Examining Cross-State Differences in Self Directed Services Provided Through 1915(c) Waivers for Older Adults

Self-Direction is a service delivery model rooted in choice, empowerment, and control over long-term services and supports that allows older adults to select their services and who provides them. States determine key Self-Direction characteristics including level of state commitment, services that can be self-directed, and employer and budget authority, which may affect access and use. This mixed-method study identifies cross-state differences in how states are allowing Self-Direction among the 60 fiscal year 2023 Medicaid Home and Community-Based Services (HCBS) 1915(c) waivers that serve older adults using Framework Analysis and descriptive statistics. Framework Analysis resulted in three qualitative categories for analysis: description of program values, determination of capacity, explanation of authority granted to self-directing participants. Descriptive findings showed significant cross-state differences in Self-Direction design, with high variation in goals set for Self-Direction participation, projected spending on Self-Direction eligible services, and number of waiver services eligible for Self-Direction. Findings indicate significant variation in design of Self-Direction across 1915(c) waivers. Older adults' access to and experience with Self-Direction may be significantly influenced by their state of residence. States can use these findings to learn from other waivers and enhance their own design.