Allow all uninsured pregnant women, and children ages 0-6, to enroll in public plan, if they are from non-working families or in families of workers whose employers do not provide coverage. Costs would be subsidized, according to ability to pay, at least for those with family incomes below 200% of poverty. Begin to improve reimbursement to providers for persons now served by Medicaid. Phase II (Year 2) Firms with 0-25 workers and average payrolls below $18,000 become eligible to receive a 40% tax credit/subsidy for cost of coverage if they provide it. The subsidy would be available for five years. The public plan is made available to uninsured children up to age 18 (those from non-working families or families where workers' employers do not offer coverage). Subsidies would be available based on ability to pay, at least for those with family incomes below 200% of poverty. Phase III (Year 3) * Firms with 100 or more workers are required to provide private insurance coverage or contribute a portion of payroll toward the cost of covering employees and dependents in the public plan. Phase IV (Year 4) If 80% of uninsured employees of firms with 25-100 workers (as of Year 1) are not insured through their employers, along with their dependents, all employers of this size are required to provide private insurance coverage or contribute toward the cost of their coverage in the public plan. If coverage target is met, the Secretary of Health and Human Services is required to recommend to Congress ways to cover those still left out. Phase V (Year 5) If 80% of uninsured employees of firms with 0-25 workers (as of Year 1) are not insured through their employers, all employers of this size are required to provide coverage or contribute toward the cost of their coverage in the public plan. If coverage target is met, the Secretary of Health and Human Services is required to recommend to Congress ways to increase coverage options for employees (and their nonworking dependents) who are not covered by their employers. All non-working adults are covered through the public plan. Phase VI (Year 6) Congress considers the Secretary's recommendations. All individuals are required to have insurance through their employers or through the public plan. Revenues for Health Care A. B. C. coverage Although some of the revenues necessary to support the above recommendations could come from savings achieved elsewhere in the federal budget, the Commission is committed to raising whatever additional revenues are necessary. In considering what revenue options to adopt, 1. 2. 3. the Commission following three The final tax package ought to be progressive, requiring a higher contribution from those most able to bear increased tax burdens. That is, families with higher incomes would be asked to contribute a greater share of their incomes than required of lower income families. Since persons of all ages would benefit, persons of all ages should contribute to financing the recommendations. Revenues chosen should grow fast enough to keep up with benefit growth so that new sources of revenue will not need to be enacted over time. Rates of growth would need to be in excess of 8% to 9% per year. Various combinations of revenue sources may be used that together meet these criteria even if individual tax sources may fall short in one category. PEPPER COMMISSION RECOMMENDATIONS ON LONG-TERM CARE Structure of the Plan 1. Social Insurance for Home and Community-based Care Severely disabled individuals of all ages are eligible for · or supervisory assistance with three out of five ADL's Eligibility is determined by a state/local government or federally-funded non-profit assessment agency using standardized assessment criteria. This agency conducts annual audits of case managers (described below) and monitors the quality of care. Case managers determine the number of hours of care and mix of services the beneficiary receives. The case manager develops an individual care plan tailored to needs of the beneficiary. The availability of informal supports is included in the decision to allocate resources. The case manager operates within a budget set by the federal government, and conducts periodic reassessments of the beneficiary with special consideration to be given to cost containment. The case manager budget, in conjunction with other available services, will be sufficient to provide all services, needed by the patient. The benefits include: - Home health care Physical, occupational, therapy services. speech and other appropriate Personal care services (feeding, transferring, personal hygiene) Homemaker housework) chore services (meal preparation, laundry, Grocery shopping and transportation Medication management Adult day health and social day care Respite care for caregivers Cost-effective training of family members for delivery of home-based family care, and support counseling of family caregivers. 2. 3. Nursing Home Program (NHP) * Individuals of all ages who are determined eligible for nursing home care by a federally certified assessment agency are covered by this program for the entire length of their stay. The plan treats income and assets as follows: assets for The plan protects $30,000 in non-housing The plan provides income protection for the spouse Any remaining income goes toward the cost of the nursing home care. Three-Month Front-end Coverage: * Protection to Return Home All nursing home users are covered for the first three months of care with full protection for their income and assets, except for a modest copayment. Benefits include: Individual Role 1. 2. Skilled nursing care Home and Community-based Care * Individuals pay 20% of the costs of care up to a maximum of the national average cost of home and community-based care. The federal government subsidizes the coinsurance at least for persons with incomes below 200% of the federal poverty level. Nursing Home Program * Individuals contribute their income toward the cost of care minus the housing and personal needs allowances. Individuals contribute non-housing assets above $30,000 for single persons and $60,000 for married persons. 3. Three-month "Front-end" Nursing Home Care 1. 2. Individuals pay 20% of the costs of care up to a maximum of the national average cost of nursing home care. The federal government subsidizes the coinsurance at least for persons with incomes below 200% of the federal poverty level. The federal government is responsible for the home and community-based care program and the three-month "front-end" nursing home care program. The federal and state Administration 1. 2. governments share the financial The federal government contracts with states to administer all three components of the plan. The federal government sets standards and guidelines for administration. These include the following: Standardized assessment criteria for determining eligibility for home and community-based care and nursing home care. Certification of assessment agencies. Guidelines for certifying case managers. * Determination of case manager budgets. Determination of provider payment rates for home and community-based care and nursing home care. State administrative functions include the following: Building on the current infrastructure for management and delivery of services, where long-term care programs already exist. Designing and implementing the system for managing and delivering services, in states without existing programs. Certifying providers. Establishing the review and appeals process. Private Sector Role 1. Private long-term care insurance fills gaps not covered by this plan. |