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federal government contract with the states to administer the plan. The federal government would be responsible for setting guidelines and adequate standards for this administration.

9. In establishing a system for long-term care, the Commission believes it essential to continue to assess the effectiveness of treatment, delivery, and management of services and to explore means to prevent the need for long-term care services. The Commission recommends that the federal government move aggressively to contain costs and mitigate human suffering by funding a research and development program aimed at preventing, delaying, and dealing with long-term illness and disabilities.

The federal government would certify assessment agencies and develop standardized assessment criteria, set guidelines for certifying case managers and establish their budgets (described below), set guidelines for quality assurance and appeals procedures, and determine provider payment rates. Within federal guidelines, states would develop and certify case management and delivery systems, certify providers, establish review and appeals procedures, and enforce quality standards.

THE PUBLIC PROGRAM

7. The Commission recognizes that financial support for long-term care can only be effective if it promotes and ensures quality of care. Furthermore, to be sustainable over the long term, a program must be designed in a way that controls expenditures. The recommended plan therefore includes several measures to ensure quality and control costs. The recently enacted nursing home requirements would apply to the recommended nursing home coverage and standards would be developed for care in the home.

The Commission's recommendations create an integrated system of long-term care designed to meet the dynamic needs of the severely disabled population. There would be a single point of entry for all beneficiaries, a single set of eligibility rules for all services, a standardized assessment to determine eligibility, and a mechanism for managing the care process across settings. The system is designed to allow individuals who qualify for service the opportunity to choose the care setting and the types of care they receive, within specified limits. An integrated system would also help ensure efficient administration and service coordination.

Who Is Eligible for Public Benefits

Alongside these standards, the Commission believes that case management, an integral part of its recommended home care benefits, plays a critical role in ensuring quality and managing costs. The Commission recommends that case managers allocate services and monitor service delivery within a budget set by the federal government. This approach would ensure fiscal constraint and the capacity to tailor services to the needs and preferences of the individual.

The Commission further recommends that the federal government establish provider payment mechanisms and determine appropriate rates. Prospective payment systems can be used to ensure access to quality care, efficiently delivered, and to control spending for care.

The Commission believes that public benefits are most critical for people who are severely disabled and in need of substantial care. To qualify for any longterm care benefits at home or in a nursing home, the Commission recommends that individuals meet at least one of the three following disability criteria: (a) need hands-on or supervisory assistance with three out of five ADLs; (b) need constant supervision because of cognitive impairment that impedes ability to function; or (c) need constant supervision because of behaviors that are dangerous, disruptive, or difficult to manage. Individuals meeting one or more of these criteria, regardless of the underlying disease or disabling condition, would be eligible for benefits.

8. The Commission recognizes both the urgent needs of the currently disabled and their families for public support and the time it will take to build a long-term care system. The Commission therefore recommends that the plan be put into place a step at a time over a four-year period. The program would begin with limited home care benefits to relieve the burdens of family caregivers. Benefits would be expanded over the next four years, until full coverage is reached. Nursing home coverage would begin in year two. Payment rates would be increased gradually over the subsequent two years, to ensure adequate supply and quality of service.

In proposing these standards, the Commission recognizes the states' success in developing tools to target services to those most in need. In fact, many states already use functional status measures for nursing home screening and for determining eligibility for home and community-based care. 1. 2 Development of these tools is an evolutionary process, however, particularly in the areas of measuring cognitive impairment and children's disabilities. The Commission expects these assessment tools to be refined and become more precise over time.

The Commission favors use of common eligibility standards for in-home and nursing home care. Nevertheless it is concerned that some individuals who would not meet the disability criteria might require nursing home care for other reasons, such as lack of social supports or medical problems not necessarily associated with functional disability. Analysis of data on nursing home residents and states' experience in screening nursing home admissions indicates that the vast majority of current nursing home residents would be eligible for benefits under the public program. To avoid displacing current residents, the Commission recommends that all persons in nursing homes when the program begins be considered to satisfy the program's disability requirements. 3

which frequently include a physician as well as nurses, social workers, and other professionals such as physical therapists. Still others use less credentialed persons who have been trained specifically to conduct assessments. The Commission recommends preserying this flexibility within adequate federal guidelines, which at a minimum include requirements for adequate training

To ensure uniformity within and across states, the Commission recommends that the assessment agency use standardized assessment criteria. Such standardization is already in place in state programs that provide extensive home and community-based care.

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for those who are able to leave their homes, day care services (for disabled adults and children).

