You asked:

1. how Connecticut's Department of Social Services (DSS) calculates the cost caps for its Connecticut Home Care Program for Elders (CHCPE), particularly the Medicaid waiver portion, and whether the caps apply to each individual or to the aggregate group of clients and

2. whether other states allow some individuals to exceed the cost of nursing home care as long as the overall annual aggregate cost for the group does not exceed the cost of nursing home care.

SUMMARY

CHCPE, which has both Medicaid waiver-funded and purely state-funded portions, calculates the monthly cost caps for each individual based on the category for which he qualifies. The only exception to the cap is that each individual can exceed the monthly limit temporarily, for instance, if he needs more help after a hospital stay, but his average costs for the year must remain under the cap. In addition, the aggregate costs for all CHCPE participants must be no more than the nursing home costs that the state would otherwise incur. Federal rules for Medicaid waivers require the aggregate cost for the group to be no more than nursing home costs (known as “cost neutrality”) and leave it to the states to decide whether to apply the cap to each individual.

The program has three categories, based on increasing level of need for help and the funding source. Each has a different cap. Category 1, which is state-funded, caps each person at 25% of the Medicaid weighted nursing home average cost (currently $ 5,150. 46 a month). Category 2, also state-funded, sets this individual cap at 50%. And Category 3, for people who need the most help and would otherwise be nursing home eligible, is Medicaid waiver-funded and sets the cap at 100% of the weighted average. Category 3 also has a 60% cap on related community-based services (only $ 3,685 of the total $ 5,150. 46 can be spent on these services).

Some other Connecticut home care waivers apply aggregate caps and allow individuals to exceed them as long as the group aggregate costs are under the cap.

Other states vary in how they apply cost caps, and caps also can vary among their different Medicaid waivers. We have identified three New England states (Massachusetts, Rhode Island, and Vermont) that apply aggregate, rather than individual, caps in their Medicaid waivers that include elderly home care.

CONNECTICUT

CHCPE Program Cost Caps Apply to Each Individual

CHCPE provides home health care and related community-based services, sometimes referred to as social services, to help people aged 65 or older who meet certain functional and financial standards avoid nursing home placement. The program, however, does not provide for 24-hour care as a nursing home would.

The federal Centers for Medicare and Medicaid Services (CMS) allow states, at their option, to impose per-person cost caps or to use only aggregate cost caps. Connecticut's cap applies to each individual, not the aggregate. The program's Medicaid waiver portion (Category 3), for those who need the most help, has an individual cost cap that allows each person's total monthly costs for medical services, home health care, and community-based services to be as much as the state spends on nursing home care, with one exception (see below). The purely state-funded portion of the program (Categories 1 and 2) has lower monthly caps of 25% or 50% of the Medicaid weighted nursing home average, depending on the individual's need for help. We have enclosed a chart from DSS describing eligibility and care plan limits for all three categories. (Unlike CHCPE, the Acquired Brain Injury Medicaid waiver has only an aggregate cap and the departments of Mental Health and Addiction Services and Mental Retardation use aggregate caps for some of their home care waivers. )

The average Medicaid weighted nursing home cost for 2006 in Connecticut is $ 5,150. 46 a month. It is adjusted annually. This weighted average is what DSS pays to nursing homes under Medicaid minus the residents' average applied income. (Nursing home residents on Medicaid must spend virtually all of their income, except for a small personal allowance, on nursing home costs with Medicaid paying the remainder. )

DSS currently permits no exceptions to its individual cap, except for an option of annualizing the cap so that an individual's specific expenses can exceed it for a short time due to unexpected illness or a temporary downturn (maybe after coming out of the hospital), as long as the person's average expenses for the year do not exceed the cap, according to Kathy Bruni, director of DSS's Alternate Care Unit, which administers the program. In other words, an individual cannot regularly exceed the cost caps during the year.

Statutory Cost Cap for Specific Community-based Services in Medicaid Portion (Category 3)

In addition, CHCPE applies a 60% of average weighted nursing home costs per-person cap ($ 3,665 monthly) for specific community-based services for each person (again expenses can temporarily go over this cap as long as the annual average is below it). The community-based services subject to this limit include, but are not be limited to, the following services to the extent that they are not available under the state Medicaid plan, occupational therapy, homemaker services, companion services, meals on wheels, adult day care, transportation, mental health counseling, care management, elderly foster care, minor home modifications and assisted living services provided in state-funded congregate housing and other state-funded assisted living pilot programs (CGS §§ 17b-342(a), 17b-342(c)).

Statutory Potential Exception to Cost Cap for Extreme Hardship in State-Funded Portion

In addition, for the purely state-funded side of the CHCPE, Connecticut law allows the 50% individual cap to be exceeded, with the commissioner's authorization, in a case of extreme hardship, as determined by the commissioner, but in no case can it regularly cost more than the average weighted cost of nursing home care (CGS § 17b-342(i)). This additional potential exception is not currently being used, according to Bruni. She was not able to provide us with information on whether the exception has been used in the past.

OTHER STATES

Neither CMS nor the National Conference of State Legislatures (NCSL) were able to provide us with comprehensive information on how other states calculate spending caps for their home care programs. We also found no other relevant central sources for this specific information.

But Nancy Grano at CMS' Boston regional office provided information on New England states' Medicaid home care waivers. (Known as 1915(c) waivers, these vary in the populations they cover. Connecticut has a specific waiver for the elderly, but some other states include younger people with disabilities in the same waiver. ) The information comes from a question on the states' waiver application that asks whether the state will refuse to offer services to an individual whose costs exceed nursing home costs.

According to Grano, Massachusetts and Rhode Island checked “no. ” Answering “no” implies they calculate the cap as an aggregate, not on an individual basis. Maine and New Hampshire are more like Connecticut; both answered “yes” to CMS' question indicating that they would refuse services if a person's cost exceeds the nursing home cost (which means an individual cap) on the particular waivers that include the elderly.

Vermont no longer has a 1915 (c) waiver. Instead, it has a more comprehensive 1115 waiver, which covers both acute and long-term care. The long-term care portion, known as Choices for Care, applies to both elderly people and younger people with disabilities. The waiver covers both nursing home and home care services and has an aggregate combined cap for both these services, but no individual caps for home care, according to Adele Edelman, Medicaid waiver manager at Vermont's Department of Disabilities, Aging, and Independent Living.

HN: dw