THE NEW MEXICO MEDICAID STATE PLAN PERSONAL CARE SERVICES PROGRAM
Martin Kitchener, Ph.D
Charlene Harrington, Ph.D
Center for Personal Assistance Services
Department of Social & Behavioral Sciences
3333 California Street, Suite 455
University of California, San Francisco
This project was funded by National Institutes on Disability and Rehabilitation Research (NIDDR) Grant No. H133B031102. Government sponsorship of this research does not constitute endorsement of the results or the conclusions presented here.
The State of New Mexico is participating in a broader CMS-funded 7-state collaborative study of its effort to rebalance long-term care and support programs, which is being conducted through a master contract with the CAN Corporation (Contract Number - RTPP CMS-04-0411). Rosalie A. Kane from the Division of Health Services Research, School of Public Health, University of Minnesota is the Principal Investigator; Charlene Harrington and Martin Kitchener from the University of California, San Francisco, are participating on the multi-organization study team. The Year 1 reports from this 3-year study are expected to be available from the investigators and CMS in the fall of 2005 and will provide fuller information and context for the material presented here. The authors acknowledge colleagues from the CMS project team who are working on the New Mexico report: Robert Mollica, Rosalie Kane, Robert Kane, Donna Spencer, and Reinhard Priester.
Table of Contents
- New Mexico State Characteristics
- New Mexico Long Term Care
- New Mexico Medicaid State Plan Personal Care Services
- Administrative Program
- Program Participants and Expenditures
- Types of Clients
- Types of Providers
- Assessment Procedures
- Assessment Tool and Need Criteria
- Financial Eligibility
- Services Available
- PCS Delivery Sites
- Cost Controls and Hours of Care
- Consumer Choice and Consumer Directed Care
- PCS Training
- Provider Rates, Wages and Benefits
- Provider Supply
- Future Plans
List of Tables
- Table 1 Socio-Demographic (Need) Characteristics, New Mexico and US
- Table 2 Economic and Political Characteristics, New Mexico and US
- Table 3 Medicaid, New Mexico and US
- Table 4 New Mexico Medicaid LTC Participants and Expenditures
- Table 5 New Mexico Medicaid 1915(c) HCBS Waivers
- Table 6 New Mexico Medicaid Personal Care in Waivers, 1999-2002
- Table 7 Personal Care in Older Americans Act Title III, 1999-2002
- Table 8 Alternative Sources of Personal Care Funding in New Mexico
- Table 9 New Mexico Medicaid State Plan PCO Program, 1999-2003
- Table 10 New Mexico Medicaid State Plan PCO Client Groups Served, 2002-2004
- Table 11 New Mexico Medicaid State Plan PCO Enrolled Providers, 2002-2004
- Table 12 New Mexico Medicaid State Plan PCO Need Assessment and Authorization, 2002-2004
- Table 13 New Mexico Medicaid State Plan PCO Financial Eligibility, 2002-2004
- Table 14 New Mexico Medicaid State Plan PCO Services, 2002-2004
- Table 15 New Mexico Medicaid State Plan PCO Delivery Sites, 2002-2004
- Table 16 New Mexico Medicaid State Plan PCO Cost Controls, 2002-2004
- Table 17 New Mexico Medicaid State Plan PCO Care Providers, 2002-2004
- Table 18 New Mexico Medicaid State Plan PCS Provider Rates, 2002-2005
- Table 19 Medicare Home Health Payment Rates & Resources
- Table 20 New Mexico Medicaid State Plan PCS Provider Benefits & Supply, 2002-2004
Although the majority of long-term care (LTC) in the United States is still provided informally (unpaid, usually by family and friends), policy-makers face mounting pressure to expand access to formal (paid) home and community-based services (HCBS). The main aim is to allow consumers to live as independently as possible rather than in institutions such as nursing homes. The pressure on states to broaden access to HCBS increased in 1999 when the Supreme Court ruled in the Olmstead case that unjustified institutionalization of persons on public programs constitutes discrimination in violation of the 1990 Americans with Disabilities Act (ADA). Subsequent consumer litigation against certain states has provided further impetus for change (Kitchener et al., 2005). HCBS programs have become increasingly popular over institutional care as a model for providing LTC. Despite these mounting pressures for HCBS, studies report that the development of HCBS funded by Medicaid (the largest single payer of LTC) remains uneven across the states and limited by factors including policies that commit 64.5 percent of the program's LTC expenditures to institutions (Burwell et al., 2005).
Previous studies of HCBS development have given limited attention to personal care services which involve non-medical assistance with activities of daily living (ADLs), such as bathing and eating, and instrumental ADLs (IADLs), such as shopping and preparing meals (LeBlanc et al., 2001). In the US, formal personal care is paid by a combination of private sources (out of pocket expenses and the limited indemnity and employer-based insurance markets) and governmental programs. While Medicaid is the main program for providing personal care, it is also funded through a variety of other federal and state programs including: Older Americans Act (OAA) Title III, the U.S. Department of Veterans Affairs' Housebound and Aid and Attendance Allowance Program, the Medicare home health benefit, and Title XX Social Security Block Grants.
Many elderly and disabled persons rely on formal personal care services (PCS) to remain independent, especially Medicaid programs delivering community-based personal care (Stone, 2001). Although states have had the option of providing PCS as a Medicaid state plan benefit since 1975, 22 states reported no commitment of funds to the benefit in 1995 (Winterbottom et al., 1995). Since then, the PCS benefit has become the major funding mechanism for personal care used by the elderly and by younger, physically disabled persons living in the community (LeBlanc et al., 2001). While the Medicaid program allows states considerable discretion in defining PCS, care must be approved by an authority recognized by the state (e.g., a physician) and cannot solely involve ancillary tasks (e.g., housekeeping or chores). The PCS benefit must be made available to all categorically eligible groups statewide although it may (at the discretion of states) include the medically needy (those who spend down to the state standard because of medical expenses).
