Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. III. Gatekeeping and Supervision Functions: Eligibility, Needs Assessment, Case-Management, Medical Supervision


A. Eligibility Determination

Adult service workers are responsible for eligibility determination, and eligibility is reassessed every 12 months. If someone has an income greater then 78% of the poverty level (the Michigan income eligibility level) then s/he has the option to spend down to the Medicaid income level on a month to month basis, based on a six month projection of the individual's income and disability related expenses. The state will pay the portion of PAS expenses after the spend down limit is reached, but the limit is so low that it does little to eliminate work disincentives.

Assets must be less than $2000 for an individual or $3000 for a couple; less home, car, household goods, and life insurance. Income and asset requirements are very strict for couples, and there are cases of people getting divorces in order to be eligible for service. Functional Imitation must also be documented, i.e. need for assistance with ADLs, housekeeping, or chore services.

B. Needs Assessment

A plan of services for each consumer is developed by the adult services worker, and reviewed every 6 months. The DSS has tried to come up with standard time allocations for each PAS task in order to assure uniformity in needs assessment among different counties, but has met stiff resistance from workers, who think that the proposed formulas do not take into account the differing needs and circumstances of consumers. Currently, each county has a different method for assessing the time allocated for different PAS tasks. If there is a dispute over the allotted hours in one county, individuals are asked to keep an actual log of time spent on PAS for a certain period in order to document the actual hours needed.

C. Case Management

Three different state agencies do case management with Medicaid funds, and all can access the HHS program for their clients. However, consumers may receive HHS through the DSS without any case-management after initial eligibility determination and needs assessment. DSS adult services workers are required to have a college degree and to participate in a state case-management training program. The DSS distinguishes a subset of HHS recipients as case-managed, and requires a home visit roughly every two months for these consumers. This service was originally designed for consumers who need a higher level of support, but is now also viewed as a way to leverage federal funding. The DSS bills Medicaid $234 per case management visit, and in the current fiscal crisis considers this an essential source of staffing funds. They have therefore issued a directive that the counties must put at least 25% of their HHS caseload into case-management.

In Kent County, the local office has recently set the following guidelines for who gets on case management: (1) individuals who receive physical disabilities services from DSS, (2) expenditure exceptions who receive more than $333 per month, (3) people who receive more than a certain number of hours per month, (4) all new cases, and (5) people in unstable or failing health. The move to increase case management has caused enormous pressure on service workers. Consumers who were formerly called occasionally now must be visited at home. When a case is opened for case management, the worker must prepare a detailed assessment and a detailed service plan. The paper work is much more cumbersome for such cases.

There has been an ongoing hiring freeze on service workers which has caused the cases per worker to jump in many counties. In one county, there are now 125 cases per worker. The hiring freeze also means that when a worker leaves a position, his/her cases are given to remaining staff. This has led to greater tension among workers. With the increased pressures, service workers and advocates are concerned that client needs are being ignored for the sake of expediency. For example, HHS exceptions for services above the $333 cap require a great deal of additional documentation and time. Workers may decide they simply don't have time to do the extra work.

The Area Agencies on Aging (AAAs) will become involved in case management if they are the point of entry for services. The AAAs use RNs for case management. If the individual is determined not to need such intensive ongoing services (i.e. are not at risk for nursing home placement) and qualifies for Medicaid, then case management responsibility is transferred to DSS.

D. Medical Supervision

The needs assessment completed by the service worker is mailed to the applicant's physician. Services may begin as soon as Adult Services determines eligibility, but a physician's certificate of need must be received within 60 days of the start of services. The authorization is good indefinitely, unless the physician specifies a time limit. A state RN reviews all case documentation annually.

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