Analysis of the California In-Home Supportive Services (IHSS) Plus Waiver Demonstration Program. Background and Purpose


California’s In-Home Supportive Services (IHSS) program provides personal assistance services (PAS) for low-income people with physical, sensory, memory, or cognitive disabilities. Services available include assistance with activities of daily living (ADLs) (e.g., bathing, dressing, eating, bladder/bowel requirements) and instrumental activities of daily living (IADLs) (e.g., shopping, meal preparation, house cleaning). In calendar year 2005, IHSS served about 385,000 aged, blind, and disabled adults or children per month, or about 408,000 persons annually. IHSS is financed through a combination of federal, state, and county funds. To qualify for IHSS, an individual must be either over age 65, or disabled; and either eligible for (including current recipients) of Supplemental Security Income/State Supplementary Payment (SSI/SSP)1 or meeting all the eligibility criteria for SSI/SSP except for income limits (DSS, 2000).2 All components of IHSS operate as an entitlement program, meaning that IHSS is available to all persons who meet the income and benefit eligibility criteria. In principle there is no waiting list for admittance into the program and no cap on the overall growth of the program. The types and amount of services provided are determined by county social workers who conduct eligibility assessments and authorize services according to state and federal policies.

From 1973 to 1992, IHSS was supported entirely by state and county funds. Starting in 1993 the state converted its program to Medicaid (aka Medi-Cal)3 State Plan personal care services and began receiving Medicaid funds for the services meeting federal reimbursement criteria. State (33%) and county (17%) funds finance the 50% federal match of the program expenditures. Services in the former program not qualifying for Medicaid were retained within IHSS in what came to be known as the “Residual” Program. These services continued to be paid solely using state and county funds. Included in the Residual Program were those IHSS recipients receiving paid care from legally responsible relatives (i.e., parents of minor children or spouses), persons authorized to receive “Advance Pay,” and recipients who received Restaurant Meals vouchers in lieu of hours of attendant care for in-home meal preparation. Advance Pay enabled recipients to pay their consumer-hired PAS workers in full and on time, rather than having to submit timesheets through the county and on to the state for payment.

In 2004, California submitted a Social Security Act section 1115 waiver request to the Centers for Medicare and Medicaid Services (CMS). This is known as the IHSS Plus Waiver. It was approved and began implementation in August 2004. The Waiver enables federal financing participation for services brought into IHSS Plus from California’s IHSS Residual Program. The effect of this is to reduce the state and county share of costs in the State Plan program. About 26,000 persons were receiving all or a portion of their IHSS personal care assistance through those elements of the Residual Program in 2004 that were to be incorporated into the IHSS Plus Waiver. Not all Residual Program services are included in the Waiver. The following are the components of the IHSS Plus Waiver:

  • Advance Pay: IHSS recipients meeting severely impaired criteria have the option to receive Advance Pay (i.e., Medicaid funds are paid to recipients in advance of PAS delivery). This allows recipients to assure timely payments to care providers (including any emergency back-up providers).

  • Parent and Spouse Providers: IHSS Plus Waiver permits spouses of adults, and parents of minor children to be paid as IHSS providers for personal care, protective supervision, domestic and related services. Other family members as well as Non-Relative providers can provide similar services under California’s regular IHSS (i.e., Personal Care Services Program (PCSP)) program.

  • Restaurant Meal Vouchers: IHSS Plus Waiver recipients have the option, under appropriate circumstances, to receive a Restaurant Meal voucher in lieu of in-home assistance for meal preparation and related tasks.

This report documents IHSS Plus Waiver implementation and recipient Medicaid service use in calendar year 2005. Analyses compare recipients in the IHSS Plus Waiver program with recipients in the IHSS State Plan (aka PCSP). Waiver recipients are minor children whose parent is a paid IHSS provider, or those whose spouse is a paid IHSS provider. Recipients are classified by these provider types on an “intention to treat” basis. Namely, recipients having either an IHSS Parent or Spouse provider for any portion of 2005 are considered to be in the Waiver for the calendar, even if they had another relative or a non-relative as a paid provider for a portion of the year. Likewise, those not having a paid Parent/Spouse provider during the calendar year are considered to by in the regular IHSS program or PCSP. This is analogous to an experiment where an individual enrolls into the innovative care group and later changes into “usual” care, but for purposes of analysis, the recipient is included within the group to which they were originally assigned.

Study outcomes include recipient state Medicaid expenditures and service use, such as hospital and emergency room (ER) use, and nursing home placement.4 This work supports the California’s evaluation of the IHSS Plus Waiver and complements other consumer-directed services research conducted under the aegis of the federal Office of Disability, Aging and Long-Term Care Policy (DALTCP)DALTCP is a unit of the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Human and Health Services. The analyses consider the consequences of allowing “legally responsible” family members (i.e., parents/legal guardians of minor children and spouses) of Medicaid beneficiaries to be paid as personal care attendants. Such payments are permitted when the financing mechanism is a 1915(c) home and community-based services (HCBS) waiver, and section 1915(j) provisions applicable to the State Plan.

  1. The SSI is a federally funded income support program (Social Security Act, Title XVI) for the aged, blind, and disabled. The SSP is a state program that supplements the SSI income level. SSI/SSP benefits in California (as in most states) are administered by the Social Security Administration (SSA). Eligibility for both programs is determined by SSA using federal criteria for income and assets. Benefits are in the form of cash assistance (CDSS, 2003, SSI Eligibility).

  2. About 2.2% of IHSS recipients did not meet income limits for at least one month in 2005, and paid a “share of cost” for services in those months where their income exceed Medicaid eligibility levels.

  3. Medicaid is a federal program (Social Security Act, Title XIX) that provides health and long-term care coverage for low-income families and aged, blind, or disabled individuals. Medi-Cal is the term California uses for Medicaid.

  4. Community care facility placement, and mortality risk were initially considered as potential programs as well. However, the indicator of placements in the IHSS recipient termination status field was found to be unreliable. Mortality similarly is not fully documented on IHSS records as death often occurs after a hospital admission and may not be recorded in the IHSS record. An attempt was made to obtain Medicaid eligibility records that have this information, but these were not made available to project.

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