You asked a series of questions about what we believe is the CHCPE and the ability for certain caregivers to receive reimbursement from the program. We will answer each one separately.

1. Will the CHCPE pay a participant's daughter, who is a registered nurse, $ 15 per hour to care for her?

The CHCPE will compensate a daughter who provides care to her parent, who is participating in the CHCPE, but only in limited circumstances. If the caregiver daughter works for a Medicare- and Medicaid-certified home health agency that provides the care, is qualified to provide the needed care, and the agency agrees to assign her to her parent, DSS will pay the home health care agency, which in turn would pay the caregiver daughter. A Category 2 participant is a very frail elderly person who needs intermediate home care. Included in this care may be the type of assistance the daughter could provide.

The $ 15 per hour cost is close to the $ 21 hourly rate that DSS currently pays home health care agencies to provide home health aide services to CHCPE clients. Typically, the agency pays the caregiver some amount less than this. But in no event can the caregiver's pay exceed the maximum allowable for the participant's category (see below).

If the daughter does not work for a certified home health agency, the only other way she could be reimbursed would be as a personal care assistant (PCA) under the relatively new, state-funded CHCPE PCA pilot program. This program was designed to provide (1) continuity of care to people with disabilities who exceed the maximum age (64) for participating in DSS's existing PCA waiver program and (2) personal care assistance to elderly people eligible for the CHCPE so they might remain in the community and not be institutionalized.

Under the PCA pilot program, the client hires his own PCA, who can be a family member, but not a spouse, conservator, or anyone working for the conservator. The program is meant to help people who need help with at least two of the five activities of daily living (ADL). These include bathing, dressing, feeding, transferring, and bowel and bladder care. And unlike a homemaker-home health aide, PCAs do not have to be trained (although they must be willing to undergo training)(see below). Clients can still access other services, including care management, emergency response system, Meals on Wheels, skilled nursing, adult day care, and skilled chore. DSS will allow payment for a PCA ranging from $ 7 to $ 10 per hour, and a single PCA may not work more than 25. 75 hours per week. (Clients may hire more than one PCA. )

The access agency that coordinates, assesses, and monitors a CHCPE client's care may only determine that the PCA is a viable option for an applicant or active CHCPE client when the person's care manager has not been able to arrange or secure the required home health services. The PCA is not meant to be a substitute for any in-kind or informal support services that the client is already receiving. For example, DSS will not pay a relative to be a PCA who has previously provided informal care free of charge.

2. When this participant moves from Category 2 to Category 3 status, is it true that a family member can no longer be reimbursed for providing the care? If so, what is the rationale?

Without knowing the CHCPE participant's specific circumstances or care needs, it is difficult to answer this question. As we mentioned above, only people in the state-funded PCA pilot can have relatives as caregivers and be reimbursed directly, which could include people at any of the three care levels. Otherwise, payment could come indirectly from a home health care agency.

The only other possible explanations are that (1) the relative caregiver is not qualified to provide the higher level of care the participant requires or (2) the payment for providing the service exceeds the cost cap (currently $ 2,033. 96 per month for category 2 and $ 2,943 per month for category 3).

As mentioned above, DSS has established different cost caps for each CHCPE category. For all three categories, DSS applies the PCA costs to the total allowable CHCPE costs based on the established care plan cap. For Category 3 clients, the total amount allowed depends on the number of ADLs with which the client needs help. To receive the maximum monthly amount, a client must need help with all five ADLs. Here, the PCA services count as part of the total care plan and are counted as medical, not social (for which there is a separate cap), services. So if someone transferred into Category 3, the amount a client could spend on PCA services would be based on his ADL deficiencies and his care plan cost cap.

3. Is it true that the caregiver for someone in Category 3 must be "accredited?" If so, what are the differences between someone who is accredited and someone who is not (e. g. , training, etc. )?

The state would expect any caregiver, except the PCA, to have minimum training, regardless of the care level category. To receive DSS reimbursement, the provider (in this case the home health care agency) would need to be enrolled with DSS as a Medicaid provider. And the agency would need to meet the licensing requirements established in regulation, including assurances that their employee caregivers meet minimum training requirements.