By 2002, 30 states operated Medicaid PCS programs with 683,099 participants and total expenditures of $5.6 billion (Kitchener et al., 2005b). Nationally, the PCS program represented 63% of public personal care expenditures. Studies of PCS programs indicate wide variation in policies including: hours provided per day, services provided outside the participant's residence, and hiring independent providers not employed by licensed agencies (Mollica, 2001; Kitchener, et al., 2005b). An increasing number of state PCS programs aim to expand consumer-directed services that give clients greater control over funds (e.g., cash allowances) and the management of care attendants. The most common approaches involve either traditional home care or personal attendant agencies or by the use of independent providers (Summer and Ihara, 2004). A study of California's PCS program indicated that allowing participants to hire relatives, friends, and neighbors may increase client satisfaction and help address the limited supply of attendants (Benjamin, 2001).
To address the information gap about state PCS programs, this study selected states that had promising practices in their Medicaid PCS optional state plan program for more in-depth study. New Mexico (NM) was selected as one of these states for two primary reasons: (1) the state reported allowing for independent providers and consumer directed care in its PCS program, and (2) NM was known for having invested in its Medicaid HCBS programs. In 2004, NM spent 67.6 percent of its Medicaid long term care expenditures on HCBS and only 32.4 percent on institutional services, giving it a rank of 2nd in the country for its distribution of HCBS expenditures to the total (Eiken et al., 2005; Burwell et al., 2005). The state was ranked 1st in the nation in the proportion of Medicaid HCBS dollars spent for the aged and disabled in 2004, and was ranked 5th in the nation on per capita expenditures for HCBS (Eiken et al. 2005; Burwell et al., 2005).
This report first presents an overview of the NM state socio-demographic characteristics, economic and political factors, and budget. The report then reviews the state NM Medicaid program and the administration and management of its HCBS programs. Specifically, it reviews the state personal care programs including the personal care in waivers, the Older Americans Act, and other programs. The primary focus is on the organization and management of the Medicaid PCS optional state plan program. The main features of its program are described.
The purpose of this in-depth study was to describe selected Medicaid State Plan PCS programs and to understand the factors that facilitated or created barriers to the development of better PCS practices. From a systematic review of the research literature, a list of better practices concerning the following three aspects of PCS programs was compiled: planning, structure/content, and review/monitoring. Better practices within each category involve issues concerning consumer perspectives.
Evidence of better practices among PCS programs was collected from two sources: (1) the PAS Center advisory panel; and (2) the researchers' annual survey of all PCS programs. The final selection of case sites involved three further criteria: (1) each program must have been operational for at least one year, (2) there must have been some quantitative or qualitative program data even if this information was not collected as part of an organized evaluative design, and (3) the set of programs was designed to include variation along dimensions including: state size, region, per capita income, population density, and various other attributes.
The information on this and the other cases was obtained from multiple sources including: secondary data, face-to-face and telephone interviews with state officials and various consumer and professional organization representatives conducted in the state in the summer of 2005. In addition, statistical data on the PCS programs were collected for l999-2005.
New Mexico State Characteristics
As background to the New Mexico Medicaid State Plan PCS Program case study, this section presents information on three sets of state characteristics shown to be important within the research literature: (1) socio-demographics, (2) economics and political characteristics, and (3) the state Medicaid program.
1. Socio-Demographic, Economic, and Political Characteristics
In 2004, the state of New Mexico (NM) had a population of approximately 1.9 million people, one of the smaller states in the nation (US Census Bureau, Population Division 2004). While the majority of the population of New Mexicans was predominantly white (70 percent) in 2003, minorities make up 30 percent of the population with American Indians/Alaskan Natives comprising a significant minority population (10 percent). NM had the 8th largest Hispanic population in the U.S. in 1999 (708,407 people, U.S. Census Bureau, 2000).
|Total Population (2004)1||1,903,289||293,655,404|
|Percent of Persons Age 65+ (2004)2||11.7%||12.1%|
|Percent of Persons Age 85+ (2004)2||1.1%||1.4%|
|Percent of Population Minority (2003)2||29.81%||23.84%|
|Percent of Persons with Disabilities (2003)3||17.0%||14.8%|
|Percent Rural (2003)1||43.2%||18.3%|
|Percent of Persons with Difficulty in Self-Care (2003)3||2.4%||2.7%|
|Percent of Persons with Difficulty in Self-Care Living Alone (2003)3||27.45%||23.5%|
|Number of informal caregivers (2004) (percentage of total population)4||200,000 (10.51%)||27,200,000 (9.26%)|
|Number of informal caregiving hours (2004)4||183,100,000||29,182,000,000|
|Value of informal caregiving (annual market value) (2004)4||$1,612,900,000||$257,096,000,000|
Sources: (1) U.S. Census Bureau Population Division (2004), (2) U.S. Census Bureau, American Community Survey (2004c), and (2004d) (3) National Center for Personal Assistance Services, State Disability Statistics, (4) Friss Feinberg et al (2004)
The proportion of the NM population who were 65+ in 2003 was slightly lower than the national average (11.95 percent vs. 11.98 percent nationally) (See Table 1). Indeed, in 2000, NM ranked 39th in the US in terms of the proportion of the population who is 65+. Although organic growth among the aged population is predicted to experience a relatively small increase over the next two decades (Summer et al 2004), the state predicts a dramatic growth due to in-migration by retired people.
In 2003, 290,000 (17 percent) NM residents over the age of 5 had a disability. Of these, an estimated 51,000 people had difficulty performing self-care activities such as bathing, dressing, or eating. In 2001, 5.3 percent of children under age 5 had special health care needs, which was lower than the US average (7.8 percent) (US Department of HHS, 2004).
