By Attorney
Hilary Sohmer Dalin
of Families
USA, Inc.
and
Attorney
Kate McEvoy
of South
Central Connecticut Area Agency on Aging
(revised by Kate McEvoy, August 2005 -- updates shown in red)
==This article was originally published in
the Summer 2002 edition of the
=====
Remaining
in one's own home is the desire of virtually everyone as we age and become
frailer, yet our fragmented long-term care system sometimes makes that goal
hard to achieve. Medicaid and Medicare,
the two major public resources for long-term care reimbursement, do not always
work together as seamlessly as is necessary to support frail elders at
home. Sadly, institutional long-term
care options often seem easier to access than home-based care.
This
article explores Medicare, Medicaid and state coverage for home-based care. Two
other programs of interest to seniors, the state-funded Statewide Respite
Program and the Family Caregiver Support Program, as well as state programs for
the 18-64 age group are also
described. The article also discusses
how advocacy interventions may be used to enable frail elders to obtain care
while remaining in their own homes, thereby avoiding unwanted and often unnecesary long-term institutional placement.
The
following is the article's Table of Contents.
If you wish to skip past the Table of Contents and begin reading, click here.
=================================================================
TABLE OF CONTENTS
1. Medicare
Home Health Coverage
2. Medicaid
(and State-Funded) Home Health Coverage: An Introduction
a. The Connecticut
Home Care Program Services for Elders, Category 3
b. State-Funded
CHCPE (Categories 1 and 2)
c. The
Mandatory Medicaid Home Health Benefit
3. Waiver
Programs for Disabled Individuals 18-64.
a. The Personal Care
Assistance Waiver ("PCA")
b. The Acquired Brain
Injury Waiver ("ABI")
4. Two
More Home Care Programs: Respite for Caregivers
a. The
Statewide Respite Program
b. The
Family Caregiver Support Program
===================================================================
Medicare
home health coverage is Medicare's only true long-term care benefit. With no durational time limit, Medicare
beneficiaries are entitled to receive Medicare home health care for as long as
they meet the coverage criteria.[1]
Moreover,
unlike the Medicare hospital and skilled nursing facility benefits, the
Medicare home health benefit does not impose out-of-pocket cost-sharing such as
a deductible or a co-payment. However,
the coverage criteria are exacting and must be carefully understood.
There
are two substantive coverage criteria:
(1) the beneficiary must be homebound;[2]
and (2) the beneficiary must be in need of a skilled service, consisting of either intermittent skilled
nursing or speech or physical therapy (or occupational therapy to keep services
in place.)[3]
A
Medicare beneficiary must be "confined to home" or homebound in order
to qualify for home health benefits.
Overall, the standard is subjective, with no quantitative test applied
in measuring a beneficiary's homebound status.
In
order to be considered homebound, it must be very difficult for the beneficiary
to leave home due to a medical condition.
Generally, if a beneficiary must use an assistive device, such as a
wheelchair, or requires the assistance of another person to leave home, this
statutory requirement has been satisfied.
The statute also provides that if it is "contra-indicated" to
leave home, a beneficiary is considered homebound, even if the beneficiary has
no physical functional limitations on mobility.
For example, it might be dangerous for a dementia patient to leave home,
due to cognitive impairment caused by dementia.
Non-medical
absences from the home must generally be short and infrequent. (In addition, medical absences, such as to
receive care and treatment not available in the beneficiary's home setting, do
not "count" in determining homebound status.)[4] The Medicare policy expressly recognizes that
an occasional walk around the block or trip to get a haircut do not preclude a
finding that a beneficiary is homebound. [5]
Moreover,
in July 2002, the federal Centers for Medicare and Medicaid Services (CMS)
issued a transmittal with a significant clarification of policy on this
requirement. The transmittal states that
attendance at family gatherings, such as reunions, funerals, graduations and
other unique or infrequent events, should not result in a determination that a
beneficiary has lost homebound status as long as the overall homebound criteria
remain satisfied. Homebound status
should be withheld only if the absences demonstrate that the beneficiary is
able to obtain the care offered by the home health provider outside his or her
home.[6] Further, in a significant statement,
CMS clarified that homebound status should be determined by reviewing the
beneficiary’s functional status “over a period of time.”[7]
b.
