to know about . . .
Medicaid personal care and related services are optional benefits that are provided at the discretion of each state. No new federal laws are needed for states to do this.
States already have the ability to offer in-home alternatives to institutions. They can choose to provide Medicaid services under the Personal Care Services benefit. If they do, anyone who's entitled to Medicaid is entitled to get this service -- personal attendant services. There are also waivers.
There's a Nursing Home Bias, though. (The nursing home lobby has a lot to do with this.) States fear spending their Medicaid dollars on in-home services, since lobbyists for institutions wouldn't let states use less money on institutional "care."
The problem is to get states to want to fund in-home services instead of nursing home services -- or offer people a choice!
The Personal Care Services Option
States can elect to provide the PCS option -- part of the Medicaid program. This option, once it's part of the State Medicaid Plan, makes unskilled personal care services a part of the state's Medicaid benefits package. If the state elects to offer the Personal Care Services option, PCS benefits must be offered to all "eligible individuals."
The Personal Care Services Option was made available to states in 1975 by Medicaid. States that make this option part of their State Medicaid Plan can use Medicaid funds to pay for attendant services.
States may choose to provide the PCS benefit, which offers unskilled personal care services as a part of the states' Medicaid benefit package. PCS benefits must be offered to all "eligible individuals" Although states that choose this course cannot restrict the services as they can with waivers, and the PCS Benefit must be available to anyone who's eligible for Medicaid; in fact, says the GAO report, states may limit the PCS benefit through two mechanisms: "medical necessity" and "utilization control."
"States can , for example, limit the hours of service provided each day or impose limits on the type of services provided."
Medicaid defines the PCS benefit as services that are:
According to information the Disability Statistics Center, only 28 states allow Medicaid funds to be used for personal assistance services outside the home -- like at the grocery , the bank or at work.
HCBS waivers, which were first introduced in 1981, operate under markedly different rules than the PCS benefit, which must be offered to all eligible individuals. HCBS waivers allow states to limit geographic availability, target specific populations or conditions, limit the number of individuals served, and cap waiver expenditures.
"The popularity of HCBS waivers is evidenced by their growth rate," says the General Services Administration in its May, 1999 report, Adults with Severe Disabilities: Federal and State Approaches for Personal Care and other Services. "From 1987 to 1998, expenditures under HCBS waivers grew at an average annual rate of 31 percent, compared with 16 percent for home health and 10 percent for the PCS benefit. "
The following is taken from
Adults with Severe Disabilities: Federal and State Approaches for Personal Care and other Services,published May, 1999 (GAO-HEHS 99-101). Download from http://www.gao.gov/
HCBS waivers provide states greater flexibility in program design, permitting the adoption of a variety of strategies to control the cost and use of services. Thus, states may "waive" certain provisions of the Medicaid statute, such as
To receive an HCBS waiver, states must demonstrate that the cost of the services to be provided under a waiver (plus other state Medicaid services) is no more than the cost of institutional care (plus any other Medicaid services provided to institutionalized individuals).
Waivers permit states to cover a wide variety of nonmedical and social services and supports that allow people to remain in the community, including personal care, personal call devices, homemakers' assistance, chore assistance, adult day health care, and other services that are demonstrated as cost-effective and necessary to avoid institutionalization.
Although other researchers have said that only 27 states offer truly consumer-directed attendant services using Medicaid money, the May, 1999 The GAO report identified 31 states that they said "offered consumer-directed personal care, primarily under Medicaid."
The problem with this map is that it's not accurate. The GAO only knew about states that use Medicaid money to pay for consumer-directed services. But many states, like Kentucky, have small personal assistance programs paid for out of another money pot -- maybe the State legislature's funded it.
As we get more information from advocates about what is really going on in states, we'll put it on this website. You can help us by emailing us with information you know.
States with consumer-directed programs
Cash & Counseling project
The Robert Wood Johnson Foundation, in cooperation with the Department of Health and Human Services, is sponsoring a four-state demonstration and evaluation of the cost-effectiveness and appeal of a consumer-directed approach to personal care services in Medicaid. Arkansas, Florida, New Jersey, and New York are taking part in this Cash and Counseling demonstration project.