Economic and Political Characteristics
In 2003, New Mexico was one of the poorer states in the union, ranking 47th in terms of per capita income (Smith 2004) with almost 19 percent of the state's population living in poverty (US Census Bureau 2005) (See Table 2). A higher than average percentage of residents was not covered by health insurance (21.3 percent vs. 15.1 percent) (DeNavas et al. 2004) and the state had a high unemployment rate, ranking 43rd in the country in May 2005 with only 8 states experiencing higher rates of unemployment (Bureau of Labor Statistics, 2005).
|State Munificence (State revenue-expenditure, 2003)1||-$1,337,734|
|Percent of Population in Urban Area (2000)2||74.96%||79.01%|
|Percent of Population in Poverty (2003)3||18.6%||12.7%|
|Personal Income Per Capita (2003)4||$24,995||$31,472|
|Percent of Population Unemployed (2005)5||6.0%||5.4%|
|Percent Persons Not Covered by Health Insurance (2003)6||21.3%||15.1%|
|Percent households with internet access7||43.1%||50.1%|
|Percent homeownership rate (2004)8||72%||69%|
|Percent of population age 25+ with High School Graduates or higher (2003)8||80%||84%|
|Percent of Bachelor level education or higher (age 25+) (2003)8||23%||27%|
|ADA US Senator liberalism rating (mean average, 2004)9||52.5%|
Sources: (1) U.S. Census Bureau (2005), (2) US Census Bureau (2004) (3) U.S. Census Bureau American Community Survey, (2004a), (4) US Bureau of Economic Analysis (2005), (5) US Dept of Labor (2005), (6) De Navas et al (2004), (7) Friss Feinberg et al (2004), (8) U.S. Census Bureau (2004) & (2004c), and (9) Americans for Democratic Action (2005).
The Governor of New Mexico is Democrat Bill Richardson elected in 2002 (New Mexico Office of the Governor, 2004). In 2005, the New Mexico House of Representatives was comprised of 42 Democrats and 28 Republicans (NCSL, 2005). The State Senate was comprised of 23 Democrats and 19 Republicans (NCSL, 2005).
In 2005, there was one Democratic US Senator (Jeff Bingaman) and one Republican US Senator (Pete Domenici). Both have been in office for over two decades, with Domenici serving his sixth consecutive term (website of U.S. Senator Jeff Bingaman, 2005; website of U.S. Senator Pete V. Domenici, 2005). Their liberalism scores demonstrate the divide in the political perspectives. The NM average US Senator liberalism rating was 52.5 percent in 2004, the Democrat had a rating of 90 percent and the Republican had a rating of 15 percent (ADA, 2005).
New Mexico had 3 U.S. Representatives in 2004, 2 Republicans (including Heather Wilson, the first woman from NM to serve in Congress since 1948) and 1 Democrat. The Democrat had an ADA liberalism score of 100 percent while the combined Republican ADA score in 2004 was much lower, at 25 percent (ADA, 2005b). The average US Senate and House liberalism score for NM in 2004 was 46 percent, which was higher than all the neighboring states (TX 39 percent, OK 9 percent, CO 28 percent, UT 21 percent, and AZ 29 percent). The New Mexico state legislature is unusual in that it only meets for 60 days on odd years and 30 days on even years. The budget and fiscal decisions are made on odd years.
State Medicaid Program
In 2003, the New Mexico Medicaid program provided services to about 452,120 participants with expenditures exceeding $2.2 billion by 2004 and greater per capita expenditures than the national average ($1,169 vs. $961) (See Table 3). In 2003, NM had 240.67 Medicaid participants per 1,000 population, much higher than the national average of 178.72 participants per 1,000 population.
|Participant per 1,000 population||240.67||178.72|
|Expenditures per capita (2004)2||$1,168.69||$961.20|
|Federal match (2004)1||77.80%|
|Financial Eligibility (% SSI)1||100%|
|State Supplemental Payment (SSP)3||Yes ($100 in Adult Residential Care Home)|
Sources: (1) Centers for Medicare and Medicaid Services (2006), (2) Burwell, Sredl, and Eiken, 2005, (3) National Association of State Medicaid Directors (2003) Also: Centers for Medicare and Medicaid Services (2006), Social Security Administration (2005) and Social Security Online (2004)
The federal government matched NM Medicaid expenditures at the rate of 77.80 percent in FY2004. The federal match (FMAP) for FY2005, however, decreased to 74.30 percent (Kaiser Family Foundation 2005) and in 2005-2006 will decrease further to 71.15 percent (Federal Register 2004). This reduction, coupled with the Governor's budget proposals, means that despite the Legislative Finance Committee having recommended full funding of the Medicaid program, cuts in services of $60 million were anticipated in 2005 (Jackson, 2005). A survey by the Kaiser Commission on Medicaid and the Uninsured found three main factors contributing to Medicaid expenditure growth in NM in 2004, these were: growth in the number of recipients, increases in utilization of prescription drugs and outpatient services, and waiver costs (Smith et al., 2004).
According to an analysis of the economic impact of Medicaid spending in states, in FY2005, NM will achieve the second highest rate of return for every state dollar spent on Medicaid ($5.57, Mississippi will be the highest with $6.22) (Klein et al, 2004). Furthermore, the same study predicts that NM will experience the second largest increase in wages per $1 million of state funds invested in Medicaid in FY2005 ($2.10 million) and that 61.30 new jobs per $1 million of state Medicaid funds will be achieved (the third largest number of new jobs amongst all states, behind Mississippi and Arkansas) (Klein et al., 2004).
As a means of cost savings, NM introduced managed care (SALUD) to their Medicaid program in 1997-8 (NM Human Services Department Medical Assistance Division, 2004a). In 2003, 64.2 percent of all NM Medicaid enrollees (Native Americans are exempt from any mandatory managed care enrollment) were receiving services through one of the three Medicaid managed care plans (Presbyterian, Lovelace, and Molina), slightly more than the national average of 60 percent for the same year (KFF, 2005). The managed care component is administered by the Medical Assistance Division (MAD).
