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Phase VI (Year 6)

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Congress considers the Secretary's recommendations.
All individuals are required to have insurance coverage
through their employers or through the public plan.

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Revenues for Health Care

A.

some

Although

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.

B.

In considering what
recommends that

the
criteria:

revenue options to adopt, the Commission choice be guided by the following three

1.

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.

2.

Since persons of all ages would benefit, persons of all ages should contribute to financing the recommendations.

3.

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.

c.

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

or

Severely disabled individuals of all ages are eligible for this program.

This includes individuals who need hands-on supervisory assistance with three out of five

ADL's (Activities of Daily Living) (eating, transferring, toileting, dressing, bathing), or who are severely cognitively impaired.

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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.

an

The case manager develops 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.

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Home health care
Physical, occupational, speech and other appropriate
therapy services.
Personal care services (feeding, transferring, personal
hygiene)
Homemaker chore services (meal preparation, laundry,
housework)
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.

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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.

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The plan treats income and assets as follows:

as

The plan protects $30,000 in non-housing assets

for single individuals and $60,000 for couples. The plan provides a housing allowance equal to 30% of monthly income for the first year of a nursing home stay for single persons and,

for married persons, long as the spouse is alive, but at least a year. The plan provides a $100/month personal needs allowance. The plan provides income protection for the

spouse living in the community up to 200% of the poverty level for a couple. Any remaining income goes toward the cost of the nursing home care.

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Three-Month Front-end Coverage:

Protection to Return Home

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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.

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Benefits include:

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Individuals pay 20% of the costs of care up to a maximum of the national average cost of home and community-based care.

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The federal government subsidizes the coinsurance at least for persons with incomes below 200% of the federal poverty level.

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Individuals contribute their income toward the cost of care minus the housing and personal needs allowances.

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Individuals contribute non-housing assets above $30,000 for single persons and $60,000 for married persons.

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Individuals pay 20% of the costs of care up to a maximum of the national average cost of nursing home care.

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The federal government subsidizes the coinsurance at least for persons with incomes below 200% of the federal poverty level.

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2.

The federal government sets standards and
administration. These include the following:

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Standardized assessment criteria for

determining eligibility for home and community-based care and nursing home care.

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Building on the current infrastructure for management

and delivery of services, where long-term care programs already exist.

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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.

insurance fills gaps not covered by this

Private long-term care
plan.

2.

The federal

encourages the government

development of private long-term care insurance through clarification of the tax code. This includes:

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3.

for

The federal and state governments share responsibility
standards and oversight of the private long-term care market.

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The federal government establishes minimum standards which private long-term care policies must meet to be eligible for the tax clarification.

It

establishes methods of disseminating to consumers non-biased, professional information regarding private long-term care policies. States regulate private long-term care insurance, using federal or stricter standards. The federal government will encourage

states to strengthen civil penalties for misrepresenting policy standards, knowingly selling duplicative insurance or marketing unapproved policies by direct mail. In addition, states should train benefits specialists regarding private long-term care insurance and the availability of state information on that insurance.

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is

The three-month "front-end" nursing home care benefit made available to all eligible nursing home users.

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The nursing home program is implemented providing income and

asset protection for all eligible nursing home users. Phase III

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