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Medicaid policies and home health care provisions for persons with disabilities.

Within recent years, the United States has experienced phenomenal growth in the provision of both formal (e.g., by paid agencies and professional personnel) and informal (e.g., by family members or friends) long term home care services for persons with mental and physical disabilities (Kapp, 1995). Mauser and Miller (1994) reported that nearly 90 percent of persons with disabilities who live in the community receive some type of informal assistance with home care, while an estimated 67 percent depend solely on help from family and friends. According to findings in the National Long-term Care Survey of 1989, persons with disabilities who rely entirely on formal/paid home health providers increased from 5.5 percent in 1982 to 9 percent in 1989 (Hanley, Weiner, & Harris, 1991).

The expansion of home health care can be partially explained by policy changes (e.g., Omnibus Reconciliation Act of 1980 which eliminated the 3-day prior hospitalization stay coverage requirement and 100-visit limit), legal actions (e.g., Duggan vs. Bowen lawsuit of 1988 file against the Health Care Financing Administration by beneficiaries and providers of home health care), and consumer preference for community-based care (Mauser & Miller, 1994). However, the significant increase in home health care can be attributed to the medical trend of discharging patients from hospitals sooner and with more complex follow-up care needs than before. As noted by Kaye and Davitt (1995), the trend toward early discharge in combination with rapid advances in medical technology have supported the home health care boom.

Home health care services can encompass a potential array of 101 services ranging from nursing and physical therapy to massage and grocery delivery (Handy, 1995). Recipients can receive one service or a cluster of services, and they generally have significant limitations in activities of daily living (ADL) such as bathing, eating, dressing, toileting, and transferring. According to Fredman, Droge, and Rabin (1992), home health recipients required assistance performing, on average, 2.50 instrumental activities of daily living (IADL) out of 6; whereas, nonusers of home health needed help performing 0.72. IADLs consist of using the telephone, doing light or heavy housework, preparing meals, shopping, or managing money.

Kapp 1995) noted that the delivery of home health care occurs within the context of extensive federal and state regulation. Thus, rehabilitation professionals must familiarize themselves with the policies and regulations of health care programs such as Medicaid. Mauser and Miller 1994) reported that home health users were commonly eligible for Medicaid, particularly those who received more than 200 home visits. For instance, section 2176 of the Omnibus Budget Reconciliation Act (OBRA) of 1981 authorized waivers to provide expanded home and community-based care to Medicaid recipients who have disabilities and otherwise would receive more costly institutional care (Miller, 1992; Jacobson, Lindsey, & Pascal, 1989). These 2176 waivers give state Medicaid programs the flexibility to cover the types of home care (e.g., personal aide, homemaker) and community care (e.g., respite care, case management) that would enable Medicaid recipients with severe disabilities to remain in their community. Therefore, assessment of a rehabilitation client's appropriateness for home health care must include an analysis of potential payment sources such as Medicaid. The purpose of this study is to examine each state's Medicaid policies that define reimbursement, utilization, and coverage of the home health care needed by persons with disabilities. The study also identifies any states that have utilized the Medicaid home and community-based waiver to develop special policies or programs for home health care needs of Medicaid recipients living in the community.

Methodology

The state Medicaid programs were surveyed to identify Medicaid reimbursement, utilization, and coverage policies for home health care implemented by the states. In addition, the state affiliates of the National Association for Home Care (NAHC) were surveyed to assess the impact these Medicaid policies have on the provision of home care services. In March of 1995, home health questionnaires were mailed to each state Medicaid program and to each state affiliate of the NAHC. Three subsequent questionnaires were mailed to the Medicaid programs and to the NAHC affiliates not responding to the survey. Thirty eight of the 53 state affiliates of the NAHC and 47 Medicaid programs returned questionnaires. These survey responses were processed and the results were organized into tables. The appropriate tables were sent to each survey participant for verification and updates, with this process completed in early 1996.

