Beneficiary centered care in services to persons with developmental disabilities.

This article provides an overview of the findings from the Evaluation of Medicaid's Community Supported Living Arrangements (CSLA) Program. Results suggest that CSLA provided a useful model of beneficiary centered care for persons with developmental disabilities. The implications of the findings of this evaluation for current management of Medicaid programs are discussed.

Asset spend-down in nursing homes. Methods and insights.

The issue of how many elderly are affected by catastrophic nursing home expenses is a major part of the debate over if and/or how to reform long-term-care financing. Currently, there is some discussion regarding the magnitude of this catastrophic event, referred to as "asset spend-down", among the elderly. National data suggest the magnitude is small, while state-specific studies indicate it is greater. In addition, the literature regarding asset spend-down has presented two different measures of its magnitude, further confusing the issue. These two measures, each based on different denominators, have often been presented without adequate explanation. In this study, the authors review both measures and analyze reasons for the differences observed across studies. Major reasons identified include the type of sample used, the mix of payor source at admission, the length of time covered by the data, data on payor source/Medicaid eligibility, and the ability to observe multiple nursing-home stays within the data. Using the measure based on the number of persons who are private pay at admission, these studies indicate that approximately one fourth will eventually deplete assets. The second measure, based on a count of Medicaid residents at a point in time, indicates approximately one third were private pay when admitted. Study results indicate that national studies have underestimated the extent of spend-down due to national-level data limitations, while state-specific studies inevitably refect the specific state data set available and circumstances particular to each state. More state studies and a better understanding of asset transfer are needed.

Eligibility for publicly financed home care.

OBJECTIVES: Proposals for publicly financed home care for the elderly now tend to include cognitive impairment criteria as well as activities of daily living (ADL) criteria. The numbers of elderly deemed eligible for services will depend on the definitions of ADL and cognitive impairment used. METHODS: Data from the 1984 National Long-Term Care Survey were used to generate a series of estimates of the community-dwelling elderly with ADL disabilities and cognitive impairment. RESULTS: When only ADL criteria are used, estimates of disability range from 472,000 to over 3 million (1.6% to 12.5% of the community-dwelling elderly). These estimates increase to approximately 1 million to 4.2 million (3.5% to 14.0% of the community-dwelling elderly) when cognitive impairment criteria are added. CONCLUSIONS: The use of more stringent or more liberal eligibility criteria will have dramatic effects on the number of elders who qualify for services. The nature of the eligibility criteria employed in any expansion of federally financed home care benefits will be a major factor in determining the costs of such a program.

Access to Medicaid and Medicare by the low-income disabled.

The most pervasive eligibility-related problems encountered by low-income disabled persons in gaining access to Medicaid and Medicare are reviewed in this article. A series of options for restructuring program eligibility requirements are presented, with particular attention to improving the plight of the low-income disabled worker during the 24-month waiting period for Medicare. Options for Medicaid involve nationwide income eligibility levels at 100 percent of poverty and mandatory buy-in provisions to Medicaid in all States. For Medicare, the reforms range from altering the waiting period for Medicare by the disabled who are expected to die within 24 months after benefit award to eliminating the waiting period altogether.

Spend-down of assets before Medicaid eligibility among elderly nursing-home recipients in Michigan.

Many elderly persons enter nursing homes as private pay clients, spend their available life savings, and then apply for medical assistance under Medicaid after their assets are depleted. However, reliable data on the size and characteristics of this "spend-down" population have been lacking. This study used Medicaid claims and enrollment data to identify the proportion of elderly Medicaid nursing-home users who originally entered nursing homes as private pay clients versus those eligible for Medicaid before or concurrent with, their nursing-home admission. The study population consisted of all elderly nursing-home users receiving Medicaid in Michigan in 1984, a total of 36,898 unduplicated recipients. Findings indicated that "spend-downers" comprised 27.2% of all elderly users. Once on Medicaid, spend downers exhibited similar nursing-home utilization patterns as other groups, but incurred lower Medicaid claims because they contributed more to the cost of their nursing-home care. In aggregate, the State of Michigan Medicaid program spent $75.4 million on nursing-home services in 1984 for elderly persons who spent down to eligibility in a nursing home. These data are relevant to state policy initiatives to reduce Medicaid spending for nursing-home care by encouraging potential spend downers to purchase long-term care insurance.

A profile of Medicaid home and community-based care waivers, 1985: findings of a national survey.

This article presents the findings of a national survey of Medicaid home and community-based care waiver programs established under Section 2176 of the Omnibus Budget Reconciliation Act of 1981. The article documents the ways states have used their waiver authority, the methods states use to target their programs to people who are at risk of institutionalization, the programs' service utilization and expenditure levels, and the quality assurance systems that have been established as of 30 September 1985. Based on these state-reported descriptions of Medicaid home and community-based waiver programs, the article discusses preliminary findings on the cost-effectiveness of the waivers and looks at some potential attributes of a cost-effective program.

Medicaid recipients in intermediate care facilities for the mentally retarded.

In this study, we examined Medicaid utilization and expenditure patterns of Medicaid recipients in intermediate care facilities for the mentally retarded (ICF's/MR) in three States: California, Georgia, and Michigan. Data were obtained from uniform Medicaid data files (Tape-to-Tape project). Most recipients in ICF's/MR were nonelderly adults with severe or profound mental retardation who were in an ICF/MR for the entire year. The average annual cost of care ranged from $26,617 per recipient in Georgia to $36,128 per recipient in Michigan. The vast majority of recipients were low utilizers of other Medicaid services. Approximately one-third of the recipients were also covered by Medicare.