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


California has paid legally responsible relatives as IHSS providers for years under a state and county financed component of IHSS known as the Residual Program. Many of the Residual Program elements were assumed into the IHSS Plus Waiver, implemented in 2005. This waiver allows Medicaid participation in jointly financing the PAS provided by parents of minor children and spouses of adults. It also allows for Advance Pay and Restaurant Meal voucher payments to qualified IHSS applicants.

The analyses presented in this report were organized around five broad questions pertaining to implementation of the IHSS Plus Waiver:

  • Do IHSS Plus Waiver recipients (e.g., Parent providers, Spouse providers, Advance Pay, Restaurant Meals voucher) differ from regular IHSS program recipients in race/ethnicity, living arrangement (e.g., household size, and availability of legally responsible relatives)?

  • What are the functional limitations, task assistance needs, and chronic health conditions of recipients in each IHSS Plus Waiver component? Do these differ from recipients in the regular program?

  • Do IHSS Plus Waiver and regular IHSS recipients differ in terms of continuity with their provider relationship, and Share of Cost?

  • Adjusting for disability levels, are there differences within age group between IHSS Plus Waiver and non-Waiver recipients in the number of authorized hours?

  • Adjusting for disability and other attributes, what are the Medicaid (aka Medi-Cal) program use and expenditures incurred by waiver program and non-waiver recipients? This includes all IHSS services; HCBS waiver programs; Medicaid hospital, ER, nursing home, home health, and medical provider claims.

Taken together, these descriptive questions assess four fundamental policy issues: whether there was a change in the number and attributes of spouses and parents of minors that are paid providers under the IHSS program; whether hiring legally responsible relatives as personal assistance providers seems to be a recipient/family preference; whether Spouse and/or Parent providers performed as well as the use of other providers in enabling IHSS recipients to remain at home, safely; and whether the employment of family providers has been budget neutral for Medicaid in terms of health care use/expenditures.

IHSS recipients fall into three distinct age groups: minor children, non-elderly adults, and elderly adults. Elderly adults are the majority (60%). Minor children represent a small minority (about 4%), but still a sizable number of recipients. As the disability/chronic illness profile of each age group is different, as is the distribution of recipients among the types of paid providers used, most of the discussion is organized by recipient age group.

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