Survey Results: Home Health Policies

An estimated $12.3 billion was spent on home health services in the United States during 1993, with $4.3 billion (35 percent) paid by the state Medicaid programs (Burner, et al., 1992). Home health providers can deliver a range of services: (1) skilled nursing care; (2) physical, speech, and occupations therapies; (3) home health aid services; (4) medical social services; (5) medical supplies; and (6) outpatient services. Although a major payor of home health services, lower Medicaid reimbursement levels make many home health providers reluctant to care for Medicaid recipients. In addition, restrictions on the utilization and the range of Medicaid-covered services can limit Medicaid recipients' access to home care services.

Policies for Skilled Nursing Care

As Table 1 demonstrates, most Medicaid programs paid for skilled nursing care (SNC) during 1995 on a per visit basis rather than per hour. Medicaid payments per visit can discourage home health providers from caring for Medicaid patients with heavy and intensive care needs because the level of the Medicaid payment does not increase as the length of the visit and the intensity of the care increase. The questionnaire asked the Medicaid programs if payments made for SNC on a per visit basis were adjusted "to reflect the intensity of care needed," with all Medicaid programs (except Louisiana) responding that they do not make intensity of care adjustments to the Medicaid payment level.

Payments. The questionnaire asked the Medicaid programs to provide the average 1995 payment level for SNC. As Table 1 illustrates, there was wide variation among the states in the 1995 payment levels of SNC, ranging from $27 per visit in Alabama to $180 per visit in Alaska. The average Medicaid payment for SNC was $68.16 per visit during 1995 for the 33 states providing 1995 data.

Utilization limits. The questionnaire asked the Medicaid programs if there was a limit to the amount of SNC that Medicaid recipients may receive during 1995. As Table 1 presents, these utilization limits can be very restrictive. For example, the Oklahoma Medicaid program covers only 12 home health visits per year.

Policies for Home Health Aides

Payments. As Table 2 illustrates, many Medicaid programs paid for the services provided by home health aides (HHA) on a per hour basis or by 15-minute units during 1995. No Medicaid program that paid for HHA services on a per visit basis reported any intensity of care adjustments to the per visit rate. Table 2 presents the wide variations among the state Medicaid programs in 1995 payment levels for the services provided by HHAs, ranging from $9.50 per visit in Oklahoma to $55 per visit in Hawaii. The average Medicaid payment for HHAS was $35.64 per visit during 1995 for the 27 states providing 1995 per visit data. The average payment for a HHA for the 12 Medicaid programs paying for these services on an hourly basis during 1995 was $15.18 per hour. (This calculation of the average hourly 1995 payment rate for services provided by a HHA includes the Medicaid programs that pay for these services in 15-minute units, adjusted to an hourly rate.)

Utilization limits. The questionnaire asked the Medicaid programs if there was a limit to the amount of HHA services that Medicaid recipients may receive during 1995. As Table 2 documents, these utilization limits can be very restrictive. Severe Medicaid utilization restrictions in many states on SNC and the services provided by HHAS may make it difficult to provide home care to Medicaid patients with physical disabilities, with the only alternative institutionalization.

Medicaid Payments/cost of Care Comparisons

The survey of the affiliates of the NAHC asked each provider association to compare the Medicaid payment for the SNC provided to Medicaid patients to the home health agencies costs of providing that care. As Table 3 illustrates, for the NAHC affiliates making comparisons, the Medicaid payment for the SNC provided to patients averaged 67 percent of the costs of care. Similarly, the survey of the state affiliates of the NAHC asked each state provider association to compare the Medicaid payment for HHA services provided to Medicaid patients to the home health agency's costs of providing that care. As Table 3 presents, for the NAHC affiliates making comparisons, the Medicaid payment for the HHA services provided to Medicaid recipients averaged 64 percent of the costs of care.

Live-in Attendant

Given the continuous assistance that many persons with disabilities require, services provided by a live-in attendant would help maintain these persons at home. In addition, the services provided by a live-in attendant would offer respite to the family and other informal caregivers of persons with disabilities living at home. The questionnaire asked the Medicaid programs if they paid for the services of a live-in attendant for Medicaid recipients. Only the Medicaid programs in Arizona, Iowa, Maine (with the Medicaid waiver only), Massachusetts, Minnesota, New York (under personal care service program, regardless of diagnosis), Oregon (paid with other programs), and Washington (with the Medicaid home and community-based care waiver program) paid for live-in attendants for Medicaid recipients.

