Location:
HOME CARE SERVICES; NURSING HOMES; WELFARE - MEDICAL ASSISTANCE (MEDICAID);
Scope:
Connecticut laws/regulations; Background;

OLR Research Report


March 15, 2011

 

2011-R-0133

LONG-TERM CARE--MEDICAID SPOUSAL ASSETS AND HOME-AND COMMUNITY-BASED SERVICES

By: Robin K. Cohen, Principal Analyst

You asked which states count spousal assets of Medicaid long-term care applicants the same way Connecticut does, that is, which ones allow the community spouse to keep up to the maximum allowed by federal law. For these states, you also want to know (1) the percentage of Medicaid funds spent on elderly home- and community-based services (HCBS) versus institutional care and (2) what types of HCBS they offer to this population.

We are still awaiting information from the federal Centers for Medicare and Medicaid Services (CMS) regarding additional states that treat spousal assets as Connecticut does. We will update this report when we receive it.

SUMMARY

The Medicaid community spouse protected amount (CSPA) law allows the spouse of someone living in a long-term care institution (e.g., nursing home) to keep some of the couple's assets to ensure the spouse living in the community does not become impoverished. Most of the remainder is used to pay for nursing home costs of the institutionalized spouse. Once the institutionalized spouse begins a continuous nursing home stay, federal law requires the couple's assets to be combined and divided in half. The amount the community spouse can keep (spousal share) can currently be as much as the federal maximum, $109,560. PA 10-73 adopted the federal maximum for Connecticut residents.

According to CMS, Connecticut and nine other states (Alaska, California, Colorado, Hawaii, Idaho, Iowa, Maine, Vermont, and Wyoming) allow the community spouse to keep up to $109,560. All but one appear to be spending a greater share of their Medicaid long-term care dollars on HCBS than Connecticut does. (To date, we have not been able to find a source that separates the elderly from others who are eligible for HCBS, such as younger adults with disabilities.)

Both here and in these states, the HCBS provided to seniors generally are offered through a Medicaid Section 1915c waiver, and some may also provide state-funded services. The HCBS vary from state to state and include personal care, respite, adult day care, and personal emergency response.

MEDICAID SPENDING ON HCBS IN STATES WITH MAXIMUM CSPA RULES

Table 1 (1) lists the states that we know allow the community spouse to keep up to the maximum federal CSPA and (2) indicates how they distribute their Medicaid long-term care expenditures between HCBS and institutional care.

Table 1: Distribution of Medicaid Spending on Long-Term Care (Fy 2009)

State/Percentage Spent on Long-Term Care

Institutional Care*

HCBS**

Connecticut1

54.5

45.5

Alaska

30.4

69.6

California

45.8

54.2

Colorado

43.9

56.1

Hawaii

39.9

60.1

Idaho

53.8

46.2

Iowa

60.3

39.7

Maine

47.7

52.3

Vermont

30.5

69.5

Wyoming

49.2

50.8

Source: Kaiser Family Foundation

*Includes nursing homes, mental health facilities, and intermediate care facilities for people with mental retardation

** May include standard home health services, personal care, targeted case management, hospice, and home- and community based care for functionally disabled elderly and services provided under HCBS waivers

1 The Connecticut Commission on Aging reports a different expenditure ratio, which is based on information from the Connecticut Long Term Care Plan. Those percentages for FY 09 are 65% for institutional care and 35% for HCBS. (The ratio for Medicaid clients was 47% for institutional care and 53% for HCBS.) We believe that most of the difference can be explained by the following, provided by the state's Office of Policy and Management:

n Different time frame: Kaiser uses the federal fiscal year and the CT LTC Plan uses the state fiscal year.

n Institutional Care:  Kaiser includes mental health facilities, which are not included in the CT LTC Plan.  Chronic disease hospitals are only included in the CT LTC Plan.

n Community –based Care:  Kaiser uses standard "Home Health Services", "Personal Care", "Targeted Case Management", "Hospice", "Home and Community-Based Care" for the functionally disabled elderly, and services provided under "Home and Community-Based" services waivers.  In contrast, the CT LTC Plan uses home health care, elder waiver, PCA waiver, Katie Beckett waiver, ABI waiver, Comprehensive DDS waiver and targeted care management (mental health and developmental disabilities).  Also note that in the CT LTC Plan the home health care expenditures are based on an estimate of the percentage of Medicaid expenditures for LTC home health care as opposed to short-term care, such as post-natal care.  It is estimated that LTC home health care services comprise 60% of the total Medicaid home health care costs.

HCBS IN THESE STATES

All states but Hawaii offer HCBS through a Medicaid 1915c HCBS waiver, which allows them to disregard some Medicaid rules (e.g., cap enrollment) if their program is cost neutral. Hawaii incorporated its 1915c waiver into a larger Medicaid Section 1115 waiver.

Connecticut also offers state-funded HCBS and we assume at least some of the other states do the same.

Table 2 lists seven of the states' Medicaid 1915c waiver services. We were unable to find Hawaii's.

Table 2: HCBS for Seniors Available Through Medicaid Waivers1

State /

Service

Case/care management or coordination

Personal Care

Respite

Companion

Adult Day care

Home / Environmental Modifications

Personal Emergency Response

Other 2

CT

X

X

X

X

X

X

X

AL, AS, CH, HOM, MH,N, TR

AK

X

 

X

 

X

X

 

CH, ME, N PDN, RSL TR

CA

X

X

X

 

X

   

C,H, HOU, N, PR, SU, TR

CO

 

X

X

 

X

X

X

AT, HOM, TR, CTS, IHS, MR

ID

X

 

X

X

X

X

X

AT, B, CH,H, HOM, ME, N,PC, PDN, RSL, TR

IA

X

X

X

X

X

X

X

AS, AT, CH, HOM, HH, N, PDN, TR

ME

X

X

X

 

X

X

X

HH, HOM, TR

VT

X

X

X

X

X

X

X

 

WY

X

X

X

 

X

 

X

HDM, N, TR

Source: CMS , “Medicaid Waivers and Demonstrations List;” state website

1 Some of these states have combined waivers serving both elders and disabled. Not all services listed may be appropriate for one group or the other.

2 Key to Other Services

AL=assisted living

AS=assistive devices

AT=attendant care (it is unclear how this differs from personal care)

B=behavior consultation/crisis management

C=communication

CH=chores

CTS=community transition services

H=habilitation

HH=home health

HOM-homemaker

HOU-housing assistance

IHS-in-home support

ME-specialized medical equipment and supplies

MH=mental health counseling

MR=medication reminder

N-nutrition (includes home delivered meals)

PC=psychiatric consultation

PDN=private duty nursing

PR=protective services

RSL=residential supported living

SE—supported employment

SU—supplemental services (e.g., professional care, protective supervision)

TR=transportation

RC: ek