Phase VI (Year 6) Congress considers the Secretary's recommendations. All individuals are required to have insurance 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, the Commission recommends that the choice be guided by the following three criteria: 1. 2. 3. 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. 16 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 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, 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. 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. 18 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. is responsible for the home and and the three-month "front-end" The federal government The federal and state Administration 1. 2. 3. 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. 1. Private long-term care insurance fills gaps not covered by this plan. 2. 3. The federal government encourages the development of private long-term care insurance through clarification of the tax code. This includes: Treating, for tax purposes, the premiums paid and the benefits received as health insurance. Enabling qualified long-term care policies to be sold in employers' cafeteria plans. The federal and state governments share responsibility for standards and oversight of the private long-term care market. The federal government establishes minimum standards which disseminating to consumers non-biased, professional 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. Phase-In Schedule Phase I * A maximum of 200 hours of home care per year is made available to all severely disabled persons. Phase II * * Phase III * * Phase IV The three-month "front-end" nursing home care benefit is made available to all eligible nursing home users. The nursing home program is implemented providing income and asset protection for all eligible nursing home users. The maximum hours of home care available per year is increased to 400. Begin to improve nursing home reimbursement rates. * The home care program is fully implemented. * Further improve nursing home reimbursement rates. 20 |