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What states can offer now


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.

What states use the PCS Benefit?

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."

How do these states limit the PCS Benefit?

Medicaid defines the PCS benefit as services that are:

(1) authorized for an individual by a physician in accordance with a plan of treatment; Under Medicaid, states may also approve "service plans," which are similar to physician-prescribed treatment plans);

(2) provided by an individual who is qualified to provide such services and who is not a member of the individual's family; ("Family member" is defined as a "legally responsible relative"; this includes spouses of recipients and parents of minor recipients, including any stepparents who are legally responsible for minor children. Adult children are not included in this definition.) and

(3) furnished in a home or, if the state chooses, in another location.

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

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

  • "statewideness," which requires that the services be available throughout the state (a waiver allows services to be provided only in particular geographic locations);

  • comparability, which requires that all services be available to all eligible individuals (a waiver allows states to target services to individuals on the basis of certain criteria determined by the state, such as disease, condition, and age); and

  • the community income and resource rules for the medically needy (a waiver allows states to use institutional eligibility rules -- which are more generous than community rules -- for individuals residing in the community). (For example, under institutional eligibility rules, the parents' income is not counted when determining their child's eligibility for Medicaid. The parents' income is counted under the community rules.)

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.

What groups of people are being served by waivers nationally?

Waivers by state, and who they serve

Consumer Direction

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."

More on "consumer direction"

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.

More on Cash and Counseling



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