Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. II. Program History


A chore program was started by the DSS in 1972, which evolved into an informal family support program for older people and adults with mental retardation. A stipend of up to $240 per month was given, primarily for family members and friends providing PAS. The program was state and Title XX funded, and there was little formal state policy.

This program grew steadily as more families became aware of the service, but during a budget crisis in 1978, the DSS circulated a proposal to eliminate payment to family providers. The ensuing uproar led to legislative hearings in which advocates and consumers, led by the Association of Retarded Citizens, convinced the state that the program services were important and cost-effective. The funding base was actually increased, and solidified state support for the program. The hearings also brought the Independent Living Centers into the debate, and program regulations began to reflect their philosophy. The state director of DSS became a strong advocate for expansion of community based services to people with disabilities.

As awareness of program services grew, so did expenditures. Title XX funds began to dry up, and the DSS began looking into other sources of federal support. In 1980, after reviewing existing programs in other parts of the country, Michigan decided to add the Personal Care Option to its Medicaid plan.

DSS staff collaborated with the regional HCFA representative to maintain the main features of their existing program, but added a medical supervision component and formalized case management. They were able to get around the exclusion of family providers by defining family in a very narrow way (i.e. spouse or parent of a minor). A fee schedule for people who don't meet Medicaid income eligibility and chore services remained part of the HHS, but these services are funded solely by state dollars. The program remained fairly decentralized in terms of administration.

The service cap has inched toward its current level of $333 per client per month, but this cap is, according to an adult service worker, "program driven, not needs driven." By keeping most payments at $333, the state is not responsible for unemployment benefits. In 1984, formal exceptions to this cap were added to the state policy manual. Roughly 2000 people currently receive "expanded home help", most of whom are considered at risk of institutionalization. Some recipients receive ongoing case-management, including home visits every 2 months.

The state again faces a serious budget deficit, and the DSS is looking for ways to cut Reprogram expenditures. Hiring of new staff has been frozen for some time. They will try to separately identify the cost of chore services and cap or drop them completely. They are also pressuring the counties to increase the number of case-managed recipients, in order to bill Medicaid for a higher number of home visits to further reduce state expenditures.

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