The Skilled Care
Requirement
In
order to receive Medicare home health services, a beneficiary must need skilled rehabilitation therapy or skilled nursing care at home.[8] These terms are defined to mean those
services "which require the skills of technical or professional personnel
such as registered nurses, licensed practical nurses, physical therapists, and
occupational therapists."[9]
The
specific skilled rehabilitation services that will trigger eligibility for
services are speech, physical or occupational therapy to renew orders for care.[10]
In
order to be deemed skilled nursing, the nursing care must be "so
inherently complex that it can be safely and effectively performed only by, or
under the supervision of, professional or technical personnel."[11] Skilled nursing care must be ordered and
received on an intermittent basis. This
means that the need for the nursing services must be less than daily.[12] There is an exception to this
"intermittency rule" for short periods of daily skilled nursing,
generally not to exceed 21 days.[13]
Daily care by a nurse may only be
authorized in "exceptional circumstances" that the statute does not
articulate.[14]
Often daily wound care is needed
for longer periods of time than 21 days.
Careful documentation by the visiting nurse and the treating physician
is essential to the continuation of Medicare coverage in such cases.
c. Technical Requirements
Home
health care must be ordered by a physician and provided pursuant to a written
plan of care.[15]
The physician is additionally
required to certify to the patient's homebound status.[16] The physician must review the plan at least
once every 60 days.[17]
d. Advocacy Tips
A
common misunderstanding is that Medicare will not cover home health care for
patients whose condition is chronic and stable.
The applicable regulations are very clear that chronicity
and stability are not determinative factors for Medicare coverage.[18] As long as the coverage criteria are met,
Medicare coverage should continue.
Likewise, beneficiaries are often told that Medicare only covers the
therapy services if improvement in a patient's condition may be
documented. The regulation is quite
clear in its directive that therapy to maintain function is Medicare-covered,
as long as the patient requires skilled interventions and the other coverage
criteria are met.[19]
Recently,
the Centers for Medicare and Medicaid Services clarified that a diagnosis of
dementia should never preclude Medicare coverage for skilled care. Indeed, dementia patients may well have a
greater need for skilled interventions in order to safely and effectively
provide rehabilitation therapy, nursing services and other forms of Medicare
care and treatment. [20]
e. What Does Medicare Home Health
Cover?
For
beneficiaries who meet the coverage criteria, Medicare covers intermittent
nursing and home health aide care.
Nursing services covered by Medicare include
·
observation and assessment of
a patient's changing condition;
·
management of the overall
plan of care, even if each individual component of the plan is unskilled;[21] and
·
nursing education, as in the
case of a newly diagnosed diabetic who needs to learn how to manage the many
aspects of diabetic care and treatment.[22]
Home health aide services primarily
consist of "hands on" personal care services, such as assistance with
dressing, bathing, toileting, and eating, and may include associated light
housekeeping for the patient.[23]
It
is not uncommon for Medicare home care benefits to be denied or threatened with
premature termination. The Center for
Medicare Advocacy remains a reliable source of information and advocacy
(1-800-262-4414). The Center's website
is also an invaluable source of information, at http://www.medicareadvocacy.org/.
Connecticut, like the other states, offers
several Medicaid "waiver" home care programs. These programs waive certain otherwise
mandatory Medicaid statutory provisions in order to offer certain Medicaid
recipients a more extensive array of home-based services than would otherwise
be permitted under Medicaid law. The largest and most well known of these
"waiver" programs is the Connecticut Home Care Program for Elders or
CHCPE, Category 3, for those age 65 and over for whom home care is safe and
cost-effective and who would otherwise require more costly nursing home
placement. Categories 1 and 2 of the
Connecticut Home Care Program for Elders are entirely state-funded and offer
assistance to additional categories of frail elders.[24] The DSS chart showing CHCPE limits is attached. Case management and purchase of services
under the CHCPE are conducted on a regional basis by three "Access
Agencies":
·
1-800-654-2183
· Agency
on Aging of South
1-888-811-1222
· South
Western Connecticut Area Agency on Aging: South Western Region
1-203-333-9288
There is also a mandatory Medicaid home
health benefit, rarely used for older persons, as the CHCPE option generally
offers more extensive services and more liberal eligibility criteria.
