Using Medicaid to Cover Services for Elderly Persons in Residential Care Settings: State Policy Maker and Stakeholder Views in Six States. Waiver Program

The Community Based Alternatives (CBA) waiver program provides home and community services to persons age 21 and older who qualify for nursing facility care. The goal of the CBA waiver program is to provide individuals with meaningful choices regarding long term care services. Waiver funds are used to allow individuals to avoid premature nursing facility placement and to provide current nursing facility residents an opportunity to return to a home or community living arrangement.

The CBA waiver program currently serves 32,793 persons and has more than 39,000 on an interest list. Placement on an interest list means potential clients have declared an interest in a program for which funding is limited, but have not yet been assessed for financial or service eligibility. The list has an attrition rate of a few thousand per month. The waiting period from the time people get on the interest list to receiving services is approximately 10 months. Eligible individuals are enrolled from the CBA waiver interest list on a "first come, first served" basis.

Within the constraints imposed by the cost ceiling on a participant's Individual Service Plan, the waiver program promotes the participant's active involvement and choices regarding the services provided. Participants may choose to live in their own homes or in a residential care setting covered under the waiver: Adult Foster Care homes or Assisted Living/Residential Care facilities. A waiver participant needing nursing care may choose to have that care delivered by a licensed nurse or, in those situations where delegation is appropriate, by an unlicensed person providing services under the direction of a registered nurse.

The majority of services offered under the CBA waiver program are provided by licensed home and community support services agencies. These agencies provide services to participants living in their own homes, adult foster homes, assisted living/residential care facilities (formerly known as personal care facilities), and other locations where services are needed.

As part of its Olmsted initiative, the State has tried to increase the ability of individuals in nursing facilities who could transition into the community to do so through the CBA waiver program. Because there are too few slots in the waiver program relative to demand, the State is using a money follows the person initiative to fund home and community care.

Under Rider 37, when there are insufficient slots or funding in the CBA waiver program, funding follows the individual from the nursing home into the community. The cost of services comes from the nursing home budget instead of the CBA waiver budget. Thus, individuals in nursing homes who are Medicaid eligible can move to the community and receive home or community residential care even when CBA waiver funding is not available.

During a recent twelve-month period, 952 individuals have taken advantage of Rider 37, with about 45 percent transitioning to residential care. Many of those who transitioned were between the ages of age 21 and 64.

The lack of CBA waiver slots can result in a person who spends down in the community having to enter a nursing home for a month in order to apply for funding under Rider 37. The state is grappling with the question of what to do with funds when persons funded through Rider 37 are no longer served. Currently, the money that funded their care is being returned to the nursing home budget.

3. The provisions of Rider 28 were originally contained in Rider 37 in the 76th legislative session. The number was changed during the 78th legislative session.

• Two groups are financially eligible for waiver services:

  • Group A includes individuals who are eligible because they are receiving SSI.

  • Group B includes persons with incomes up to the special income standard of 300 percent of SSI, which is $1656.

• Asset limits for both groups are $2,000 for an individual and $3,000 for a couple.

• The state does not allow spend-down to waiver eligibility levels. For individuals with income that exceeds the institutional limit, federal policy requires the state to allow the use Qualified Income Trusts, known as Miller Trusts, to become eligible for Medicaid.

The state does not require persons in Group B who are receiving waiver services in their own home to share the cost of services.

For people in Group B who are living in residential care settings, the cost sharing amount is equal to the client's remaining income after all allowable expenses have been deducted. These deductions include:

1. the cost of the client's maintenance needs allowance, which is equal to the SSI federal benefit rate of $552 per month. The client keeps $85 as a personal needs allowance and the remainder is used to pay for room and board costs;

2. the cost of the maintenance needs of a spouse if the spouse is the only dependent of the recipient. This amount is equal to the monthly SSI federal benefit rate less the spouse's income;

3. the cost of the maintenance needs of the client's dependent children. This amount is equivalent to the Aid to Families with Dependent Children (AFDC) basic monthly grant for children or a spouse with children, using the recognizable needs amounts in the AFDC Budgetary Allowances Chart;⁴ and

4. the costs incurred for necessary medical or remedial care, which are not covered by Medicare, Medicaid or any other third party insurance, including the cost of health insurance premiums, deductibles and co-insurance.

If any income remains after all these deductions, the cost sharing amount is applied only to the cost of services covered by the waiver program and specified on the client's individual service plan and must not exceed the actual cost of services delivered. Clients must pay the cost sharing amount to the provider contracted to deliver authorized waiver services.

4. Although the AFDC program no longer exists, allowable maintenance costs are still tied to the basic monthly grant when it did exist.

• The state's maximum monthly maintenance needs allowance for the spouse of a waiver client is the monthly SSI limit for an individual. The spouse's income is deducted from the SSI limit and the wavier recipient's income is diverted to make up the difference.

• Resource protection is the same as for the spouses of institutionalized persons. The protected resource amount will be the greater of the following: the state minimum resource standard, which is $18,132; or one-half of the couple's combined countable resources not to exceed the maximum resource standard of $90,660; or the amount transferred to the community spouse under a court order. All assets over this maximum must be spent before Medicaid will begin to pay.

Family payments for an individual's food, clothing, and shelter are considered support and maintenance for waiver clients and a value is assigned. Because support and maintenance are not considered for clients in institutional settings, and institutional and waiver financial eligibility rules are the same, support and maintenance is not considered for waiver clients.⁵

5. "Support and maintenance are not counted as income if eligibility is being tested for a waiver program; for example, Community Living Assistance and Support Services (CLASS), the Community Based Alternatives (CBA), Home and Community-Based Services (HCS), and Medically Dependent Children's Program (MDCP). The 1929(b) program is not a waiver program." Texas Administrative Code, Title 40, Part I, Chapter 15, Subchapter E, Rule 15.455.

To be eligible for waiver services, a person must meet the nursing home level-of-care criteria and several CBA waiver specific criteria. They must:

• choose CBA waiver services in lieu of institutional care based on an informed choice;
• have an individual service plan for waiver services with an estimated annual cost not exceeding 100 percent of the individual's actual Texas Index for Level of Effort (TILE) payment rate;⁶
• have ongoing needs for waiver services whose projected costs indicated on their service plan do not exceed the maximum service ceilings set for the services listed below:
  • Adaptive Aids and Medical Supplies cannot exceed $10,000 per individual per service plan year;
  • Minor Home Modifications service category cannot exceed $7,500.00 per individual;
• receive waiver services within 30 days after waiver eligibility is established;
• reside either in their own home or in a licensed assisted living facility or adult foster care home contracted with the Texas Department of Human Services to provide CBA waiver services.

6. The TILE classification system was developed by the Department of Human Services to group nursing home residents on the basis of their clinical conditions and functional abilities.