Individuals eligible for Supplemental Security Income (SSI) are automatically qualified for Medicaid services as categorically eligible individuals. NM is not a medically needy state and does not implement the 209(b) rule for the aged, blind and disabled (Legislative Research, Policy, & Committee Services, 2003). The federal SSI standard for an individual was $579 per month in 2005. Medicaid eligibility is determined by the Income Support Division of the Human Services Department.
NM allowed for the maximum level of 300 percent of SSI for its special income standards for institutional and HCBS waiver care, for the categorically needy (NM Human Services Department, Medical Assistance Division, 2001; New Mexico Human Services Department, Medical Assistance Division, 2005).
Long Term Care in New Mexico
As background to this study of the New Mexico Medicaid State Plan PCS Program, this section presents information on five aspects of the publicly funded LTC in New Mexico: (1) organizational structure, (2) Medicaid LTC participants and expenditures by provision type, (3) personal care delivered through Medicaid waivers, (4) other programs delivering personal care, and (5) strategic planning.
In July 2004, the administration of some major HCBS programs, including the Personal Care Option (and the Disabled and Elderly (D&E) waiver and PACE program) was transferred from the Medical Assistance Division of the NM Human Services Department to the Aging and Long Term Services Department (ALTSD). This followed a report from the Medicaid Reform Committee set up by the Legislature in 2002 which made many recommendations for improving Medicaid in NM, including the continuation of the personal care option and an increase in public awareness of its services. Another recommendation was the consolidation of state long-term care services under one agency for all ages (NM Legislative Council Service, 2003). The ALTSD also includes Adult Protective Services, Information and Referral, and the Traumatic Brain Injury state-funded program. The state made ALTSD a cabinet level department in 2004. ALTSD does not include nursing homes, home health and developmental disability or the state veteran's homes and nursing homes. The state Medicaid program is housed in the Department of Human Services. NM uses "intergovernmental collaborative" bodies to aid in coordinating across its LTC programs.
Medicaid LTC Participants and Expenditures
NM Medicaid LTC participants were less likely to use both nursing facilities and intermediate care facilities for the mentally retarded (ICF/MRs) when compared with the national average in 2002. Of the total number of Medicaid LTC participants in New Mexico, 32.69 percent were served in institutions (nursing facilities and ICF/MRs) and 67.31 percent were HCBS recipients (See Table 4). Total state spending on Medicaid HCBS was more than the state's spending on institutional care in 2004 and the percentage of NM's Medicaid LTC dollars spent on HCBS (67.6 percent, $422,462,453) was more than the national percentage (32.4 percent) (rank of 2nd in the nation).
In receiving 32.4 percent of all state Medicaid LTC expenditures, nursing facility residents constituted less than 30 percent of participants. NM's total Medicaid expenditures per capita exceeded the national average and its Medicaid LTC expenditures per capita were more than $29 above the national average (See Table 4). NM's total Medicaid HCBS expenditures per capita were double the national average ($222 and $108 respectively).
|Participants (per 1,000 population)||NM||US|
|Nursing facility (2002)1||5,221 (2.81)||1,346,686 (4.68)|
|ICF/MR (2002)1||519 (0.28)||117,497 (0.41)|
|Total Institutional (2002)||5,740 (3.09)||1,464,183 (5.09)|
|Home Health (2002)2||487 (0.26)||722,257 (2.51)|
|PCS (2002)3||6,614 (3.57)||683,099 (2.37)|
|Waivers (2002)4||4,659 (2.51)||920,833 (3.20)|
|Total HCBS (2002)||11,760 (6.34)||2,326,189 (8.08)|
|Total Medicaid LTC participants||17,557 (9.46)||3,790,372 (13.16)|
|Expenditures $ (per capita)|
|Nursing facility (2004)5||$179,818,250 ($94.48)||$45,835,646,786 ($156.09)|
|ICF/MR (2004)5||$22,940,983 ($12.05)||$11,761,206,072 ($40.05)|
|Total Institutional(2004)||$202,759,233 ($106.53)||$57,596,852,858 ($196.14)|
|Home Health (2004)5||$436,468 ($0.23)||$3,445,549,127 ($11.73)|
|PCS (2004)5||$178,003,798 ($93.52)||$7,028,041,064 ($23.93)|
|Waivers (2004)5||$244,022,187 ($128.21)||$21,244,610,417 ($72.35)|
|Total HCBS (2004) 5||$422,462,453 ($221.96)||$31,718,200,608 ($108.01)|
|Total Medicaid LTC expenditures5||$635,221,686 ($333.75)||$89,315,053,466 ($304.15)|
Source: (1) CMS (2006) (2) UCSF Annual Survey Home Health (2004), (3) UCSF Annual Survey PCS (2004), (4) UCSF Annual Survey 372 reports (2004), (5) Burwell et al (2005)
Medicaid 1915(c) Waivers
NM was one of the first states to establish a Medicaid 1915 (c) HCBS waiver program in 1983 and in 2005 operated four of these waivers. The largest was a waiver serving people with MR/DD, which had 3,335 participants and a waiting list of 3,400 persons at the end of 2004 (See Table 5). By 2005, this program had 75 new MR/DD slots added to it, and the waiver grew to 3,600 participants in 2005.
|Waiver name (identifier)||Population served||Participants (2004)||Expenditure (2002)||Services provided include:||Personal care|
|Developmental Disabilities (0173.90)||MR/DD||3,335||$196,737,068||Case management, habilitation, therapies and personal care||Yes|
|Disabled and Elderly (0169.90)||Physically disabled and/or people aged 65+||2,438||$42,858,938||Case management, homemaker/personal care, emergency response, respite, private duty nursing||Yes|
|Medically Fragile with developmental disability (0223.90)||Children and adults under 22 years||168||$4,138,413||Case management, private duty nursing, home health aide, therapies||No|
|HIV/AIDS (0161.90)||HIV/AIDS||25||$287,768||Homemaker, private duty nursing, case management||No|
Sources: National Center for Personal Assistance Services (2005) and UCSF survey of 372 reports, 2005.
