Medicaid in-home support programs: getting more for less

From time to time we publish guest blog posts that help illuminate a policy issue or advance the discussion of public policy in Oklahoma (see our guest blog guidelines). This post was written by Laura Dempsey-Polan of Life Senior Services, a Tulsa senior service care provider. Laura may be reached at (918) 664-9000 X267 or The opinions stated below are not necessarily the opinions of OK Policy, its staff, or its board. This blog is a venue to help promote the discussion of ideas from a variety of different points of view.

Oklahomans and their families prefer in-home supports over institutionalization and we know these supports offer marked savings with much better outcomes. Over two decades, Oklahoma developed five in-home support Medicaid programs (i.e., 1915C Waivers) now serving 31,000 eligible citizens, and 2 more are in the works. Yet, in-home programs are increasingly squeezed by nearly eight years of stagnant reimbursement.

One way to generate new funds is through Medicaid provider assessments. Through assessments, fees levied on “classes” of services generate revenues matched with federal funds to help cover provider costs. Provider assessments on institutions like nursing facilities allow them to average annual 10% increases even while operating at 65% occupancy.

To investigate in-home provider assessments, the Home and Community-Based (H&CB) Services Council joined Representative Peters to organize an Interim Study (2009H-080) on Provider Assessment Options for Home & Community-Based 1915C Waiver programs. In-home support recipients, advocates, and providers endorsed the study in the belief that Oklahoma should lead through stewardship and prevention across the lifespan for disabled and aging populations, and with measures that assure cost-effective, quality-proven programs. In-home programs save Oklahoma nearly half of a billion dollars annually by preventing costly institutionalization, promoting individual responsibility, self-determination, and full participation in the community –all with better outcomes, including help with employment and a full life in the community no matter how complex the disability.

Medicaid experts spoke with legislators and agency heads on implications for in-home programs if assessments are not passed. According to consultants, CMS (the federal agency overseeing Medicaid), has not updated assessment classes since 1981, preventing states from assessing fees on in-home programs like other providers. National advocacy is underway to change this omission. Missouri and Texas passed bills pursuing in-home assessments, Kentucky has an assessment with the knowledge of CMS, Michigan created an in-home assessment in managed care, and Maine adopted an assessment through allowed taxation. Clearly, preventive, cost-saving opportunities through in-home programs are motivating states to pursue assessments. Conversely, as California cut citizen choice for in-home programs, families/advocates filed a lawsuit under the Olmstead Supreme Court Decision, one that mandates services in the most integrated setting possible.

Additional considerations:

  • Oklahoma’s in-home programs support citizens, ages 3 through late adulthood and all are deemed “nursing-facility-level-of-care.” Without in-home programs, these Oklahomans are forced into more costly options, including emergency rooms, nursing and intermediate institutions;
  • Oklahoma’s legislated Rate Review recommends a rate adjustment to sustain in-home services.
  • Estimates suggest that over 100,000 Oklahomans are employed in in-home programs providing a range of proprietary and non-profit supports. Experts agree that rate stagnation lowers preventive, quality services, and employment for Oklahoma citizens.
  • Oklahoma’s Health Care Authority received Oklahoma’s 2nd Freedom Initiative grant for over $45M to bring over 2,000 citizens out of institutions due to recognized benefits of community living. With CMS ‘ strong encouragement, the state is writing two additional waivers for children and adults with disabilities and seniors to advance use of in-home supports.

With the age wave upon us, increasing numbers of Oklahomans with disabilities across the lifespan, and when recognizing the place Medicaid holds in state budgets–the chief funding for long-term care–it seems logical to endorse in-home support programs to save Oklahoma substantial dollars, assure better outcomes, and serve individuals and families as desired–in their own homes and communities.


