You asked which states count spousal assets of Medicaid long-term care applicants the same way Connecticut does (i.e., which ones allow a 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.

This report updates OLR Report 2011-R-0133, which indicated that eight states and Connecticut allowed a community spouse to keep the maximum amount of assets.

SUMMARY

Federal Medicaid law (42 USC § 1396r-5(f)(2)) 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. The amount retained by the non-institutionalized spouse is generally referred to as the community spouse protected amount (CSPA). Most of the remainder of the couple's assets 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 the Centers for Medicare and Medicaid Services, 19 states, including Connecticut, and the District of Columbia (D.C.) allow a community spouse to keep up to the maximum federal CSPA. The states are Alaska, Arkansas, California, Colorado, Connecticut, Florida, Hawaii, Idaho, Iowa, Louisiana, Maine, Mississippi, New Mexico, Oklahoma, Pennsylvania, Tennessee, Texas, Vermont, and Wyoming.

In FY 09, eight of the above states and D.C. spent a greater portion of their Medicaid long-term care funds on institutional care than Connecticut, which spent approximately 55%, according to the Kaiser Family Foundation's website. The states include Arkansas (70.3%), Florida (63.6%), Louisiana (61.7%) and Mississippi (85%).

All but two of the 19 states and D.C. appear to offer home- and community-based services (HCBS) through a Medicaid Section 1915(c) waiver. Hawaii offers HCBS through a different Medicaid waiver. The services vary from state to state and include personal care, companions, and personal emergency response.

Table 1 lists all the states that allow the community spouse to keep up to the maximum federal CSPA and (2) indicates how they distributed their Medicaid long-term care expenditures between HCSB and institutional care in FY 09.

Table 1: Distribution of Medicaid Spending On Long-Term Care

(FY 09)

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:

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

● 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.

● 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.

It appears that all 19 jurisdictions that allow the maximum CSPA, except Hawaii, Tennessee, and D.C., offer HCBS through a Medicaid 1915(c) waiver. Hawaii incorporated its 1915(c) waiver into a larger Medicaid Section 1115 waiver. We were unable to determine what HCBS Hawaii offers, or whether Tennessee and D.C. offer HCBS using state or local funds.

Table 2 lists the states with Section 1915(c) waivers and the services they offer to their elderly population.

Table 2: HCBS for Seniors Available Through Medicaid Waivers¹

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

AFC=adult foster care

AL=assisted living

ARS=advanced restorative services

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

D=prescribed drugs

DEN=dental services

FAM=family training

H=habilitation

HH=home health

HOM-homemaker

HOS=hospice

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)

OT=occupational therapy

PC=psychiatric consultation

PDCS=participant –directed community supports and services

PDN=private duty nursing

PR=protective services

PT—physical therapy

RT=respiratory therapy

RSL=residential supported living

SE—supported employment

ST=speech therapy

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

TR=transportation

V=vision services

RC:ro