In recognition of the immense burdens experienced by family caregivers, the Commission recommends that the program cover respite services to provide them with some temporary relief. Such relief would allow family members to take a much needed vacation, to meet unplanned obligations, or just to have a little time to themselves. Some caregivers desire in-home respite periodically; others prefer to place the disabled person in a nursing home for a brief period. Respite benefits, therefore, should be flexible and available in all settings. In addition, the Commission recommends that the program cover training of family members in how to deliver home-based care more effectively and support counseling for family caregivers.

Finally, the Commission recommends that skilled nursing care as well as physical, occupational, speech, and other appropriate therapy services be covered. Providing these benefits would not replace the current Medicare home health benefit; rather it would extend skilled services to persons not now eligible for Medicare.

MARILU HALAMANDARIS/NATIONAL ASSOCIATION FOR HOME CARE

Cost Sharing—The Commission believes that individuals who can contribute to the cost of their care should be expected to do so. The Commission recommends that beneficiaries be required to contribute 20 percent of the actual costs of care or 20 percent of the national average cost of home and community-based care, whichever is lower, with federal subsidization for the poor and near-poor. Since copayment would place a heavy burden on low-income individuals, the federal government would fully subsidize these costs for persons with incomes at or below the poverty level and partially subsidize them at least for those with incomes between 100 percent and 200 percent of poverty.

Commission recommendations ensure home care for the severely disabled to sustain their independence and support family caregivers.

Managing and Allocating Care—The Commission is concerned that home care services support but not replace family caregiving and be managed in a fiscally responsible manner. The Commission recommends reliance on case managers to develop and oversee individual care plans. Case management is an effective way to allocate the appropriate types and amount of services, to help individuals navigate an often uncoordinated and unwieldy system, and to manage and monitor the care process. A comprehensive case management system addresses three major problems in financing and delivering long-term care-quality, access, and costs—and can be particularly useful for a population with multiple problems that cut across traditional service delivery systems.

In requiring case management, the intent of the Commission is to build on the experience that some states already have and to preserve the flexibility and creativity that exists. The Commission recognizes that case management can be designed in a number of ways.5 Case management can be located in free-standing organizations not responsible for the service provision, or as part of a service-providing organization. 6 Some argue that case managers must remain independent of direct service delivery in order to avoid conflicts of interest and to choose the optimum service package without constraints. Advocates of the service provider approach, by contrast, suggest that those closest to the clients have the best perspective from which to make care planning decisions; that a case management/provider combination reduces administrative costs; and that this arrangement may facilitate better access to services.

The Commission does not prescribe a specific approach but recognizes that if case managers are to be located in provider agencies, safeguards must be built in to ensure the independence of the case manager in arranging and monitoring the plan of care. Audit by the assessment agency, described below, could provide that safeguard.

The case manager would then assume the responsibility for assessing the needs of the individual and tailoring a home and community-based care plan.

To ensure adequate performance, the Commission recommends that the assessment agency periodically audit the case managers. Audits may address the purposes for which the dollars are spent, the appropriateness of service allocation, implementation of the care plans, and whether reassessments are done in a timely fashion.

To ensure fiscal responsibility in the proposed public program, the Commission recommends that the case manager operate within a budget set by the federal government. The budget established under this program, in conjunction with other available services, should be sufficient to provide all services needed by the individual. To achieve this objective, per capita amounts would be set appropriate to the service needs of individuals at different disability levels (perhaps two or three levels). The Commission recommends that the per capita amount for the most severely disabled level be set at a maximum volume of service or as a share of nursing home costs.? Amounts below the maximum would be set for lower levels of disability. The total case management budget would then be the product of per capita amounts appropriate to the disabilities of a case manager's enrolled population, adjusted to reflect area costs and the number of enrollees.

Nursing Home Care-The Commission considers financing home and community-based care a top priority. At the same time, it acknowledges that not all persons enter a nursing home to die; many return home after relatively short stays and need resources to maintain their standard of living. Many more may be able to afford to return home if their financial resources are not consumed by the nursing home stay. The Commission's recommendations, therefore, extend social insurance to cover short nursing home stays.

Working within this budget, the case manager would develop a care plan tailored to the needs of the individual beneficiary. Where care is already being provided by family and friends, the intent is to supplement and reinforce rather than to replace this informal caregiving. States with experience in providing in-home services have built the formal plan of care around the core supports provided by families and friends, and have worked cooperatively with families in building the plan. The Commission recommends that the case manager be free to allocate services to a client as needed within the budget. Expenditures for an individual's care, however, should not exceed the costs of care were the individual in a nursing home.