The average wait time on the Disabled and Elderly waiver was half the average time experienced by people on the Developmental Disabilities waiver waiting list (24 months vs. 48 months in 2002) even though there were more people on the Disabled and Elderly waiver waiting list (5,000 in 2002). The Medically Fragile waiver also had a waiting list (130 persons, with an average wait time of 12 months in 2002). Only one waiver, the HIV/AIDS waiver, did not have a waiting list (UCSF survey data 2003).
ALTSD established a centralized Disabled and Elderly waiver registry. In 2005, there was a waiting list of 6,700 for about 42-48 months on the registry. These individuals are not necessarily eligible for services. The Resource Center which runs the registry contacts individuals every 6 months to see if they are still interested and the Center can refer individuals to other services such as personal care.
NM was one of eleven state recipients of the second round of Cash and Counseling grants in 2004. NM is developing the option for waiver recipients to direct their own care through a new interagency Medicaid self-directed waiver program called Mi Via (interagency collaboration between the NM Aging and Long Term Services Department, Department of Health and the Human Services Department). The waiver application to support this new program is to be submitted to CMS in 2005 (NM Concept paper, 2005).
Medicaid Personal Care in Waivers
After the State Plan PCS program, the second largest Medicaid program delivering personal care is 1915(c) HCBS waivers. The number of participants receiving personal care through HCBS waivers increased by nearly three quarters between 1999 (741) and 2002 (1,275) (See Table 6). Additionally, expenditures increased by almost two-thirds (64.5 percent) in the same period. When adjusted for inflation, the increase is more modest, but still greater than half (52.3 percent). Expenditures per capita followed a similar trend, increasing by 60.6 percent over the study period. Despite this growth, expenditures per participant actually decreased by $917 between 1999 and 2002. This indicates that while more people were receiving services in 2002 than before, less money was actually being spent on each of them.
|Per 1,000 population||0.41||0.46||0.56||0.69|
Source: Kitchener, Ng and Harrington (2005)
Personal Care Through the Older Americans Act
The federal Older Americans Act (OAA) is authorized until FY 2005. Title III of the Act enables states to provide services to support older people to stay independent in the community, including through providing personal care services. Federal Administration on Aging data report that the number of New Mexicans receiving personal care through Title III OAA funds increased dramatically by more than 30-fold between 2000 (3) and 2002 (109). (See Table 7). There was a slight dip in the number of participants from 2001 to 2002, however overall expenditures nearly quadrupled (from $7,312 to $29,334) and similarly, expenditures per participant increased by more than four times (from $67 to $302).
|Per 1,000 population||0.00||0.00||0.06||0.05|
Source: Kitchener, Willmott, & Harrington (2004b), using data from Administration on Aging (2005)
In addition, NM participates in the National Family Caregiver Support Program and was allocated $858,751 in federal funding in 2004 (Administration on Aging, 2005a).
Other sources of HCBS funding in NM
The state-funded Developmental Disabilities Program is available only to people aged 22 years or older who do not already receive Medicaid waiver services and they do not need to meet medical and financial eligibility requirements (See Table 8). Services are limited to respite (which can include assistance with ADLs), residential services and habilitation/vocational services (NM Department of Health website 2005).
|Title of State-only Funded Program||Expenditure (year)||Total Systems Change Grant ($thousands)|
|State General Fund Developmental Disabilities Program||Not known||50||1,385||0||949||2,736|
|Multi-Service Group||$10,905,536 (FY02 Appropriation)||50||1,385||0||949||2,736|
|Indian Area Agency on Aging||$1,665,352 (FY02 Appropriation)||50||1,385||0||949||2,736|
|Navajo Area Agency on Aging||$1,006,642 (FY02 Appropriation)||50||1,385||0||949||2,736|
Source: Kitchener, Willmott & Harrington (2004a), (2004c) and (2004e).
Since 2001, NM has received a total of $5,120,000 in Federal 'Systems Change' grants from CMS. In 2004, NM was awarded two federal 'Real Choice Systems Change' grants, one to develop a Family Health Information Center ($150,000) and one to develop Aging and Disability Resource Centers ($798,900), a combined total of almost $949,000. Since the program did not spend all the funds, an extension was requested for the grant in 2005. The Aging and Disability Resource Center aims to increase public information on and access to long-term care and is overseen by the NM Interagency Long-Term Care Committee. A further grant of $2,736,384 was awarded in 2005. This 'Systems Transformation' grant is intended to help states to develop more comprehensive and integrated long-term care systems.
In addition to the 4 waivers in NM, there is a PACE program available in 3 counties which provides Medicaid home and community-based services for people who also receive Medicare (NM HSD, 2005).
NM offers a tax credit or deduction to encourage the purchase of long-term care insurance. Despite this, NM ranked 43rd in the US in terms of number of long-term care insurance policies sold in 2001 (32,200 policies, compared to the largest number sold in any state, Florida, which sold 677,400 in the same year) (Summer et al. 2004).
Strategic Planning Activity
The federal Supreme Court Olmstead ruling suggested that states demonstrate compliance with the ADA integration mandate by producing formal plans for increasing community integration. In 2002, it was estimated that one-fifth of the population of NM could benefit from the Olmstead decision, including people on waiting lists for HCBWS and an additional 46,000 individuals not on waiting lists, but who could qualify for such services (Legislative Research, Policy, & Committee Services, 2003). In February 2002, the NM State Legislature passed Senate Joint Memorial 54, charging the Governor's Committee on Concerns of the Handicapped to develop a plan to better integrate people with disabilities into the community (Legislative Research, Policy, & Committee Services, 2003). The Olmstead Task Force had no official members and was open to all stakeholders. Participants included: the Arc of New Mexico; Centers for Independent Living; the state Protection and Advocacy agency; the Home Care Association; the Nursing Home Association and others, including state agencies (NM Legislative Council Information Bulletin: State Compliance with Olmstead, at: http://legis.state.nm.us/lcsdocs/148087.pdf. (Plan not available online).