Finally, there are two smaller waiver
programs serve special populations under age 65: the "Personal Care
Assistance Waiver" and the "Acquired Brain Injury Waiver."
a. The Connecticut
Home Care Program Services for Elders, Category 3[25]
This
Medicaid "waiver" home care program is often referred to as
"CHCPE". It is available to
frail elders, aged 65 and older, who can be safely supported with care in their
home settings and who, without the services of this program, would need nursing
home placement at a higher cost to Medicaid. CHCPE offers many non-medical
support services that would not generally be covered by Medicaid in the absence
of a waiver home care program. For
example, CHCPE is the only public resource for payment of adult day care. Other
non-medical services offered through CHCPE are case management, homemaker,
companion services, home-delivered meals, chore services, emergency response
systems, respite care, and minor home
modifications.
In
recent legislative sessions, two new options have expanded service delivery
options under the CHCPE. First, a small
state-funded Personal Care Assistance (PCA) pilot program now permits up to 150
individuals statewide who are age 65 or older and meet all of the technical,
functional and financial eligibility requirements of the CHCPE. The PCA waiver allows eligible individuals to
hire a Personal Care Assistant to perform up to 25.75 hours of assistance per
week. The only limitations on hiring of
a Personal Care Assistant is that the individual's spouse, power of attorney or
conservator (and their employees), are not eligible.[26] Individuals must be referred for
consideration for this pilot by the Access Agency through which their services
are received.
The second option permits CHCPE participants
who reside in certain authorized state-funded congregate housing buildings and
state/federally-funded senior housing to elect to receive their CHCPE services
through an on-site assisted living services provider.
CHCPE Category 3 Cost Caps
Unlike similar waiver
programs in other states, Connecticut requires that Access Agency care
management staff, working with clients and/or legally responsible individuals,
establish that the home-based care plan is cost-effective in comparison with
the comparable costs of maintaining the individual in a nursing home. Moreover, several different
cost-effectiveness tests are applied to each client. Generally, the total cost of a recipient's
care plan may not exceed the average Medicaid nursing home facility payment,
$4,135.62 in 2005. Moreover, the cost of the non-medical social
services, such as companion, shopping, housekeeping or adult day care, may not
exceed 60% of the average cost of nursing home care, $3,010.00.
CHCPE Category 3 Eligibility Criteria
All applicants for Category 3 must satisfy
both functional and financial eligibility criteria. Functional eligibility is determined by
reference to a Health Screen, to test whether or not the applicant would
otherwise be in need of nursing home placement. The screening assesses deficits
in ability to self-manage critical need areas (known popularly as
"activities of daily living"), including eating, meal preparation,
medication management, dressing, transferring and ambulating, toileting and bathing. The Department regards difficulties in three
critical need areas as indicative of a need for nursing home placement. Safety factors are also tested by the Health
Screen, which is administered by the Alternate Care Unit of the Department of
Social Services.
Connecticut has adopted the federal option
to use the more favorable financial criteria for long-term care, including both
spousal impoverishment prevention and transfer of assets rules, to determine
financial eligibility. Thus, an
applicant may have up to $1,737.00 (300% of the
SSI payment amount) in income. However,
recipients with higher income than 200% of the federal poverty level, or $1,596.00 per month in 2005, must apply some of their
income, in accordance with a calculation made by the Department of Social
Services Alternate Care Unit, to the cost of their care. "Applied income" is determined
according to a calculation that subtracts the personal needs allowance
(currently, $1,596), the Medicare Part B premium
(currently, $78.20) and monthly medical
insurance costs from gross monthly income.
