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Medicaid Coverage of Home and Community Services: Overview 15instead of securing a waiver). 50 (See Chapter 4 forfurther discussion.)Given the expressed statutory purpose of the benefit—toassist individuals to obtain services from awide variety of public and private programs—thescope of services a state may furnish through thetargeted case management option is relativelybroad. Covered activities include assistance inobtaining food stamps, energy assistance, emergencyhousing, or legal services. Covered activitiesalso include service/support planning (includingassessment) and monitoring delivery ofthe services and supports in order to ensure theyare meeting a beneficiary’s needs.Financial Protections for Spouses Living inthe CommunityThe Medicare Catastrophic Coverage Act of 1988established special financial eligibility rules forinstitutionalized persons, to allow a spouse whoremained in the community to retain more assetsand income than had previously been allowedunder Medicaid’s financial eligibility rules. Thefigures for retainable resources are adjusted annuallyto reflect increases in the Consumer PriceIndex. 51 The purpose of these rules is to preventimpoverishment of the spouse who is not institutionalized.States have the option to extend theserules to the spouses of beneficiaries receivinghome and community services and also to followthe minimum maintenance allowance rules mandatedfor spouses of nursing home residents. (SeeChapter 2 for a detailed discussion of these andother financial eligibility provisions.)Program of All-Inclusive Care for theElderly (PACE)The Balanced Budget Act of 1997 (BBA) establishedthe Program of All-inclusive Care for theElderly (PACE) model of care as a permanentprovider entity within the Medicare/Medicaidprograms. 52 This provision enables states to providePACE services to Medicaid beneficiaries as astate option, rather than as a demonstration aswas formerly the case. The number of new PACEsites that can be established nationwide is limitedto 80. The typical PACE program serves fewerthan 300 individuals. PACE programs are fundedby both the Medicare and Medicaid programs,and participants are generally eligible for both.PACE programs provide and manage all health,medical, and social services, and arrange otherservices as needed to provide preventive, rehabilitative,curative, and supportive care.The PACE approach provides an alternative toinstitutional care for persons age 55 and over whorequire a nursing facility level of care. Services areprovided in adult day health centers, homes, hospitals,and nursing homes. PACE providersreceive payment only through the PACE capitationrate and are responsible for provision of allitems and services covered under both Medicareand Medicaid. The individuals enrolled in PACEreceive benefits solely through the PACE program.* * *This brief overview of Medicaid’s statutory, regulatory,and policy provisions related to home andcommunity services for people with disabilitiesprovides a context for more detailed discussionsin the chapters to come. Some of the institutionalbias that remains in the program can be changedonly by congressional amendment of Medicaidlaw (e.g., the requirement that a person must meetan institutional level-of-care standard to receiveHCBS waiver services). But numerous provisionsgive state policymakers considerable freedom indesigning their home and community service systemto fit their state’s particular needs. They havethe option, in particular, to eliminate use of morerestrictive financial criteria for HCBS waiver servicesthan for institutional care. They also have considerableflexibility to create consumer-responsivesystems that facilitate home and community living.(See Chapter 7.)In the next several decades, as already noted, theU.S. population will age dramatically. Between1987 and 1996, for example, the proportion ofnursing home residents who were 85 and overrose from 49 to 56 percent for women, and from 29to 33 percent for men. The severity of disabilityamong the nursing home population has alsobeen increasing. Almost 83 percent of nursinghome residents in 1996 needed help with three or
16 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERmore ADLs, for example, compared with 72 percentof residents in 1987. 53 Even if disability ratesamong older persons decline, more people willneed long-term care services than at any othertime in our nation’s history.Institutional care is costly. Given the projecteddemand for long-term care services, it is advisablefor states to start planning now to create comprehensivelong-term care systems that will enablepeople with disabilities—whatever their age orcondition—to live in the community rather thanrely on institutional residence and services. TheMedicaid program can be the centerpiece of sucha system—allowing states numerous options toprovide home and community services that keepcosts under control at the same time as theyenable people with disabilities to retain their independenceand their dignity.Endnotes1. The primary contributors to this chapter are GarySmith and Janet O’Keeffe. In addition to the sourcesnoted in the citations, a major source of information forthis chapter is the Medicaid source book: Background dataand analysis (1993). Washington, DC: U.S. GovernmentPrinting Office.2. The Federal government’s share of medical assistanceexpenditures under each state’s Medicaid program,known as the Federal Medical Assistance Percentage(FMAP), is determined annually by a formulathat compares the state’s average per capita incomelevel with the national average. States with higher percapita incomes are reimbursed smaller shares of theircosts. By law, FMAP cannot be lower than 50 percent orhigher than 83 percent. In 1997, the average FMAP was57.0 percent. States are also reimbursed for 50 percentof administrative costs. Congressional ResearchService. (1993). Medicaid source book: Background data andanalysis (a 1993 update) (p.5). Washington, DC: U.S.Government Printing Office.3. Congressional Research Service. (1993). Medicaidsource book: Background data and analysis (a 1993 update)(p.267). Washington, DC: U.S. Government PrintingOffice.4. Data on long term services are from Burwell, B.(April 25, 2000). Memorandum: Medicaid long-termcare expenditures in FY 1999. Cambridge: The MED-STAT Group.5. Ibid.6. Ibid.7. Prouty, R., and Lakin, K.C. (Eds.). (May 2000).Residential services for persons with developmental disabilities:Status and trends through 1999. Minneapolis:University of Minnesota, Research and Training Center onCommunity Living, Institute on Community Integration.(Study underwritten by the Administration on DevelopmentalDisabilities and the Health Care FinancingAdministration).8. Data compiled by John Drabek, Office of the AssistantSecretary for Planning and Evaluation from datacollected by HCFA’s Office of Financial Management.9. Kane, R.L., Kane, R., Ladd, R.C., and Nielsen Vealie,W. (1998). Variation in state spending for long-termcare: Factors associated with more balanced systems.Journal of Health Politics, Policy and Law 23(2): 363–390.10. Section 1902(a)(10)(d) of the Social Security Act.Because state plan coverage of nursing facility servicesis mandatory for categorically eligible persons age 21and older, home health services are mandatory for thispopulation. If a state chooses to cover nursing facilitycare for younger persons, or for the medically needy,home health services become mandatory for thesegroups as well.11. 42CFR 441.15 (c).12. Medicaid Assistance Manual. 5.50.1 1977.13. 42 CFR 440.70 (b).14. 42 CFR 440.230(d).15. 42 CFR 440.230(b).16. Health Care Financing Administration. (September4, 1998). Letter to State Medicaid Directors. (Availableat www.hcfa.gov/Medicaid.)17. Skubel v. Fuoroli. (No. 96-6201). United States Courtof Appeals, Second Circuit. Decided May 13, 1997.18. Social Security Amendments of 1965 (P.L. 89-97).19. Social Security Amendments of 1967 (P.L. 90-248).20. P.L. 90-248 effective July, 1970.21. Act of December 14, 1971 (P.L. 92-223).22. Social Security Amendments of 1972 (P.L. 92-603).23. Section 1619 P.L. 96-265 of the Social Security Act .24. Omnibus Budget Reconciliation Act of 1981 (OBRA81, P.L. 97-35).25. P.L. 103-66. Section 13601 (a1/5)8. Section 134 of theTax Equity and Fiscal Responsibility Act (TEFRA) con-
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