The Commission recognizes that comprehensive social insurance for longer nursing home stays would allocate substantial public dollars to protect the estates of the wealthiest segment of the population. Given limited resources and the potential for these individuals to purchase private insurance, the Commission chose another approach. To protect moderate- and low-income individuals against the catastrophic costs of nursing home care, the recommendations include a government-provided floor of asset protection to eliminate the risk of impoverishment and leave most people's life savings intact.

In addition to care planning and service allocation, the case manager would be responsible for monitoring implementation of the care plan and conducting periodic reassessments to determine whether changes in the amount or type of services (including the need for nursing home placement) are warranted. While the Commission does not recommend a specific schedule, it notes that most programs undertake a formal reassessment with a home visit every six months, at least during the first year. 8

The Commission recommends that those determined eligible for nursing home care by the federally certified assessment agency be entitled to coverage for the first three months of institutional care, with each three-month period of coverage considered an episode of care. Benefits would include custodial care as well as skilled nursing services for persons not receiving those services from Medicare. The Commission does not recommend a specific lifetime limit on the number of episodes to be covered. But it considers a maximum eligibility for two or three episodes to be plausible, each interrupted by a reasonable period of time (perhaps six months) to ensure that the program does not become a revolving door.

For severely disabled nursing home residents returning home, the case manager would also facilitate the transition back into the community. Before the resident's discharge, the nursing home would be required to give reasonable notice to a case manager.

As with social insurance coverage for home and community-based care, front-end nursing home coverage would not be free. The Commission recommends that all individuals be required to contribute 20 percent

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five current elderly individuals would be immediately eligible for benefits at these asset levels. Over time, the Commission expects that eligibility levels would be adjusted to sustain that scope of protection.

These recommended levels would be a vast improvement over current Medicaid rules, which require single persons to spend down their non-housing assets to $2,000. The Medicare Catastrophic Coverage Act of 1988, in a provision still in effect, did improve the asset protection for noninstitutionalized spouses, setting a minimum resource allowance at $12,000, and allowing spouses to keep half of assets up to $60,000.9 The recommended program, however, would set the floor for spousal assets at $60,000. Individuals with non-housing assets in excess of the levels protected by the program would be required to liquidate these resources and use them to finance their nursing home care before becoming eligible for program benefits. A case example of how this program would affect one individual appears on the next page.

The Commission recommends that individuals with long nursing home stays be required to contribute income toward the costs of this nursing home care, after certain portions of income are protected.

EARL DOTTER

Under the Commission plan, people needing nursing home care would be protected no matter how long they stayed. of the actual costs of care, or 20 percent of the national average cost of nursing home care, whichever is lower, with federal subsidization for the poor and near-poor. The federal government would fully subsidize this copayment for individuals with incomes at or below the federal poverty level, and partially subsidize it at least for those with incomes between 100 percent and 200 percent of poverty.

The program would allow single individuals to keep 30 percent of their monthly income for the first year of their nursing home stay so that they can maintain their homes in the community. Married persons would be eligible for this housing allowance as long as the community spouse were alive. This allowance is designed primarily for people who are likely to return to the community and have housing costs that must continue to be metsuch as mortgage payments, property taxes, rent and condominium fees, and home repairs-during their nursing home stay. The program would also provide a personal needs allowance of $100 per month to the person in the nursing home, which is a vast improvement over the typical $30 per month currently available under Medicaid.

The Commission believes that no severely disabled person should have to exhaust life savings and face the stigma of a welfare program in order to get coverage for longer stays in a nursing home. For individuals with nursing home stays of more than three months, the Commission recommends establishing a floor of asset protection and more generous income protection than is available under current law to ensure that no individual or noninstitutionalized spouse faces impoverishment. For those who meet the disability criteria, this program would replace the welfare-based Medicaid program.

Finally, the program would improve the spousal income protection provided by the Medicare Catastrophic Coverage Act. Under current law, states are required to set aside a sufficient amount of the institutionalized spouse's income to raise the community spouse's income to 122 percent of the federal poverty level for a couple; up to 133 percent of this level as of July 1, 1991; and up to 150 percent of this level as of July 1, 1992. The Commission recommends raising the minimum spousal income protection to 200 percent of the poverty level for a couple. In 1990, this would protect $16,900 for the spouse. Any remaining income would go toward the cost of the nursing home care.

Single individuals would be allowed to keep $30,000 and couples $60,000 in non-housing assets. Three out of

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