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

OBJECTIVES: 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 (e.g., 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<0.001). Annually, children with C-CD had mean payments of $1,496 (IQR: $296-$1,733), 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 $1,178 (95% CI: [$1,071, $1,296]) for children with C-CD (p<0.001). Among those enrolled in MCCW, adjusted mean annual payments were $2,571 (95% CI: [$1,426, $4.637]) for children with no CD, $3,335 (95% CI: [$1,794, $6,200]) for children with NC-CD, and $4,460 (95% CI: [$3,348, $5,942]) 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.