Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. VI. Attendant Issues: Family Providers, Wages, Benefits, Withholding


A. Family Provider Regulations

Family members are not allowed to become providers. Family is broadly defined as spouse, parent child, stepparent, stepchild, aunts, uncles, cousins, nieces, nephews, in-laws. Grandparents apparently can become providers. Several nurse case monitors inter-viewed said that a relaxation of these rules would increase quality of services and make recruitment easier.

B. Attendant Wages

Roughly 90% of program expenditures go to provider wages. The program pays independent providers a daily rate of $ 1 0 for level I recipients, $20 for level II recipients, or $25 for level III recipients. The state limits the amount of recipients that can be served by a single provider. The provider is allowed work for up to four level I clients at the same time, or two level I and one level II client. They can also work for two level II clients, or one level II and one level III client, if both clients share a single residence.

The low pay makes it very difficult to hire and keep high quality attendants. According to advocates, many consumers recognize the pay is unreasonable, so they are more tolerant of fraud and abuse. One consumer reports giving medication for the attendant to sell in order to supplement his wages. Adding to the low pay problem is the delay of 4 to 6 weeks between submission of an invoice and payment. This delay is a source of frustration for attendants and case monitors. Attendants monitored by local health department nurses are able to get paid sooner, because the health department advances payment while waiting for state reimbursement.

C. Attendant Benefits

No benefits are provided by the state.

D. Withholding and Liability Issues

The attendant is considered self-employed, and this is stated in the hiring contract. The DHMH sends out 1099 forms which go to the attendant, who is responsible for withholding. Several causes have been brought by providers which tried to establish the state as the employer and responsible for worker's compensation, but they were not successful. The daily pay rate is offered as evidence that the attendant is not a regular state employee, but an independent contractor. Concern over liability has deterred the DHMH from switching to an hourly rate.

The state has never been sued for negligence. A case monitor was sued because the provider failed to follow the plan of care, but the case was settled out of court. The DHMH is concerned with potential liability in assistance with medications, and is considering dropping this task from the list of allowed services.

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