long-term care - Legislative Reference Bureau

CONCEPT OF A SINGLE ENTRY POINT
eligibility for the elderly long term care population. Ultimately, Oregon was
allowed to create a single entry point, but had to agree to a state level paper review
of eligibility decisions conducted retroactively.
However, it is not always easy to combine both financial and functional eligibility
determinationwithin one access system. It was found that: 81
Medicaid financial eligibility determination seems to be the function which is the
most difficult to integrate with other access activities. . .. In states with mUltiple
entry points, [attempts to maximize the use of state funds by trying to obtain
Medicaid payment when clients appear to be Medicaid-eligible] means that clients
must be referred by the case manager to another agency for Medicaid eligibility
determination. . . . Depending on the complexity of the eligibility process,
significant amounts of a case manager's time can be expended on this task [of
assisting older people to complete the required paperwork for Medicaid
enrollment]. . .. Older people themselves are the most negatively affected by these
multiple referrals in most of the study states. Elderly long term care clients have
... limited capacities to maneuver through the process.
Service Authorization -- Advocacy and Cost Control: The six state community care
systems reviewed in Justice, et al. place the power to authorize services within the local
agency performing the entry process tasks of screening, assessment, and case
management. 82 Because the assessment process leads to service authorization, the study
states have consciously placed this function in agencies that do not directly provide publicly
financed long term care services. In four of the six states, assessments are performed by the
same agency (and sometimes by the same staff) that provide ongoing case management. 83
Being empowered to authorize services, case managers doubling as assessment staff
reduce necessary bureaucracy and also directly affect program costs and service utilization: 84
In managed systems of care financed by state resources and state administered
federal funds such as Medicaid. state government can designate case management
agencies to act as agents of the state in authorizing needed services. Without an
explicit delegation of this authority case management agencies can help older
. people locate services but cannot directly allocate public resources to individual care
plans.
However, service authorization is almost always separated from actual service
delivery. This helps to avoid conflicts of interest where case managers are also capable of
providing direct services for clients they haye assessed. This separation also serves a cost
containment function by requiring case managers to act as gatekeepers to control service
utilization. At the same time, case managers (and assessment staff) can continue to fulfill an
advocacy role by managing and coordinating needed long-term care services for their clients.
However, it is the former function of cost containment that is in the ascendancy. This
is so because more and more community long-term care is being offered under Medicaid
waivers .. Medicaid waiver policy specifies that community care services for program clientele
can be no more costly than nursing care. Besides limiting the average cost per case, some
waiver programs also place a ceiling on expenditures for individual care plans. Such limits
have also been adopted for some state-funded care programs. 85 In some cases, these
waiver ceilings have been placed at some lower proportion of nursing home care. For
example, Maine had at one time limited per case expenditures to 75 percent of nursing home
costs. Arkansas had set the dollar cap at an amount equal to 80 percent of nursing home
care. Wisconsin does not impose a ceiling on the cost of services by "requires within each
county that on the average, program expenditures per client not exceed the state share of
26