According to Michelle Parsons, program manager for DSS's Alternate Care Unit, a registered nurse could be qualified to provide the less intensive services that a PCA would typically provide. And a home health care agency could employ her as a nurse, home health aide, or nurse's aide.

Home health aides employed by home health care agencies must receive minimum training, as prescribed by state regulations. This includes completion of a training program of at least 75 hours and a competency evaluation. The standard curriculum must include such areas as (1) communication skills; (2) observing, reporting, and documenting patient status and services and care provided; (3) reading and recording patient temperature, pulse, and respiration; (4) basic infection control; (5) appropriate and safe techniques in personal hygiene and grooming, including bathing, shampooing, skin care, toileting, and elimination; and (6) safe transfer techniques and ambulation.

The home health care agency regulations deem nurse's aides who have completed the requisite training and competency evaluation (see below) to have completed the home health aide training. These individuals must still complete a competency evaluation and must be provided with 10 hours of orientation by the agency employing them before they can provide services (Connecticut Agency Regulations, Sec. 19-13-D66, et. seq. ).

Nurse's aides working more than 120 days in a licensed nursing home must complete a 100-hour training program and competency evaluation program. They must also be registered with the Department of Public Health. A minimum of 75 of these hours must cover basic nursing skills, personal care skills, care of cognitively impaired residents, recognition of mental health and social service needs, basic restorative services, and residents' rights. An additional 25 hours of the standard nurse's aide lecture and clinical setting curriculum must include specialized training in understanding and responding to physical, psychiatric, psychosocial, and cognitive disorders.

The regulations likewise allow nurses to be deemed nurse's aides. People who have successfully completed one or more courses comprising at least 100 hours of theoretical and clinical instruction in fundamental nursing skills in a practical nursing or registered nursing education program are considered to have completed a nurse's aide training program (CGS Sec. 20-102aa, et. seq. , and Connecticut Agency Regs. Sec. 19-13-D8(l)).

PCAs need only be (1) 18 years old; (2) able to understand and carry out client directions and the care plan duties, including operating any special equipment; (3) willing to receive training, (4) able to handle emergencies; and (5) able to maintain an effective working relationship with the client.

4. Is there a process by which a registered nurse could become an accredited caregiver, thereby potentially allowing the daughter nurse to continue to provide care at this higher need level?

Assuming the daughter complied with the regulatory requirements described above, she could theoretically provide less skilled services as a home health care agency employee and be reimbursed by that agency, which gets reimbursed by DSS. As a registered nurse, the daughter caregiver is licensed to provide the type of skilled nursing care that a Category 3 client might need.

5. Can someone who might need a higher category of care (Category 3) apply for that level before he actually needs it, thus potentially preventing lapses in service payments? If not, why? How do other states with comparable programs handle early applications for different categories?

According to DSS's Parsons, DSS cannot set a cost cap for CHCPE services at a different care level until someone is determined eligible for Medicaid since DSS will pay only for the services for which the person is currently qualified. But, says Parsons, DSS will approve the provision of additional services to someone in Category 2 if (1) it determines that the client would be facing an imminent health or safety risk without it and (2) the client submits a Medicaid application.

We are still awaiting information on other state's programs. We will get this to you when we receive it.

6. Is cost reimbursement for CHCPE services retroactive? Does this apply to all services or only some (e. g. , home health care), and if only some, why is there no uniformity?

Federal law requires DSS to make a Medicaid applicant's eligibility effective no later than the third month before the month he applies if he (1) received Medicaid-covered services at any time during that period and (2) would have been eligible for Medicaid if he had applied or someone else had applied for him. This means that it will pay for any and all Medicaid-eligible medical costs incurred up to 90 days before the person applied for Medicaid. But DSS will not reimburse someone who has already paid a bill.

In the case of all three CHCPE categories, DSS will go back to the date the access agency assessed the client and pay the family for any unpaid home health care bills accrued from that day forward. Alternatively, the family could ask the home health care agency to reimburse them and the agency could bill DSS directly.

RC: ts