January 28, 2011
MEDICAID ABI WAIVER PROGRAM
By: Robin K. Cohen, Principal Analyst
You asked for information about the state's Medicaid Acquired Brain Injury (ABI) waiver program. Specifically, you want to know (1) how the program works, including the average amount of time a program participant receives waiver services and whether program eligibility depends on the severity of the person's brain injury; (2) if the program has a waiting list; how long the list is; and how long, on average, someone remains on it; and (3) if someone “transitioning” from a nursing home into the community under the federal Money Follows the Person (MFP) demonstration program would be given priority over someone on the waiting list who is not in a nursing home.
Since 1999, the Department of Social Services (DSS) has offered home- and community-based services to individuals with acquired brain injuries through the ABI waiver program. This program is available to individuals with relatively low incomes who, without its services, would have to be institutionalized. The services a participant receives are based on a plan that he or she helps design.
The program offers 18 services, including personal care assistance and homemakers. A contracted entity, Allied Community Resources, helps clients manage the financial aspect of hiring a personal care assistant and other direct care providers.
The ABI program's manager, Dorian Long, was unable to tell us how long the average waiver participant receives services but she indicated that on average, one to two slots open up each month.
To qualify, individuals must meet several eligibility criteria, such as (1) being between age 18 and 64, (2) having a brain injury that is not the result of a developmental or degenerative condition, and (3) passing a financial eligibility test.
In order to meet a federal requirement that the services be no more costly than they would be if a participant were institutionalized, the program limits a participant's service costs. In the aggregate, these costs may not exceed 75% of what it would cost the state if this person were in an institution, but on an individualized basis, the state can spend up to 200% of that amount. The severity of someone's brain injury could potentially make someone ineligible for waiver services but to date, no one has been turned away for this reason, according to Long.
Because the program is operated under a Medicaid home- and community-based services (HCBS) waiver, in which the federal government typically authorizes a set number of slots (DSS has approval for 369 slots, all of which are filled) it is not available to anyone who might be eligible for it. Because of this limit, DSS began to institute a waiting list in 2008 and 50 people presently are waiting for services. The average wait on the list is two years.
The MFP program is a federal demonstration program designed to help states further rebalance their long-term care systems so that more individuals can be served in their homes and communities rather than institutions. For the first year someone is in the program, a federal block grant pays for most of the service costs, including providing states a higher Medicaid match for Medicaid services that participants receive. For someone with an ABI, this includes services that a program like the ABI waiver provides. Once the year is up, clients continue to get services but from the regular waiver programs. In October 2010, DSS amended its ABI waiver to reserve 35 additional slots to serve MFP clients after their first year in that program.
ABI WAIVER PROGRAM
Since 1999, DSS has run the ABI waiver program. It is called a waiver program because it is authorized by federal Medicaid law's 1915(c) home- and community-based services waiver.
The state's ABI waiver program offers the following services:
1. personal care assistance,
3. environmental accessibility adaptations,
5. case management,
6. respite care
7. pre-vocational services,
8. supported employment,
9. vehicle modifications,
10. independent living skill training,
12. specialized medical equipment and supplies,
13. personal emergency response system,
15. cognitive and behavioral programs,
16. home delivered meals,
17. community living support systems, and
18. substance abuse programs.
To qualify for the ABI waiver program, an applicant's income cannot exceed 300% of the monthly maximum federal Supplemental Security Income (SSI) benefit, which is currently $2,022 per month. Assets are limited to $1,600 for a single person. For married couples, a certain amount of assets over $1,600 may be protected for the spouse while he or she lives in the community.
Individuals who qualify for the Medicaid for Employed Disabled program, whose financial eligibility criteria are significantly higher than for the waiver program, can also receive waiver services if they are otherwise eligible.
Care Cost Limits
In order to keep the program's costs at a level that will meet federal cost neutrality requirements, the program sets annual caps on the amount that can be spent based on the level of institutional care the program participant would otherwise need. In general, the aggregate cost cap is 75% of the level of care cost in an institution. These are shown in Table 1.
TABLE 1: AGGREGATE COST CAPS IN ABI WAIVER PROGRAM
Annual Cost Cap
Level I (nursing facility (NF)
Level II (ABI/NF)
Level III (ICF/MR)
Level IV (Chronic Disease Hospital)
Although the aggregate cap is 75% of the institutional cost, an individual's care plan can be as high as 200% of the institutional cost.
Developing a Service Plan
Eligible individuals work with a DSS social worker and a “person-centered team” to develop a service plan that includes services that the client will need to live in the community and avoid institutionalization or re-institutionalization.
Client as Employer
Under the program, the client is the employer of all of his or her service providers. As an employer, clients must hire, pay wages, and fire the providers, including deducting taxes and unemployment benefits. DSS contracts with a community provider, Allied Community Resources, to help waiver participants carry out these financial functions.
The number of ABI participants has grown from under 50 in 1999 to 369 today. In 2008, DSS was forced to institute a waiting list in the program due to growing enrollment and a limit on the amount of waiver slots. Currently, 50 people are on the waiting list, with an average wait of two years. Slots are filled on a first-come, first-served basis. Someone who has been on the list since March 2008 was just moved onto the program, according to DSS' Long.
The MFP program is a federal demonstration program designed to help states rebalance their long-term care systems to better support people living in institutions who would prefer to live in the community. It is intended to serve elderly people and others with mental illness and developmental disabilities. As of May 2010, Connecticut was one of 29 states (and the District of Columbia) participating in the demonstration.
DSS began implementing MFP in December 2008. To be eligible, a person must (1) have been institutionalized for at least 90 days and (2) meet Medicaid eligibility criteria. Additionally, it cannot cost more to care for the person in the community than in an institution. After someone qualifies for MFP, DSS assesses the person's service needs, develops his or her care plan, and helps the person find housing and services. (See OLR Report 2010-R-0209 for additional information about Connecticut's program.)
The state is eligible for an enhanced federal Medicaid match (75% instead of 50%) for the first year that MFP participants receive services.
MFP and the ABI Waiver. The success of the MFP program is dependent on the continuing availability of community-based services once the first year is up. Hence, the state's Medicaid HCBS waiver programs, including the ABI waiver, need to be available to ensure (1) the continuity of care for MFP participants and (2) that clients do not have to be re-institutionalized because these services are not available. The state's MFP protocol that DSS submitted to the federal government contained assurances that its waiver programs would be amended to reserve slots needed for this purpose.
In October 2010, DSS asked the Human Services and Appropriations committees to approve an amendment to the ABI waiver. The amendment asked the federal Medicaid agency, retroactive to January 1, 2010, to (1) increase the total number of slots from 369 to 404 and (2) allow these 35 to be reserved for people transitioning off the demonstration grant-funded portion of MFP. The committees unanimously approved the amendment, although many members were absent.
The first 10 of the 35 reserved slots will be for those individuals transitioning off the demonstrations between January 1, 2010 and December 31, 2011, according to ABI program manager Long.