July 30, 2008



Legislation Concerning Assisted And Other Managed Residential Living And Home Health Care Since 2005



By: Nicole Dube, Legislative Analyst II



You asked for an update of OLR Report 2007-R-0612, which summarizes legislation enacted since 2005 dealing with assisted living or other managed residential living and home care. This report includes personal care assistant (PCA) legislation, since PCA services are typically provided in the home, but it does not include elderly housing legislation.


Complete summaries of these acts can be found at www.cga.ct.gov/olr/.




Since 2005, the legislature has passed several bills dealing with these topics. Most of them amended existing programs. For example, in each year from 2005 to 2007, the legislature increased the number of slots in the state-funded Personal Care Assistance program. Major legislation included allowing (and subsequently requiring) the Department of Social Services (DSS) to begin a Money Follows the Person Demonstration Program, which allows individuals to leave institutional long-term care and return to their communities, and further regulating assisted living.




Home Care


Personal Care Assistants (PCA). PA 05-209 increased, from 100 to 150, the number of people who could participate in the state-funded PCA pilot program (which, at that time, had not been implemented). Individuals qualify for the program if they (1) are age 65 or older and (2) meet the functional and financial eligibility requirements for the Connecticut Home Care Program for Elders (CHCPE). The act also required the services to be cost effective. Previously, the per-person cost for the PCA could not exceed the average annual per person cost of home health services under the CHCPE. Finally, the act repealed an older pilot program, which had more restrictive eligibility criteria, and moved its clients into the expanded one. The newer pilot allows family members other than spouses to be PCAs.


Connecticut Home Care Program for Elders (CHCPE). Another 2005 act increased the asset limit for the state-funded part of CHCPE, starting April 1, 2007. For single individuals, the limit rose from 100% to 150% of the minimum Medicaid community spouse protected amount (CSPA, the minimum amount federal Medicaid law requires states to allow spouses of institutionalized Medicaid applicants to keep) and 150% to 200% of the CSPA for married couples. (Currently, the minimum CSPA is $20,880) (PA 05-280).   


Prior Authorization for Home Health Care.  The same legislation required the DSS commissioner to establish prior authorization procedures in the Medicaid program for home health services involving more than two weekly skilled nursing visits.


Nursing Oversight of Homemaker-Home Health Aides.  The 2005 legislature provided that any state regulations defining minimum service quality standards for home health care and homemaker-home health aide agencies had to require a registered nurse (RN) to perform patient assessments, with the aide present, at least once every 60 days. Previously, the assessment had to be done at least once every four weeks, but an RN did not have to do it (PA 05-64).






PA 06-188 eliminated the upper age limit for the Medicaid-funded PCA waiver program, thus allowing people aged 65 and older to participate in that program. Previously, those individuals “aging out” of the waiver program had to apply for the state-funded PCA pilot. Elders who have never been in the waiver program can also qualify, provided they meet the eligibility criteria: income 300% or less of the maximum Supplemental Security Income (SSI) benefit (currently $1,869 per month) and assets generally under $1,600, if they are single. The asset limit is higher for married applicants and depends on whether one or both spouses need PCA services.


This same act increased from 150 to 250 the number of slots for the state-funded PCA pilot.


Money Follows the Person


The 2006 General Assembly authorized DSS to submit an application to the federal government to establish a “Money Follows the Person” demonstration project, as authorized by federal law. The demonstration, which was limited to 100 participants and includes PCA services, will allow individuals to use money that would otherwise be spent on nursing home care on services that allow them to return to, and remain in, their communities (PA 06-188).


Prior Authorization for Medicaid Home Health Services


The legislature amended the 2005 prior authorization law by also requiring it for home health aide visits totaling over 14 hours per week. It also allowed home health providers to submit monthly PA requests, even if the PA changed during the month, provided they were for the same client (PA 06-188).


Home- and Community-Based Services for People with Psychiatric Disabilities


This same legislation allowed the DSS commissioner to seek federal approval to offer Medicaid-funded home- and community-based services to adults with severe and persistent psychiatric disabilities, regardless of age, who were diverted or discharged from nursing homes.


Homemaker-Companion Agency Registration


The 2006 legislature required homemaker-companion agencies to register annually with the Department of Consumer Protection (DCP), as well as require their new employees to undergo criminal background checks. The legislation required the agencies to provide clients with written contracts or service plans that identified the services to be provided. It explicitly excluded home health care agencies and homemaker-home health aide agencies from this process (they are already subject to DPH licensure and oversight) (PA 06-187). 




Regulation of Assisted Living


The 2007 legislature enacted significant assisted living legislation. PA 07-2, JSS, increased oversight of assisted living facilities and established a residents “bill of rights.” DPH has licensed the agencies providing the assisted living services (called assisted living service agencies, ALSAs) for some time; the act set requirements for the managed residential communities MRC) where individuals receiving their services reside. Among other things, the act required the MRCs to:


1.   provide each resident with a written residency agreement;


2.   enable residents to access ALSA services in accordance with a service plan that the act requires the ALSA to develop and maintain;


3.   comply with provisions currently in DPH regulations governing MRCs; and


4.   be subject to DPH oversight and regulation.


