OLR Research Report

February 8, 2000





By: Robin Cohen, Principal Analyst

You asked a series of questions about the CHCPE program. Specifically, you want to know (1) its eligibility requirements, (2) the services it provides, (3) if there is a cap on income and the fiscal implications of removing it, (4) how much Connecticut spends on CHCPE versus nursing home care and how its spending compares to other states with similar programs, and (5) Connecticut's current nursing home and home care census versus other states with similarly sized general populations.

The Office of Fiscal Analysis (OFA) is attempting to determine the fiscal impact of removing the income cap. It is also collecting data on other states' long-term care spending. We are attaching copies of OLR reports 99-R-0805 and 99-R-0891, which include some comparative spending information on Oregon and Vermont.


The CHCPE provides home-and community-based services to people age 65 and over who are institutionalized or at risk of institutionalization whose monthly income is no more than $1,536. The Department of Social Services (DSS) runs the program, which is funded with both state and federal (Medicaid and Social Services Block Grant) dollars. Program eligibility is based on both financial and physical need. State-designated access agencies develop care plans; contract with local care providers; and in most cases, manage client care.

As of December 31, 1999, 10,065 people were receiving services, which represents an 8% increase from the previous December. For FY 1997-98, the average monthly cost for clients in the Medicaid portion of the program was $1,101. For people in the state-funded portion, the average cost was $530. In contrast, the average monthly Medicaid cost for nursing home care was $3,410. (OFA projects that this figure will rise to $3,873 during FY 1999-2000, while average Medicaid CHCPE costs are projected to fall to $947.) The average cost of the home care program dropped from the previous year while the average nursing facility cost rose.

Oregon is clearly ahead of the states that we surveyed in terms of spending on home- and community-based care, at least in its Medicaid waiver program. It is the only state that enrolls more Medicaid-eligible clients in home- and community-based care programs than in nursing homes.



CHCPE offers the following services:

1. adult day health services,

2. adult family living,

3. care management,

4. chore services,

5. companion services,

6. homemaker services

7. home-delivered meals,

8. home health services,

9. laundry,

10. mental health counseling,

11. respite care,

12. personal emergency response system, and

13. transportation.

Care management services are provided by access agencies. It is these agencies that determine what services a client needs and then subcontracts for them with local providers. (They may not provide any direct services other than the care management.) CHCPE supplements and does not supplant existing help. (All available third party payments, such as Medicare, must be exhausted before the program will pay for services.)

Eligibility Categories

The program operates under a three-tiered structure that provides a range of home and community-based services, depending on the applicant's financial and physical dependence. Category 1 provides limited, state-funded home care for moderately frail people who are at risk of hospitalization or short-term nursing home placement. Per-client expenditures must be less than 25% of what it would cost for nursing home care (currently $954 per month). Category 2 services are also state-funded but are for people who need short- or long-term nursing home care. Per client expenditures for these clients must be less than 50% of the nursing home cost (currently $1,908 per month). And Category 3 services are for people who would otherwise be in a nursing home and whose care would be paid by Medicaid. Care costs cannot exceed 100% of the nursing home cost, which is currently $3,815 monthly (this figure differs somewhat from the OFA figure as DSS uses its own models when projecting program activity). (Someone qualifying for Medicaid but needing fewer services than those in Category 3 would have medical services (i.e., home health care) paid by Medicaid and the social services by state appropriations.)

Financial Eligibility

To qualify for any of the categories an individual's income cannot exceed 300% of the federal Supplemental Security Income (SSI) benefit (currently $1,536 per month). Individuals in the state-funded portion of the program whose income is 150% of the federal poverty level (FPL) (currently $1,030 per month) or higher must contribute something toward the cost of their care, based on a sliding fee scale. Clients in the Medicaid portion must contribute once their income, less the cost of medical insurance premiums, reaches 200% of the FPL. (Clients who were previously enrolled in the old Pre-Admission Screening or Promotion of Independent Living programs, which had higher income limits, are also eligible and must contribute more of their income.)

