State-by-State Medicaid-Funded Employment Services Inventory

The inventory includes the “unit” used for payment. A unit is most commonly a unit of time in which a service is delivered (e.g., 15 minutes, an hour, a day, a month). A unit may also be an item or a pre-defined outcome (e.g., an hour worked, a job obtained, a completed discovery or vocational profile, a benefits analysis report, a job retention milestone, an earned income milestone, career advancement, etc.).

The inventory includes payment/reimbursement rates, if available. However, what is more commonly available is the anticipated average cost per unit. Note that the average cost per unit is not the same as the payment or reimbursement rate paid to providers of the service. Multiple payment/reimbursement rates may exist for a single service. The average cost per unit is based on the total anticipated spending for all units of a service divided by the total anticipated number of units that will be purchased. For example, if, in a given year, a state anticipates spending $500,000 on purchasing 50,000 units of service, the average cost per unit of service would be $10.

The number of units States anticipate purchasing in a year is based on an anticipated number of people who will receive the service and the average number of units anticipated to be used by each person receiving the service. For example, if a state anticipates 300 participants will use a service and, on average, each participant will use 300 units of that service, the total anticipated units of service the state will purchase is 90,000.

The 1915(c) HCBS waiver is the most common Medicaid authority used to provide services to support American job seekers and workers with disabilities. When a 1915(c) HCBS waiver is featured in this inventory, the state’s anticipated number of service users, average units per user, average cost per unit, and total spending for the service are included. A state is required to report these figures in their applications for each year it seeks approval to operate the 1915(c) waivers, which is typically for a five-year approval period. Please note, LEAD Center only included Year 1 and Year 5 projections. This is done for two reasons.

• First, states are required to base projections for the five-year period on actual utilization and spending on the services. Year 1 projections are the best indicator of what actual utilization and spending was in the prior period, and likely in the prior year.
• Second, Year 5 projections are included so Year 1 can be compared to Year 5, showing whether the state expects growth or decline in number of users, average units per user, average cost per user, and/or overall spending per service. This is very important given the focus on increasing the employment rate among people with disabilities.

The inventory includes rate determination methods for states where that information was available. The inventory describes how states determine the specific payment/reimbursement rates for the various services they offer in their Medicaid programs. Other information related to rate setting includes descriptions of how fee-for-service rates were calculated as well as information describing how any alternative payment methodologies were developed. This includes payments based on measurable milestones or outcomes (e.g., an hour worked, a month worked, a job obtained, a completed discovery or vocational profile, a benefits analysis report, etc.). This also can include payments based on quality, which is above what is typical (e.g., higher earned income, more hours worked, career advancement, longer retention milestones met, etc.).