findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.