Liquid assets are also capped for eligibility. For an individual applying for Category 1 or 2 the asset limit is $16,824, if single, or $24,228 if married. Single Category 3 applicants may have no more than $1,600. For couples, the limit is $3,200 if both spouses are clients, or $18,424 if only one is a client.

Functional Eligibility

Potential clients can be referred to the program or can directly contact one of the five DSS Alternate Care field offices. These offices must screen the individual to determine whether she is appropriate for the program, including whether she meets the eligibility requirements.

Field clinical staff use a number of criteria when making this determination. They consider the degree of help the person needs with activities of daily living (ADL), such as bathing or dressing, which are measures used in assessing limitations and functional independence. They also look at the degree of help needed with instrumental ADLs, which measure one's ability to perform more complicated tasks, such as managing money and taking medications. In addition, they look at behavior and cognitive impairments, informal support systems available, and financial eligibility. DSS also does a preliminary determination of the category of services in which the applicant would be placed if she were determined to be a good candidate for the program. Then, if appropriate, it refers the applicant to an access agency for a more in-depth assessment, usually within 24 hours.

Access Agencies

Access agencies are creatures of state law and are considered a vital component of the program. When an agency receives a referral from DSS, it must set up an appointment within one working day. The first thing it does is confirm the extent of the client's functional limitations and assess her medical, psychosocial, and economic status. The assessment is completed in a face-to-face interview with the applicant. (The evaluator is not given a copy of the DSS assessment to ensure an objective decision.) The access agency also educates the applicant about the services available, the rights and responsibilities of CHCPE clients, and any fees that might be required. It has seven days to complete the assessment and develop a plan of care.

The care plan is developed with the client and her family or representative. It summarizes all the services a client is receiving, including their frequency and cost. Placement in a program category depends on the applicant's level of functional need and the development of a cost-effective care plan. In most cases, access agencies can modify a care plan's number and frequency of services without DSS approval, as long as the cost limits are maintained.

The access agencies collect the client fees, and DSS reduces its reimbursement to them based on the fees collected.

The Alternate Care field office authorizes services to be provided after it reviews the plan of care to assure its adequacy and that it is within the established financial caps. This usually involves comparing its initial assessment with that of the access agency and the plan of care to make sure that the client's needs will be met.

Occasionally, a client may need care that exceeds the cap amount. The care manager may request an administrative exception, which must be approved by the manager of the Alternate Care Unit. Exceptions are limited to three months, and under no circumstances can the care plan exceed 100% of the average nursing home cost.

Once DSS approves a care plan, the access agency implements it. It arranges for care delivery through subcontracts with providers. Ongoing monitoring of the client is done either by the access agency, or in some cases (currently 4% of the caseload) the client monitors her own care. At the initial assessment the access agency uses a self-directed care check list to determine whether a client can be served without case management services. CHCPE clients are reassessed every two of the first six months that they receive services, and then annually thereafter, to determine whether they still need to have their care managed.


We identified seven states that have general populations (1997 estimates) similar to Connecticut's. Table 1 presents their average monthly enrollment of elderly individuals in Medicaid-funded home- and community-based service programs equivalent to the CHCPE and nursing homes for FY 1997-98. The last column provides trend data.

Table 1. Comparison of Medicaid Home- and Community-Based Services And Enrollment with Nursing Facility (NF) Enrollment


Population (in thousands, 1997 est.)

Ave.Mo. HCBS Enrollment

Ave. Mo. NF Enrollment 1

NF Residents 65+ in 1990








5,906 2

20,007 3












Oklahoma 4



23,428 5




21,104 6



South Carolina





1 Unless otherwise specified, this figure includes a small percentage of younger adults with disabilities.

2 The average number of clients for the entire program (including state-funded portion) during this period was 7,981; as of June 30, 1998, approximately 74% of participants were waiver clients.

3 Projected average for FY 1999-2000.

4 These figures are for FY 1998-99.

5 This represents the total number of Medicaid residents who were served in FY 1997-98.

6 This was as of June 1999.