Performance Improvement 2007. How Did Texas Modify Its Medicaid Program In Order to Have "Money Follow the Person" When Nursing Home Residents Chose to Live in the Community?



This study examined the transition process, participant characteristics, and service utilization and costs for a program in Texas that allows institutionalized individuals receiving Medicaid to live in the community. In 2001, the state enacted legislation to promote choice, independence, and community integration for nursing home residents who expressed a desire to live in the community. In part, this was a response to the 1999 Supreme Court finding in Olmstead vs. L.C. that unnecessary segregation of individuals with disabilities in institutions may constitute discrimination based on disability. The state legislation ("Rider 37" and subsequently reauthorized as "Rider 28"), allows Medicaid funds spent for a person living in a nursing facility to be moved to the Texas community-based care budget when an individual elects to move back to the community. Any interested Medicaid nursing facility resident who meets medical and functional eligibility criteria for one of the state's community care waivers is eligible, regardless of his/her length of stay under Medicaid. The study of the first years of this program included qualitative field research and quantitative analysis of state administrative data. The study sought to understand the experience Texas had in implementing this state-initiated effort to rebalance the long-term care system.

 The initiative in Texas demonstrates that a money-follows-the-person component can be incorporated relatively easily into an existing Medicaid long-term care program. This far-reaching change in the state's approach to long-term care was accomplished through authorization of an accounting mechanism allowing funds to be shifted provisionally from the nursing facility component of the Medicaid budget to the community care component. Because community care programs were in place in Texas before this accounting change, the only change "money-follows-the-person" made to the Medicaid long-term care program was, in effect, to identify the nursing facility population as a separate eligibility category for community care programs and to make this eligibility group exempt from any upper limits ("caps") on enrollment in these programs. The comprehensive nature of the waiver benefits package allowed a diverse population of nursing facility residents to move back to residential settings that were more integrated in the community. The accounting provisions later became one component in a comprehensive funding policy, which defined a Medicaid long-term care program and incorporated lessons from the initiative transition process.

In all three regions where the research team conducted site visits state staff caseworkers and social workers at nursing facilities served key roles in identifying clients who were interested in or suitable for transition to the community. Local ombudsmen and advocates for the elderly and disabled were an important additional source of information, In some regions, they advocated for and assisted residents' transitions. As the initiative matured, word of mouth became a source of information for potential clients.

Report Title: Examination of Texas Rider 37: A Medicaid "Money Follows the Person" Long-Term Care Initiative
Agency Sponsor: ASPE, Office of the Assistant Secretary for Planning and Evaluation
Federal Contact: Bergofsky, Linda, 202-690-6443
Performer: Urban Institute; Washington, DC
PIC ID: 8332

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"PerformanceImprovement2007.pdf" (pdf, 717.63Kb)

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