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


The Department of Health and Mental Hygiene started the Medical Assistance Personal Care program in 1981 in order to curtail nursing home admissions. The program was based on the personal care program in Oklahoma. It paid a flat rate of $9 per day per client, and according to DHMH representatives, was intended to supplement the clients' existing informal support systems (i.e. friends, neighbors). The decision to implement the program was apparently made without extensive planning or consultation with other state departments, and to some degree duplicated the services of another state program, In-Home Aide Services (IHAS), administered by the Department of Human Resources (DHR). In order to justify the new program to the state legislature, the DHMH had to demonstrate that services were not being duplicated. A decision was therefore made to transfer people in the IHAS program who were income eligible into the MAPC program. This had the advantage of accessing uncapped federal matching funds for clients who were until this point served with limited Title XX and state funding.

The assumption that the $9 stipend would go to informal supports was soon disproved a state survey showed the majority of service providers had no personal connection to recipients' prior to their employment. The DHMH had, in the words of one administrator, created "a cottage industry" for PAS providers and nurse case monitors. As the state medical services branch, the DHMH was unprepared for the rush of applicants for the service. It became apparent that the MAPC was filling a vacuum in state services for people with disabilities. Many of these services were traditionally what the state would consider "social services", which the DHMH had no experience or desire to provide. Moreover, the stipend was clearly not sufficient to meet the scope and depth of consumer need.

One suggestion was to bring MAPC in line with the DHR's IHAS program, by creating an hourly wage for attendants. However, the DHMH feared that hourly payments could be a factor in identifying the department as the legal employer for a large and growing number of providers of an entitled service (i.e. Medicaid eligible could not be refused PAS services, so there was no simple way of capping the caseloads).

In order to cope with the extensive needs of some MAPC consumers, the DHMH decided to categorize recipients by three levels of need and offer daily reimbursements based on these levels (a forth level has recently been added for high need people with AIDS, but this has not be utilized as yet). This decision had the advantage of recognizing the different needs of consumers while avoiding an across the board raise to providers. By keeping the daily wage rate structure, the DHMH strengthened its case (should it be challenged), that it is not the attendant's employer. The daily rates remain so low, however, that high need consumers still cannot get adequate PAS.

The MAPC program has continued to grow dramatically; current expenditures are over 400% of what they were in 1984. Ongoing frustration with program inadequacies has led to the formation of a group called Marylanders for Adequate Attendant Care (MAAC). Within the state government,complaints about the MAPC program were the subject of legislative hearings. The Governor's Council on Handicapped Individuals (GOHI) has also examined the issue, but some advocates complain about this group's failure to issue strong policy directives for program reform because of cost considerations.

The state of Maryland faces a large budget deficit, and the growth of Medicaid in general and specifically personal care is viewed with alarm by both the legislature and the governor's office. Directives have been issued by the governor's office to cut expenditures, and DHMH officials anticipated slashing program expenditures by up to 50%. This has led to an extraordinary consumer backlash, led by members of MAAC. They have conducted demonstrations and acts of civil disobedience in order to draw attention the MAPC program.

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