The first draft of the plan was delivered to the state legislature in October 2002 and offered recommendations for action that should be taken immediately and those which required further planning (NCSL, 2003). One of the recommendations resulted in Senate Bill 839, The Consumer Direction Act, which requires all departments or agencies offering long-term care services to provide a consumer direction option (NCSL, 2003). In 2004, the state continued to work on its plan (Fox-Grage et al, 2004; Gran et al., 2003).
In its application for 'Real Choice Systems Change' grants for FY 2002, NM identified several problems with its long-term care system, including; high turnover among community service and health care workers, lack of affordable housing, lack of transportation, long waiting lists and difficulty in providing services in remote areas, underdeveloped outreach to nursing facility residents regarding community-based alternatives, a lack of consistent information to people requiring long-term care (O'Keefe, 2003). A lack of consumer directed services in HCBS program was also identified, along with the disjointed system of agencies, programs and providers although these two issues are evidently being tackled through restructuring efforts (see NM Medicaid section, above) and the development of a 'Cash and Counseling' project. Many of these areas addressed by the state are discussed in this report. The perceived strengths of the NM long-term care system included the Medicaid PCS program offering personal assistance and consumer direction and a Disabled and Elderly Waiver centralized intake and screening system (LTC Link) in the Medical Assistance Division which standardizes the gathering of individuals' information for assessment of needs and can be shared across programs and agencies (O'Keefe, 2003).
Litigation Related to Olmstead
NM is one of only 9 states to have closed all of its state-operated MR/DD institutions (Rizzolo et al, 2004) and it has been suggested that litigation played a significant part in achieving this (Enbar et al 2004). There are only two identified community integration cases in NM. The first was Olmstead-related and concerned the right of institutionalized people with MR/DD to live in the community (Jackson v. Fort Stanton, closed 1992). The second specifically brought an ADA claim to argue for increased HCBS for people with MR/DD and more prompt assessment of people's needs (Lewis et al. v. New Mexico, closed 2005) (Enbar et al. 2004; Kitchener et al., 2004d).
NEW MEXICO MEDICAID STATE PLAN PC
Implemented in 1999, NM's state plan PCS program, called the Personal Care Option (PCO), is one of the newest such program in the US. In 2002, PCO had the largest expenditure growth of any of NM's Medicaid HCBS programs (Interim Legislative Medicaid Reform Committee & Advisory Group, 2002). In addition, it was estimated that by 2003, the number of participants exceeded the number of Medicaid participants in nursing facilities by almost 900 (The Interim Legislative Medicaid Reform Committee and Advisory Group, 2002). This section describes the NM state plan Personal Care Option (PCO) program.
From inception until July 1, 2004, the PCO program was administered in the Medical Assistance Division (MAD) of the Human Services Department. From then, the program (along with the Disabled and Elderly HCBS waiver and PACE program) moved to the newly formed Aging and Long Term Services (ALTSD (MAD, 2004b). A number of the administrative staff for the program, including the Program Manager, remained the same after the transfer.
The two DD waiver programs are administered by the Department of Health but there is discussion of eventual consolidation of all the LTC programs into one department. Entry into the PC program for the aged and disabled is through Loveless Health Plan, which became a third party contractor for administering the PCO program in 2004.
Program Participants and Expenditures
The number of participants in the PCO program has been increasing since it started, more than doubling in size between 2001 and 2003, after a nearly fourfold increase between 2000 and 2001 (See Table 9). Similarly, expenditures have been rising, increasing by greater than a factor of 10 between 2000 and 2001 and more than doubling in the following year.
|Per 1,000 population||n/a||0.45||1.68||3.57||4.77|
Source: Kitchener, Ng and Harrington (2005)
Expenditures per participant nearly tripled from 2000 ($6,062) to 2002 ($18,899) followed by a slight decline of 6 percent between 2002 and 2003. In 2004, NM spent $178 million on its PCO program or $93.54 per capita, ranking it 3rd in the nation among states in its personal care state plan expenditures per capita (Burwell et al., 2005). Although program costs were significantly higher than expected, the state has taken a number of steps to improve the program and to control costs. These are described below.
Types of Clients
The PCO program serves all categorically needy groups who qualify for Medicaid except for children, who can receive personal care through early periodic screening, diagnostic and treatment (EPSDT) services. The populations served in the program have not changed between 2000 and 2004. (See Table 10).
|Clients Groups Served||2002||2003||2004|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
Types of Providers
A number of entities can qualify to be PCO service providers, including: Medicare certified home health agencies, licensed home health & personal care agencies, Centers for Independent Living, independent providers with a fiscal intermediary organization, and other family members & friends who are not deemed "legally responsible" for the client (this includes siblings and close relatives but excludes spouses and legal guardians ). (See Table 11).
|Medicare certified home health agencies||Y||Y||Y|
|Licensed home health & personal care agencies||Y||Y||Y|
|Centers for independent living||Y||Y||Y|
|Independent providers (no agency affiliation) with fiscal intermediary||Y||Y||Y|
|Independent providers (no agency affiliation) without fiscal intermediary||N||N||N|
|Persons legally responsible for client (using state only money)||N||N||N|
|Other family members & friends, not legally responsible for client||Y||Y||Y|
|Facilities such as foster care/residential/assisted living etc||N||N||N|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
The PCO program does not cover residential care. Income eligible individuals living in assisted living facilities would be able to receive PCO services not otherwise included in the facility arrangement.
Until 2004, agencies providing PCO conducted the determination of the level of care and the assessment of the appropriate amount of services and Blue Cross/Blue Shield served as the fiscal intermediary assessor. Following the revisions to the PCO program in the summer of 2004, these duties became the responsibility of a third party assessor (TPA) Lovelace Health Plan, a designee of the Medical Assistance Division (8.315.4.16 of NM Human Services Department, Medical Assistance Division, 2004c).