After an initial calculation, "applied income" will be further
adjusted to account for the applicant's (1) medical expenses; (2) need to
provide support to a related household member; and (3) shelter costs. For married couples, spousal impoverishment
provisions are applicable to Category 3 recipients and the spouse of a
recipient may retain a minimum monthly needs allowance, or "MMNA." ($1,603.75 is the minimum monthly needs allowance,
effective
Like all Medicaid recipients, Category 3
participants are allowed no more than $1,600.00 in assets. Because spousal impoverishment prevention
rules apply, the "healthy spouse" is afforded the asset protections
of a "community spouse" and may retain at least $19,020 in 2005.
Therefore, in total, a couple will be allowed to retain at least $20,620.00 ($1,600 plus
the community spouse protected amount of $19,020.) For further information Paying for Nursing Home Care With Medicaid,
published by the Legal Assistance Resource Center of Connecticut, http://www.larcc.org/,
is a good reference.)
CHCPE Category 3 Application Process
The application process starts with the
submission of a Home Health Request Form, W-1487, to the Department of Social
Services Alternate Care Unit (ACU). Home
Health Request Forms may be obtained directly from the ACU by calling
1-800-445-5394 and choosing Option 4.
The form can be faxed to the ACU, or the information may be called
in. The Alternate Care Unit completes a
functional health screen, and will require submission of a complete Medicaid
application if the applicant appears from the financial screening form to be
eligible. (As explained above, an individual
must be on Medicaid to receive Category 3 services.) If found likely to be
eligible by the Alternate Care Unit, the applicant is then referred to the
regional Access Agency, which performs an in-home assessment to gauge the
individual's needs. If those needs can
be met by the program (e.g. do not exceed permitted care plan cost caps),
Access Agency care management staff develop an individualized plan of care for
each client that is monitored over time.
To receive Category 3 services, all individuals must complete and submit
a Medicaid application. This must be
approved before services are initiated.
The cost cap formulas preclude coverage
for extensive or round-the-clock care.
Such a care plan could never be deemed cost effective. However, family contributions of care or
payment for care may be used to extend the amount of care provided. Moreover,
it is possible to coordinate Medicare home health care with CHCPE home care
services to offer clients more home-based care than either program could offer
without the other. Further, the cost of
Medicare home health care is not included in the CHCPE cost cap formula.
b. State-Funded
CHCPE (Categories 1 and 2)[27]
Categories 1 and 2 of the Connecticut Home
Care Program for Elders are entirely state-funded. Category 1 offers services to individuals who
are at risk of hospitalization or short-term nursing home placement, in that
Category 1 clients must demonstrate one critical need deficit in order to
qualify for assistance. The cost of the care provided may not exceed 25% of the
cost of nursing home placement, or $1,033.90 per month in 2005. Category 2 is designed for those who would
otherwise require nursing home placement, either short-term or long-term. The Category 2 cost cap is 50% of the cost of
nursing home care, or $2,067.81 per month.
There is no income
eligibility limit. However, recipients
with higher income than 200% of the federal poverty level, or in 2005 $1,596.00, must apply some of their income, in
accordance with a calculation made by the Department of Social Services
Alternate Care Unit, to the cost of their care.
The methodology for determining "applied income" of a single
applicant is the same as described above for Category 3 CHCPE.
Asset eligibility is
based upon the minimum figures for married applicants for long-term care
Medicaid. Accordingly, a single applicant
may have up to $19,020 in assets and a couple in
which both spouses require care may retain up to $28,530.00
in assets. Category 1 clients must
demonstrate a critical need for assistance.
Advocacy Tips
While Categories 1 and 2 are not a part of
the federally-funded Medicaid program, those participants who are
Medicaid-eligible, such as through a "surplus income" spend-down, may
receive full Medicaid benefits in addition to their state-funded CHCPE home
care services. The cost of
Medicaid-funded home care services are, however, counted toward the cost cap
for an individual's plan of care.
