Steve Gold

Despite Congress' numerous reductions in the basic Medicaid law (recently enacted in the Deficit Reduction Act of 2005) that will negatively affect low income persons, including persons with disabilities, there are a number of provisions that disability advocates can take advantage of to increase home and community-based services and to reduce unnecessary institutional services.

First, State Medicaid Plans can now provide Home and Community-Based services to eligible persons who need the services. This provision could "Close the Front Door" and prevent unnecessary nursing home placement. For example, in the data available that tracks long-term care services (also known as MDS data), as of September 31, 2005, nationally there were 173,194 (12.3%) persons in nursing homes who went directly from their homes "with no home health services" before they were institutionalized. Many of these persons were institutionalized in nursing homes before they were provided or even offered home and community-based services. Similarly, in the same MDS data, nationally there were 806,831 (57.3%) persons placed in nursing homes directly from an acute hospital. Many of these people were never offered home and community-based services before they were sent away to nursing homes.

The recent Congressional amendments could prevent many unnecessary institutional placements in the future IF disability advocates together with your MA officials respond creatively. Amend your State Plan to require and to document that before a person is institutionalized in a nursing home they must be offered home and community-based services.

Second, Congress will now permit States to set "more stringent needs-based criteria" for nursing home placement than for home and community-based service. This modifies the Medicaid Waiver provision that required that a person had to be nursing home eligible before s/he could receive community-based services. Now States can (IF they chose) reduce their nursing home expenditures by offering community-based services to persons whose Activities of Daily Living (ADLs) are not at the nursing home level.

Third, Congress has mandated independent evaluations and assessments for persons who request home and community based services to determine what the person requires. These include face-to-face evaluations by trained evaluators. In a truly IRONIC TWIST, Congress wanted independent evaluations and assessments to prevent "unnecessary or inappropriate care" in the community but has NEVER REQUIRED such for institutional care. Disability advocates should ask your State Medicaid officials for the same independent evaluations and assessments BEFORE persons are placed in nursing homes. That will greatly increase EQUALITY and at the same time prevent unnecessary institutionalization.

Fourth, as with Medicaid Waivers, States can limit the numbers of persons who receive the home and community-based services and have "waiting lists" to receive these services, which States may not have for other State-plan services. While this is an unfortunate limitation, it should make your State Medicaid officials more confident that costs will be controlled, and we will be able to show the savings from preventing unnecessary institutionalization. From disability advocates' point of view, it's a start, and again like Waivers, "waiting lists" for community services will be balanced against unnecessary expenditures in institutions. Like Waivers, unfortunately States will not have to provide home and community-based services on a "state-wideness" basis nor the same income and resource criteria applicable to other MA services. Thus, States will be able to pick and limit who will receive these services and in what part(s) of your State.

Fifth, persons in the community will be able to SELF-DIRECT their home and community-based services.

Sixth, States can reduce their nursing home expenditures with "Money Follows the Person" options for persons who have been in nursing homes for at least six months. States can receive a significantly increased federal match (more money than they receive for other State Plan services) to provide home and community-based services so that persons can return to the community with services instead of remaining unnecessarily institutionalized in a nursing home. Your State must apply for this and compete against other States.

Read more of Steve Gold's briefs at http://www.stevegoldada.com/