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


Many state Medicaid program administrators are interested in having the flexibility within their Medicaid State Plan personal care programs to authorize paying family members to provide care to recipients. A number of factors contribute to this. For example, traditional providers, such as licensed home care agencies, are experiencing direct care worker shortages (Stone, 2000; GAO, 2001). Within both agency and independent provider situations, there are also concerns about absenteeism, frequent schedule changes, and high turnover of attendants (Harmuth & Dyson, 2002; Salsberg, Wing, Langelier, et al., 2002; Stone, 2001). Perhaps most germane is the recognition that for many severely disabled individuals, home care is not a cost-effective substitute for facility care unless paid home care is provided as a supplement to unpaid family care. The evidence on which program administrators and recipient advocates base their arguments in favor of permitting legally responsible family members to become paid workers is, other than in the Cash and Counseling Demonstration, largely anecdotal.5 Thus, further examination of these issues may be helpful for policy makers.

This analysis is interested in understanding who the IHSS Plus Waiver provisions serve, and in evaluating program and recipient outcomes. Outcomes are represented by IHSS, Medicaid service use and expenditures by IHSS recipients. The following questions are examined:6

  • Do IHSS Plus Waiver recipients (e.g., Parent, 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.

  1. The federally funded Cash and Counseling Demonstration has reported positive experience from the Florida program which allows payments to parents of minors in the consumer-directed program for children with developmental disabilities. Reports from the demonstration are available at

  2. Qualitative interviews explored a number of issues with both waiver and non-waiver recipients and their families (Newcomer & Scherzer, 2006). Among these were the other caregiving arrangements that had been tried; why they elected (or did not elect) to participate as a paid Parent/Spouse provider; or to accept or not accept the benefits of Advance Pay or Restaurant Meal vouchers; and whether being a paid Parent or Spouse provider affected Medicaid, SSI, or other program eligibility.

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