Note that the mandatory Medicaid home care
benefit may be coordinated with CHCPE services, as may Medicare home health
care benefits. The cost of any
Medicaid-funded home care services such an individual receives are, however,
counted toward the cost cap, as explained above, that limits an individual's
plan of care.
Any Medicaid recipient
(even under age 65) who would otherwise require nursing home placement is
eligible for the home health benefit. As
is the case with CHCPE, it must be determined that care provided at home would
be as safe and cost-effective as care offered in an institutional setting. Cost-effectiveness is calculated by comparing
the cost of the home-based plan of care to the comparable cost of placing the
individual in the applicable institutional long-term care setting, whether it
be a hospital, nursing home or facility for developmental delayed adults
(ICF/MR).
The Medicaid mandatory home health benefit
should cover nursing, physical, speech and occupational therapy as well as home
health aide services. Up to twenty hours
a week of care may be provided upon a physician's orders without the
Department's prior approval. More than
twenty hours a week of service requires prior approval from the Alternate Care
Unit of the Department of Social Services.
While the benefit package of the Medicaid mandatory home health benefits
closely resembles the Medicare home health benefit, Medicaid imposes no
homebound requirement nor does Medicaid impose a skilled service trigger
requirement.
Additional waiver programs have been
established to meet the needs of individuals age 18-64. Both programs are administered by the DSS
Division of Social Work and Prevention Services Disability Services Unit, from
which applications may be obtained. The
direct number for the unit is 1-860-424-5373.
An applicant may have no more than $1,737
per month in income and $1,600 in assets.
For couples, spousal impoverishment prevention provisions apply. Transfer of assets rules are also applicable.
a. The Personal
Care Assistance Waiver ("PCA")[29]
The PCA waiver program serves
A
PCA applicant may have no more than $1,737 in
income and $1,600 in assets. Like the
CHCPE waiver program, spousal impoverishment prevention provisions apply when
the applicant is married. Transfer of
assets rules are also applicable to the PCA waiver.
b. The Acquired
Brain Injury Waiver ("ABI")[30]
4. Two More Home Care Programs: Respite for Caregivers
Two additional programs,
both administered statewide by the Department of Social Services Elderly
Services Division and on a regional basis by the Area Agencies on Aging, seek
to provide respite for those providing care to adults age 60 and over.
This state-funded
initiative provides up to $3,500 in respite services to qualified
individuals. Services are provided
according to an individualized plan of care, and may include adult day care,
home health aide support, homemaker, companion, skilled nursing visits and/or
short-term stays in a nursing or assisted living facility. Respite services may be provided during the
day, or as needed, overnight.
Eligibility for the program is determined
by assessing the health status, income and assets of the care recipient. The care recipient must have been diagnosed
with an irreversible and deteriorating dementia and must have income of no more
than $30,000 and assets of no more than $80,000. Dementias may include, but are not limited
to: Alzheimer's Disease, multi-infarct dementia, Parkinson's Disease with
dementia, Lewy Body dementia, Huntington's Disease,
normal pressure hydrocephalus and Pick's Disease. Individuals who are otherwise
eligible for Medicaid coverage, including coverage through the Connecticut Home
Care Program for Elders, are not eligible for services under this
program. Eligible individuals must pay a
20% co-pay of the cost of each service received under the program. In certain cases, this co-pay can be waived
where a hardship can be demonstrated.
The Family Caregiver Initiative, a new
title of the federal Older Americans Act, provides relief for caregivers of
individuals with at least two or more deficits in Activities of Daily Living or
a cognitive impairment that requires supervision because of health or safety
risks. There are two major components of
the program: Respite Services and Supplemental Services. Respite Services provides up to $3,500 in
services such as adult day care, home health aide support, homemaker,
companion, skilled nursing visits, and/or short-term stays in a nursing or assisted
living facility. Supplemental Services
can include payment for one-time, health-related items or services designed to
"fill the gap". Examples have
included durable medical equipment, medically necessary items, minor home
modifications, transportation, seasonal clothing, emergency items or
services.