Specialized Home and Community-based Services

Specialized home and community-based services are important for persons with disabilities because these services enhance the care that families and other informal caregivers provide. Equally important, these specialized services give the families and other informal caregivers a needed break from the constant demands of patient care (Caserta, et al., 1987; Powers, 1989). Among these specialized home and community-based services that are important to persons with disabilities and their informal caregivers are homemaker services, personal care, various types of respite care, home-delivered meals, and companion services (Skinner & Jordan, 1989; Caserta, et al., 1987).

The questionnaire asked the Medicaid programs if their Medicaid state plan as distinct from the Medicaid waiver program for home and community-based services for persons who are elderly and/or have a disability) reimbursed the following: (1) homemaker services; (2) personal care services; (3) at-home respite care; (4) respite care at an adult day care center; (5) night-assistance respite care at home; (6) home-delivered meals; and (7) companion services. As Table 4 documents, only the Arizona program covered all these services. However, Arizona's long term care program is a waiver program and all these services are covered by that waiver program.

Home and Community-based Care Waivers

As Table 4 illustrates, most of the specialized home and community-based services beneficial both to persons with disabilities and to their families and other informal caregivers are not covered by any of the Medicaid programs under their conventional coverage as defined in their Medicaid state plans. However, Section 2176 of the federal Omnibus Budget Reconciliation Act of 1981 authorized Medicaid waivers to provide home and community-based services to Medicaid recipients who are elderly or have a disability, and who otherwise would receive more costly institutional care Miller, 1992; Jacobson, et al., 1989). Through these waivers the state Medicaid programs can offer an expanded array of home and community-based services and offer these additional services to a targeted group such as persons with disabilities. In addition to this expansion of covered home and community-based services, the waiver programs also allow the state Medicaid programs to set more generous eligibility standards for the targeted groups to receive waiver services than the eligibility standards for the states' regular Medicaid benefits (Congressional Research Service, 1993; Miller, 1992; Jacobson, et al., 1989). To qualify for coverage under the waiver program a potential beneficiary can have income as high as 300 percent of the Supplemental Security Income benefit. This waiver eligibility standard is much easier to meet than the eligibility standards for regular Medicaid benefits (Congressional Research Service, 1993).

The questionnaire asked the Medicaid programs to list any home health services covered under the Home and Community-Based Care Waiver for persons who are elderly or have a disability that would benefit Medicaid recipients with Alzheimer's Disease. Although the questionnaire focused on the waiver services beneficial to elderly persons with Alzheimer's Disease, most of these services also benefit persons with various disabilities living at home. Table 5 presents the expanded array of home and community-based care services that the states cover with the Medicaid waiver program. Among the waiver services that could benefit people with disabilities and their families are: (1) homemaker services, chore and housekeeping services; (2) adult day care and adult day health care; (3) emergency response systems; (4) in-home respite services, (5) respite care at an adult day care center, and night-assistance respite care at home; (6) home modification and maintenance services; (7) case management; (8) companion services; (9) medication oversight; (10) medical and nonmedical transportation; (11) nutritional counseling; (12) home-delivered meals; 13) medical alert services; (14) wellness monitoring; (15) psychological consulting to help caregivers deal with behaviors); (16) medical social work; (17) disposable garments; (18) disposable bed pads; (19) specialized medical equipment and supplies; (20) adult foster care; (21) attendants; and (22) adaptive aids.

Summary

This study surveyed the state Medicaid programs and the state affiliates of the NAHC to identify Medicaid policies for home health services and the impact these policies have on the provision of care. In addition, the study identified states that have developed special Medicaid home and community-based care programs to assist Medicaid recipients who are elderly or have a disability. The survey of the state Medicaid programs found wide variation among the states in the level of Medicaid payments for home health services, averaging $68.16 per visit for SNC and $35.64 per visit (15.18 per hour) for services provided by HHA during 1995. The survey of the state affiliates of the NAHC indicate that Medicaid payments for the SNC delivered to Medicaid patients averaged 67 percent of the costs of providing that care. According to the NAHC affiliates, Medicaid payments for the HHA services delivered to Medicaid recipients averaged 64 percent of the costs of providing that care.