Paul Shinn

Paul Shinn served as Budget and Tax Senior Policy Analyst with OK Policy from May 2019 until December 2021. Before joining OK Policy, Shinn held budget and finance positions for the Oklahoma House of Representatives, the Department of Human Services, the cities of Oklahoma City and Del City and several local governments in his native Oregon. He also taught political science and public administration at the University of Oklahoma, University of Central Oklahoma, and California State University Stanislaus. While with the Government Finance Officers Association, Paul worked on consulting and research projects for the U.S. Environmental Protection Agency, the U.S. Department of Transportation, and several state agencies and local governments. He also served as policy analyst for CAP Tulsa. He holds a Ph.D. in Political Science from University of Oklahoma and degrees from the University of Oregon and the University of Maryland College Park. He lives in Oklahoma City with his wife Carmelita.

8 thoughts on “Medicaid in-home support programs: getting more for less

  1. Dr. Dempsey-Polan is an expert on these topics, and our best local advocate for Vulnerable Adults. Her knowledge and passion assist Tulsa Area population on a daily basis. We support her views, and hope that the much-needed attention will be given to our Vulnerable Adults. We all would pray we could stay in our own homes, when disabled or ill, and wish those in “power” will understand the advantages.

  2. This is a critical issue to all Oklahomans. Economic recessions tend to lead to declining state revenues while states are faced with rising Medicaid costs from the increased demand for Medicaid programs and services. The current economic environment is causing most states to look at making deep budget cuts and Medicaid is usually targeted. Since HCBS is still considered “optional” but nursing facility services are an “entitlement” for Medicaid beneficiaries, the continuation of in home programs and services are at risk when cuts are considered.

    Evidence indicates that states investing in HCBS experience slower Medicaid expenditure growth with the dual benefit of offering its citizens long term care choices. Now, more than ever, farsighted and innovative thinking are necessary for ensuring in home services and programs are retained as one of our choices for long term care. One practical and proven way to invest in HCBS is through “in home provider assessments”. With this approach, the investment starts with the Providers investing in Medicaid by paying assessments. This in turn creates a return on the provider’s investment to the state along with a federal match that benefits the state Medicaid budget, the Provider with reasonable reimbursement, and ultimately the Medicaid beneficiary. Other states are already considering this approach. It would seem farsighted for Oklahoma to be one of those states also.

  3. I appreciate Dr. Dempsey-Polan’s article and support her views completely…I strongly endorse this plan of action and would like to see more focus on this issue immediately. Oklahoma, it’s time to break through the red tape and do what is best for Oklahomans and their families—it truly would be a win~win for everyone.

  4. This is such an important issue. An AARP study shows that over 90% of older Oklahomans want to receive their long-term services in their own home. And we know that home and community-based services are far more cost effective than instituional care. So it’s clear that HCBS is a win-win for older adults and their families and for Oklahoma’s budget (and taxpayers). This seems like such a easy issue to understand. We must do what it takes to make Oklahoma’s HCBS system work and we must hold our legislative representatives and government officials accountable on this important issue. Dr. Dempsey-Polan’s comments and efforts are completely on target. I would love to see the Oklahoma Policy Institute more involved in this issue and other issues of aging and caregiving.

  5. Dr.Dempsey-Polan’s passion for and support of this subject is critical to all Oklahomans, especially seniors and caregivers. I support this article and her vision completely. I agree that this is the plan of action to take and hope that Oklahoma will wake up and do the right thing for this state and all Oklahomans.

  6. With a growing senior population, it makes sense to support programs that help stretch taxpayer dollars, and provide much needed care in ways that seniors and their families prefer to receive it.

  7. It’s seems crazy to ignore the facts:

    -People want to stay in their homes.

    -People who stay in their homes with proper in-home care costs less than a nursing home.

    -People who stay in their home live heathier, longer lives.

    There is no downside. It’s time to get with it and properly support a win-win solution.

  8. This analysis promoting in-home care is both responsibly-presented and entirely convincing. It is essential that the measures Dr. Dempsey-Polan is so persuasively arguing for be adopted, as they clearly promote the well-being of a growing number of our citizens, along with the undeniable tax-dollar savings involved. A rare win-win opportunity for all Oklahomans.

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