The TPA is not allowed to delegate responsibilities to the PCO agency (MAD, 2004c). A 2003 review highlighted the need for standardization in assessment and procedures (Personal Care Option Committee, 2003). NM appears to have no system for tracking unmet needs.
In order to access the PCO program, clients may call a toll free line to get a packet for enrollment which the physician fills out and signs. The form then goes to Lovelace Health Plan which uses subcontractor agencies in some counties to conduct the home assessments. These subcontractors are home health agencies that are not PCO providers.
The TPA is also responsible for developing personal care service plans, issuing prior approvals and utilization reviews for PCO consumers as well as explaining the difference between the two PCO service delivery models: consumer-delegated and consumer-directed (see below).
|Non-physicians assess client's needs for State Plan PC e.g., nurses||Y (PCO providers)||Y (PCO providers)||Y (TPA assessors)|
|Need assessment based on a scoring system such as ADLs||N||N||N|
|After assessment, non-physicians authorize State Plan PC||Y (PCO providers)||Y (PCO providers)||Y (TPA assessors)|
|Specific criteria used for the authorization decision||Y||Y||Y|
|State tracks unmet needs, that is, services (e.g., respite) or extra hours of care that are needed by clients but not currently available||N||N||N|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
Table 12 shows that nonphysicians in the TPA assess client needs and authorize state plan services. NM, however, requires all clients to obtain a physician's signature on a form indicating the need for services prior to the state assessment. This represents a barrier to accessing services that is generally not required by other states.
Assessment Tool and Need Criteria
The state has developed a 17-page form for its assessment tool and need criteria. The TPA or MADs designee uses the Long Term Services Utilization Review Instructions for Nursing Facilities (Attachment II of 8.312.2-UR) to make these assessments (Personal Care Options Committee, 2003). The PCO program criteria is set at a minimum of 2 activities of daily living and chronic care needs, which is the NM nursing facility level of care requirement.
New Mexico is not a medically needy state and does not allow participants in the PCO program to spend down. The state does serve categorically needy participants in the PCO program although there is little information as to whether persons with higher income might be eligible for the program.
|100 percent of SSI||Y||Y||Y|
|150 percent of SSI||n/a||n/a||n/a|
|300 percent of SSI||n/a||n/a||n/a|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
In 2004, changes were made to the services that can be provided in the PCO program and the list of restricted services was clarified. Services that are permitted include; individual bowel and bladder services, meal preparation and assistance, support services (e.g. shopping with or without the consumer, transportation, assistance getting in and out of vehicles, translation/interpreting services), hygiene/grooming (e.g. oral care, nail care, toileting), minor maintenance of assistive technology (minor routine maintenance on wheelchairs and durable medical equipment), eating, skin care, cognitive assistance and household services (MAD, 2004c). (See Table 14). Services not covered include childcare and personal care for other household members (MAD, 2004c).
|PC services to assist directly with ADLs e.g., bathing, feeding, toileting||Y||Y||Y|
|PC services to assist directly with IADLs e.g., housekeeping, shopping, cooking||Y||Y||Y|
|'Cuing' or monitoring||Y||Y||Y|
|Animal Assistance e.g., Guide Dogs||N||N||N|
|Assistive Technology (AT)||N||N||N|
|Task delegated by nurse e.g., injections||N||N||N|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
PCS Delivery Sites
Unlike more permissive states (e.g., MA), NM limits use of services to the client's home. (See Table 15).
|Client's work site||Y||Y||Y|
|In the community, outside residence & work site||Y||Y||Y|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
Cost Controls and Hours of Care
There are no limits to the maximum cost or maximum hours of care per recipient for the PCO program. (See Table 16). The shift in responsibility of the assessment and care planning from the provider to the TPA in 2004 may, however, result in reductions to the amount of hours for which consumers were previously approved.
|Maximum cost per recipient||N||N||N|
|Maximum hours of care per recipient||N||N||N|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
Consumer Choice and Consumer Directed Care
PCO services may be delivered through one of two models: consumer-directed or consumer-delegated. Although both models involve a consumer and a personal care agency, the responsibilities assigned to both parties are different.
Under the consumer-directed model, the consumer (or their representative) is responsible for interviewing, hiring, training, firing, and scheduling the personal care attendant, which includes checking for a driver's license and insurance (if driving related activities are necessary). Additionally, the consumer is responsible for developing a list of emergency back up attendants, reporting any incidents to the agency, verifying timesheets accurately reflect services rendered, ensuring the attendant has agreed to undergo a nationwide criminal history screening, and obtaining a signed agreement that the attendant will not provide PCO services under the influence of drugs or alcohol. The personal care agency also has a number of responsibilities which include; keeping the provider on file, explaining payroll documentation to the consumer, performing payroll activities for attendants, arranging workers' compensation insurance, and providing consumers with information on training resources (MAD, 2004c).
Under the consumer-delegated model, the personal care agency is charged with all of the same responsibilities that they would have under the consumer-directed model, as well as employing, scheduling and terminating attendants, training attendants (for a minimum 12 hours per year), maintaining a registry of trained attendants for emergency/back up care, and checking for a driver's license and insurance. (MAD, 2004c).
Personal care agencies can offer either consumer-directed or consumer-delegated PCO services or both (different models to different clients). However, all personal care agencies must provide information on both models to consumers upon request. It is the responsibility of the TPA to explain both models to consumers on an annual basis.
In 2005, 170 PCO agencies offered PC and did not have to be licensed by the state. In 2005, there were 8,700 individuals who received PC. While the consumer-directed model is more popular with consumers, it represented only 3 percent of PCO consumers in 2003 and 4 percent in 2005.