Many Medicaid programs place utilization limits on the amount of home health care Medicaid recipients may receive. For example, the Oklahoma Medicaid program only reimburses 12 home health visits per year. Severe Medicaid utilization limits in many states on home health services may make it difficult to provide home care to Medicaid patients with disabilities, with institutionalization as the only alternative.

Specialized home and community-based services are important to persons with disabilities because these services enhance the care that families and other informal caregivers provide and, equally important, these specialized services give the families and other informal caregivers a needed break from the constant demands of patient care. Among the specialized home and community-based services important to persons with disabilities and their informal caregivers are homemaker services, personal care, various types of respite care, home-delivered meals and companion services. No state Medicaid program provided a broad array of these specialized home and community-based services through their regular Medicaid programs. However, many states used the Medicaid home and community-based care waiver programs for persons who are elderly and/or have a disability to offer these specialized home services that can benefit persons with disabilities. Table 5 presents the expanded array of services that state Medicaid programs cover through these waiver programs. These home and community-based waivers give state Medicaid programs the flexibility to cover the types of home and community-based care and services that enable Medicaid recipients with disabilities to remain in the community.

The study has identified a number of Medicaid policies that can improve the quality of home health care provided to Medicaid recipients with disabilities. Medicaid programs should expand their coverage of home health services to include specialized home and community-based services that allow persons with disabilities to remain at home and to assist family members and other informal caregivers with their care. In addition to a broader array of home and community-based services covered, the waiver program allows states to establish more generous eligibility standards for waiver services, enabling more persons with disabilities to qualify for waiver coverage than would qualify for the traditional Medicaid program.

References

Burner, S., Waldo. D., & McKusick, D. (1992). National health expenditure projections through 2030. Health Care Financing Review, 14(1), 1-29.

Caserta, M., Lund, D., Wright, S., & Redburn, D. (1987). Caregivers to dementia patients: The utilization of community services. The Gerontologist, 27, 209-214.

Congressional Research Service 1993). Medicaid source book: Background data and analysis (A 1993 update). Washington, DC: U.S. Government Printing Office.

Fredman, L., Droge, J.A., & Rabin, D.L. (1992). Functional limitations among home health users in the national health interview survey supplement on aging. The Gerontologist, 32, 641-646.

Handy, J. (1995). Alternative organizational models in home care. Journal of Gerontological Social Work 24, 49-65.

Hanley, R., Weiner, J., & Harris, K. (1991). Will paid home care erode informal support? Journal of Health Politics, Policy. and Law, 16(3), 507-52 1.

Jacobson, P., Lindsey, P., & Pascal, A. (1989). Aids-Specific Home and Community-based Waivers for the Medicaid Population. Santa Monica, CA: Rand.

Kapp, M.B. (I 995). Legal and ethical issues in home-based care. Journal of Gerontological Social Work. 24, 31-45.

Kaye, L.W., & Davitt, J.K. (1995). The importation of high technology services into the home. Journal of Gerontological Social Work, 24, 67-94.

Mauser, E., & Miller, N. A. (1994). A profile of home health users in 1992. Health Care Financing Review-16 (1), 17-33.

Miller, N. (1992). Medicaid home and community-based care waivers. Health Affairs, 11 (4), 162-171.

Powers, J. (1989). Helping family and patient decide between home care and nursing home care. Southern Medical Journal, 82, 723-726.

Skinner, P., & Jordan, D. (1989). Home management of the patient with Alzheimer's disease. Home Healthcare Nurse, 7(1), 23-27.

Weinberger, M., Gold, D.T., Divine, G.W., Cowper, P.A., Hodgson, L.G., Schreiner, P.J., & George, L.K. (1993). Social service interventions for caregivers of patients with dementia: Impact on health care utilization and expenditures. Journal of the American Geriatrics Society, 41, 153-156.
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Title Annotation:Disability and Health Care Policy: Medical Coverage, Service Provision and Professional Preparation
Author:Alston, Reginald J.
Publication:The Journal of Rehabilitation
Date:Jul 1, 1997
Words:3033
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