The act required DPH to conduct biennial reviews of MRCs and receive and investigate any complaints brought against them.


Extending CHCPE to Younger People with Disabilities


The same public act also required the DSS commissioner, within available appropriations, to establish and operate a state-funded pilot program to offer people between the ages of 18 and 64 the same home care services that the CHCPE provides to elders.  To qualify, these individuals must be inappropriately institutionalized or at risk of this and have assets no higher than 100% of the Medicaid CSPA, if single, or 150% of this amount, if married.


New Home Care Option Program for Elderly


PA 07-130 established a Connecticut Home Care Option Program for the Elderly and a related trust fund to help people plan and save for the costs of services that (1) allow them to live at home or other non-institutional settings as they age and (2) are not covered by a long-term care health insurance policy or supplement services that such a policy or Medicare covers. The act allowed participants to establish individual savings accounts and a designated beneficiary to withdraw funds to pay for eligible home care expenses. The interest on these accounts is exempt from the state income tax.


Elimination of Cap on State-Funded PCA Pilot


The 2007 legislature eliminated the 250 person cap on the state-funded PCA program (PA 07-130).


Increase in Money Follows the Person Slots


PA 07-2, JSS required, rather than allowed, DSS to run the Money Follows the Person Demonstration. And it increased the number of program slots from 100 to 700.  DSS has received federal grant funds for this demonstration.


Flu Vaccinations by Home Health Care Nurses


Another 2007 act allowed nurses working for licensed home health care or homemaker-home health aide agencies to administer flu and pneumonia vaccines to patients in their homes. They may do so without a physician’s order but only according to a physician-approved agency policy and only after assessing any contraindications (PA 07-9).




PA 07-23 required newly licensed hospices to provide hospice services in all settings and sets conditions on the use of hospice-related titles and terms. Beginning January 1, 2008, it requires an organization seeking initial hospice licenses to agree to provide hospice services for terminally ill people on a 24-hour basis in all settings and provide DPH evidence that it has adequate personnel to do so.


Residential Care Homes


Another 2007 act allowed unlicensed residential care home employees to perform limited health-related activities for residents. Specifically, the staff can obtain and record a resident’s blood pressure and temperature using certain instruments that do not require the user’s discretion or judgment. The employees can also obtain and document a resident’s weight and help the residents use blood glucose monitors (PA 07-76).





Continuing Care At Home


PA 08-36 allows continuing care retirement communities (CCRCs) to provide care to individuals in their own homes if they are given future access to services and shelter in the CCRC facility. Prior law allowed a CCRC to provide shelter and medical services only to residents in its facilities.




PA 08-158 requires DSS to amend the Medicaid state plan to add hospice services, beginning January 1, 2009. Previously, the state provided Medicaid-funded home health care services but not the full panoply of hospice-type benefits required by Medicaid law, such as bereavement counseling. Under federal Medicaid law, states have the option to cover these services.


Homemaker-Companion Services


The legislature amended the 2006 homemaker-companion agency registration law by specifying that these agencies can neither offer nor provide homemaker or companion services without a current DCP certificate of registration. Prior law prohibited agencies only from “offering to provide” services without a certificate (PA 08-17).


Homecare Option Program for the Elderly


PA 08-140 amends the 2007 HOPE legislation by exempting dividends and capital gains earned on contributions to an account in HOPE from the designated account beneficiary's state income tax. It expands the specified people who can benefit from a HOPE account to include any designated beneficiary. Previously, only a person who entered the HOPE participation agreement or who was later designated as that person's spouse or civil union partner could benefit.


State-Funded Home Care Program for the Disabled


PA 08-88 increases the asset limit for the state-funded home care program for the disabled. Previously, assets were limited to 100% and 150% of the minimum Medicaid community spouse protected amount (CSPA) for single and married applicants, respectively. The act increases the limits to 150% and 200% of the minimum CSPA, respectively, by tying the limits to those in the state-funded Connecticut Home Care Program for Elders. Under the act, the increases for 2008 are: (1) $20,880 to $31,320 for a single person and (2) $31,320 to $41,760 for a married couple. (Federal law requires the state to update the CSPA each January 1.)


Money Follows the Person Demonstration Program


PA 08-180 requires, rather than allows, the DSS commissioner to apply for federal approval of its Money Follows the Person Demonstration (MFP) protocol. (DSS subsequently applied for and received federal approval.) And it increases the number of program slots from 700 to 5,000.


The act also requires the commissioner to develop a plan to establish and administer a similar home- and community-based services project for adults who may not meet the MFP institutionalization requirement.  And it establishes a separate, nonlapsing General Fund account to hold the enhanced federal matching funds the state receives for MFP.  It specifies the uses of account funds and requires a report on expenditures from it.