The consumer-delegated model of PCO requires that attendants pass a written competency test within the first 3 months of employment and receive a minimum of 12 hours of training annually (see Table 17). Additionally, the attendant is required to be trained in CPR and first aid within the first 3 months of employment. There are no training requirements under the consumer-directed model.
|State requires formal training for care providers||Y||Y||Y|
|State requires certification of care providers||N||N||N|
|State requires supervision of care providers||Y||Y||Y|
|State allows client to hire & fire care providers||Y||Y||Y|
|State requires criminal background check for care providers||Y||Y||Y|
|Every client have a care plan||Y||Y||Y|
|Every client have a case manager||N||N||N|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
There is no formal certification process of attendants in NM, however, attendants are required (under both models) to submit to a nationwide criminal history screening. All PCO participants must have a personal care services plan developed by the TPA (MAD, 2004c).
Provider Rates, Wages and Benefits
Provider rates for PCO services stayed the same between 2002 and 2004, provider agencies were paid $16 for every hour services delivered and the individual providers were paid $9 an hour. (See Table 18).
|What $ rate is paid to agencies?||$16/hr||$16/hr||$16/hr||$13.50/hr|
|What $ rate is paid to care providers?||$9/hr||$9/hr||$9/hr||$8/hr|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
In 2005, the consumer directed care provider rates were $11.50 per hour and consumer delegated rates to providers were set at $13.50 for the first 100 hours and $11.50 for 101 or more hours. Under consumer delegated care, the individual provider receives at least $8 per hour.
NM had more Home Health Aides per 1,000 65+ population than the national average in 2003, despite paying a lower median hourly rate than the median US average. Conversely, Personal and Home Care Aides were paid an average of almost $1 per hour more than the national average (Gibson et al., 2004). (See Table 19).
|Percent of Medicare beneficiaries receiving Home Health Services (2002)||5.3%||6.3%|
|Medicare-certified Home Health Agencies (per 1,000 population, age 65+) 2003||0.27||0.20|
|Medicare Reimbursement per day for nursing facility care (average) 2002||$255||$265|
|Medicaid Reimbursement per day for nursing facility care (average) 2002||$103||$118|
|Private pay rate per day in nursing facility (urban average) 2003||$137||$158|
|Medicare reimbursement per Home Health visit (average) 2002||$132||$124|
|Private pay hourly rate for Home Health Aide (urban average) 2003||$17.00||$18.12|
|Personal & Home Care Aides (per 1,000 population age 65+) 2003||Not available||14|
|Personal & Home Care Aides median hourly wage (2003)||$8.84||$7.91|
|Home Health Aides (per 1,000 population age 65+) 2003||20||16|
|Home Health Aides median hourly wage (2003)||$8.59||$8.77|
Source: Gibson et al (2004)
4,400 people were employed as Home Health Aides in NM in 2003, earning an average salary of $18,770, slightly less than the national average annual wage of $18,980 (US Department of Labor, 2003 and 2004). It is anticipated that NM will need 3,350 additional Home Health aides in 2025 to maintain the 2001 ratio of 163 aides per 1,000 85+ population (Summer et al 2004).
|Care providers receive health care benefits||N||N||N|
|Care providers receive sick leave?||N||N||N|
|Shortage of care providers||N||N||N|
Source: UCSF Annual Survey of Medicaid State Plan PCS Programs, 2004.
Although the state does not offer the providers in the PCO program either health care benefits or sick leave, there does not appear to be a shortage of care providers in the state (see Table 20). Agencies have the option of providing benefits and some agencies do in fact offer health benefits and sick leave.
As noted above, NM was one of eleven state recipients of the second round of Cash and Counseling grants in 2004. NM is developing the option for waiver recipients to direct their own care through a new interagency Medicaid self-directed waiver program called Mi Via (interagency collaboration between the NM Aging and Long Term Services Department, Department of Health and the Human Services Department). The waiver application to support this new program is to be submitted to CMS in 2005 (NM Concept paper, 2005). This would allow PC with consumer direction for individuals with MR/DD and the aged and disabled.
The Medical Assistance Division proposed a conceptual paper to CMS for a Medicaid 1115 Global funding waiver in 2002. This waiver would enable Medicaid nursing home and HCBS funding to be combined but has not yet been implemented (O'Keefe, 2003). The state continues to consider plans for moving LTC into a managed care contract. Meanwhile, the state is working on revising its overall LTC plans and expanding its waiver programs.
This case study of the New Mexico Medicaid Personal Care Optional (PCO) program highlights five features. First, since the program was initiated in 1999, the state has been able to shift its long term care programs away from institutional care to HCBS. Through the PCO program and waivers, the state is generous in its support for home and community-based services, ranking number two in the nation for expenditures per capita for HCBS and ranking 3rd in its personal care state plan spending per capita.
Second, the New Mexico PCO program operates a single entry point for all aged and disabled individuals, and plans are being made to move to a more integrated LTC program for the waiver programs. With the establishment of the ALTSD, the state has an infrastructure which can be used to consolidate all its LTC programs over time from other departments. Meanwhile, the state is using interagency cooperatives to coordinate its programs and planning efforts.
Third, NM has made a strong commitment to developing HCBS and has an active strategic planning effort underway. This planning effort appears to involve the many stakeholder groups and is continuing to evolve, offering PCO as one of its central LTC services.
Fourth, NM offers a consumer directed care option for PCO. To date this option has seen limited use because of its original structure which allowed PCO agency providers to conduct assessments and care planning, and these PCOs encouraged the use of agency care. As the state has changed to an independent assessment structure and care planning process, this gives consumers greater choice in PCO providers. Moreover, the state is developing a new waiver that is specifically for consumer directed care for all target groups which should allow for an expansion of this option.
Fifth, the state has refined its assessment procedures and criteria for PCO to ensure greater accountability and equity in access for applicants. Although PCO program costs were significantly higher than expected, the state has taken a number of steps to improve the program management and control program costs.
Overall, the development and management of NM's PCO program represents an interesting example of some of the start-up problems of a new program that other states may want to consider in planning new state plan personal care optional programs.
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