Long-Term Care Planning and Medicaid Home Care
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Medicaid provides long-term services and supports for low-income older adults and people with disabilities. Since the beginning of Medicaid in 1965, most of these services have been provided in institutional settings, but over the past decade a greater emphasis has been placed on rebalancing the system and keeping people in the least restrictive setting, which means the individual’s home or in the community of the individual’s choosing.
To accomplish this, many states are providing more home- and community-based services so that people don't have to go into nursing homes or other facilities, which are generally costly and not the individual's preference.
Medicaid's rules vary by state, and each state sets its own financial threshold for eligibility, which are typically very low income and few or no assets. Federal regulations require all Medicaid programs to provide home health services. Optional services include personal care and even private duty nursing. States can choose which optional services they want to provide.
In addition, states can apply for a variety of waivers from the federal government that allow them to provide a much broader range of medical and nonmedical service. Benefits can include case managements, home care aide services, personal care, adult day health care, and respite care, as well as other services states were not permitted to offer, such as home modification assistance.
The goal of all these programs is to keep people safe and cared-for at home. These waiver programs, plus state funds, come under the general heading of home- and community-based services (HCBS).
States facing severe budget shortages may decide to eliminate optional services or opt out of waiver programs altogether. Agencies may restrict access through their practices of establishing eligibility for Medicaid itself or for specific waiver services. Not all states have agreed to participate in the Affordable Care Act's expansion of Medicaid, which includes financial incentives to expand the Medicaid ranks to include people who were formerly uninsured.
Although the range of HCBS may seem impressive (and in some states actually is), many states have waiting lists. You also may have difficulty finding out about these programs and whether you're eligible for them, and, if so, whether there are any limits on the services. It is at best a patchwork quilt, without strong seams holding the pieces together.
Many states are changing the way they manage Medicaid by turning to Medicaid Managed Long-Term Care plans. Managed care organizations run these plans and are paid to coordinate services and supports. Although considerable potential exists for better integrated care and improved outcomes as well as higher utilization of community-based service options, these plans are still evolving. For more information, see the report by the National Senior Citizens Law Center.
Whether a Medicaid enrollee receives services under the traditional Medicaid system or under a managed Medicaid plan, the person should be given adequate notice of a decision to reduce, deny, or terminate a Medicaid service, as well as an opportunity to appeal that decision. For further assistance with a Medicaid appeal, you can contact your local Legal Services Organization.