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A crisis is unfolding. We have enjoyed the expansion of Medicaid home care benefits through the Nursing Home Transition and Diversion (NHTD) Waiver, the Consumer Directed Personal Assistance Program (CDPAP), the Managed Long Term Care (MLTC) Program and similar programs as providing a much needed safety-net for those in jeopardy of being placed unnecessarily into a skilled nursing environment. Unfortunately, in recent years we have encountered the disheartening scenario of a lack of available caregivers to fill the hours that are approved through these programs.
 
Most of our readers know that the home care industry often struggles to find viable staffing for its Medicaid-funded home care cases. There are a number of reasons for this, including low wages and the fact that these are usually physically and emotionally demanding jobs. Staffing becomes even more of a problem in outlying areas where public transportation is limited or simply unavailable. This is not necessarily the fault of the home care agencies, as they are bound by the reimbursement rates set by the Medicaid program. The Medicaid program pays what the Medicaid program pays and there are few options for these providers in the way of negotiating these reimbursements.
 
We should point out that this problem is not necessarily limited to those seeking Medicaid funded care, as similar challenges exist for those who are privately paying for home care services. But private individuals can choose to pay a higher hourly wage, so finding a provider can be easier when paying privately for care. On the other hand, few can afford the private pay expenses in perpetuity. One might even argue that the private pay system exacerbates the Medicaid funded staffing problem, as the pay-scale for workers funded through Medicaid is capped.
 
And as we discussed in our last newsletter, the favorable financial eligibility rules for Medicaid funded home care programs will be changing effective October 1, 2020 so as to make basic Medicaid eligibility to secure these much-needed services even more difficult.
 
Understanding Medicaid Funded Home Care
 
There is a lot of misinformation and confusion in the area of Medicaid funded home care. As a preliminary matter, it is important to understand that being eligible for Medicaid is quite a different thing than actually receiving home care services; Medicaid is simply a payment source for various types of health and social services program’s. For those seeking long term care coverage through either the NHTD or MLTC programs, securing Medicaid coverage is only the first step. Once Medicaid is approved, the focus then turns to establishing a plan of care, seeking approval of that plan through the responsible agencies and insurers and then implementing that plan (once approved).
 
The amount and type of services available to a program participant are influenced by a number of practical factors, some of which are within the control of the applicant, and some of which are not. For example, budget pressures can influence the number of hours that are approved under an individual’s care plan. In addition the manner in which questions are answered in the plan development process can impact how and whether a particular service is received. Advocacy at the outset is crucial to the development of a comprehensive plan of care.
 
Your average applicant can expect a 4 to 6 month ‘waiting-period’ before services can be implemented under most Medicaid funded home care programs. This is due to the many steps needed to secure Medicaid coverage and the separate set of steps required to obtain services under one of the home care programs.
 
Unfortunately, in a growing number of cases a successful application will result in a letter of approval which tells an applicant that he is entitled to X-hours of home care, but the successful applicant may then find that there are no workers available to cover the hours. This requires families to cobble together some form of a care plan through a network of family, friends, local not for profit services and other community supports (disrupting work and family schedules in the process).
 
Skilled Nursing Facilities Face Similar Challenges
 
Skilled nursing placement is rarely an acceptable alternative. Even the best nursing home (and there are many, many homes that are run very well with caring staff and clean facilities) possesses an air of institutionalization. And these facilities are also faced with significant challenges in maintaining the bottom-line and remaining profitable. As such, many of the same problems faced by the home care agencies – difficult jobs and relatively low pay for direct care staff – are encountered by skilled nursing facilities as well. Finally, the cost to our community of premature institutionalization will also rise as the expense of paying for a skilled nursing patient in a facility through the Medicaid program is typically higher than paying to keep someone at home.
 
The situation does look brighter for those who live in more highly populated areas… While a fast food worker can earn $15 per hour, the average compensation for a home care worker is in the $11 to $12 range, making it difficult for the home care worker to locate affordable housing and inexpensive transportation to do his or her job. Rural communities still pay the greatest price in these situations. In these communities, the person who had the audacity to be a farmer in a rural town will be forced to leave the land that he or she had sown and loved, not because they were ineligible for services, but because it is cost-ineffective for an agency to have a worker travel 2 hours one way in order to work for 4 hours at $11.00 per hour.
 
The Importance of Advocacy
 
Regardless of whether you are in an urban or a rural community, appropriate advocacy and counsel are the key to navigating and maximizing the benefits provided under these programs. We have successfully shepherded clients through the process of funding and then implementing critically important home care services, assisting them with allocating funds to subsidize shortfalls in the amount of care provided through the Medicaid program, and advocating for better care once services are in place. And in those cases where home care is no longer appropriate or simply unavailable, we are able to advise and assist clients in reconfiguring assets in order to obtain funding for skilled nursing home placement through the Medicaid program.
 
With the new financial eligibility rules making home care coverage more challenging beginning in October, it is more important than ever to have an effective and knowledgeable advocate in your corner to protect your loved ones. As we explained in our prior newsletter, some important planning strategies will become much more limited after October 1, 2020. We encourage clients to contact us if they would like to discuss their options in more detail.