Applications
are available through each of the regional Area Agencies on Aging. The statewide access number for the AAA's is
1-800-994-9422. This number
automatically directs the caller to the AAA in greatest geographic
proximity. AAA staff review and approve
applications, and conduct in-home visits to assess the needs of both the
caregiver and care recipient.
With
so many plans, it can be confusing to understand whether and when an individual
may receive services under more than one plan.
Coordination of benefits among CHCPE, mandatory Medicaid home health
benefit, and Medicare home health care, are discussed at the beginning of this
article. Some additional coordination
issues are as follows:
An
individual age 65+ who is an active client of the CHCPE may receive his or her
CHCPE services through the "vehicle" of a personal care attendant -
an option to a traditional care plan where (1) the person has had a PCA
prior to turning 65 and coming onto the CHCPE; or (2) the person is unable to
access adequate home care services in the community; and (3) DSS gives approval
for this "self-directed" option (currently limited to fifty
participants statewide).
An
individual may not qualify for the Statewide Respite Program if he or she is
(1)eligible for or (2) receiving services through Medicaid or CHCPE.
An
individual may qualify for the Family Caregiver Support Program through
the Area Agencies on Aging if he or she is (1) eligible for or (2) receiving services
through Medicaid or CHCPE. Note,
however, that AAA care managers will not duplicate respite-type services
(homemaker, home health aide, adult day care, respite stays in nursing
facilities, etc.) received from either source.
Instead, items (adult diapers, etc.) or otherwise uncovered services
(payment for prescription drugs) might be provided through the
"Supplemental" category.
[1] 42 U.S.C. § 1395f(a)(20(c); 42 C.F.R. § 409. 31 et. seq.
[2] 42 U.S.C. §
1395n(a)(2)(f)
[3] 42 U.S.C.§ 1395f(a)(C)
[4]
[5] Medicare Home Health Agency Manual (HIM
11)
[6] Medicare Home Health Agency Manual
Transmittal 302,
[7]
[8] 42 U.S.C. § 1395f(a)(2)(C)
[9] 42 C.F.R. § 409.44
[10] 42 U.S.C. § 1395f(a)(2(C)
[11] 42 C.F.R. § 409.32
[12] 42 U.S.C. § 1395x(m)
[13]
[14] Id
[15] 42 C.F.R.§ 309.33
[16]
[17]
[18] 42 C.F.R.§ 409.44(c)(3)(iii)
[19] 42 C.F.R. § 409.44(c)(2)(iii)
[20] CMS Program Transmittal AB-01- (September
25, 2001)
[21] 42 C.F.R. §§ 409.32-.33
[22] 42 C.F.R. § 409.33(a)(3)
[23] 42 C.F.R § 409.45
[24] The state-funded program has more limited benefits and does
not include other medical services, such as prescription coverage. Currently (effective January
1, 2005) the maximum expenditure for Category 2A of the state-funded
program is $2,067.81, whereas Category 3, which
has Medicaid funding, may permit expenditures of $4,135.62
($3,010.00 non-health social services cap). These amounts are updated periodically; check http://www.ctelderlaw.org/.
[25]UPM § 2540.92
[26] Specifically, the State "guidelines" (an internal
memorandum) state that a personal care assistant must be (a) at least 18 years
of age; (b) able to understand and physically carry out directions given by the
client; (c) able to physically perform the duties of the plan of care;
(d) willing to receive training in the duties to be performed; (e) able to
handle emergencies; and (f) able to maintain an effective working
relationship with the client. Also,
spouses, conservators, legal representatives and people employed by the
client's conservator are excluded from being PCA's.
[27] UPM
§ 8040.20 et seq.
[28] 42 U.S.C. § 1396d(a)(7)
[29] See C.G.S. §17b-605a for the PCA
waiver. Corresponding Regulations are
final.
[30] See C.G.S. §17b-260a for the ABI
waiver. Corresponding Regulations are
not final.
[31] Conn. Agencies Regs.
§§ 17b-349e-1 through 17b-349e-9
[32] When final, regulations will appear at
Conn. Agencies Regs. §17b-423-8, Title IIIE
"Caregiver Support."