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Four states:
How In-Home Services work in . . .

California
Kansas
Maine
Oregon
. . . about worker pay

For its report Adults with Severe Disabilities: Federal and State Approaches for Personal Care and other Services,published May, 1999 (GAO-HEHS 99-101), General Accounting Office researchers visited four states to see how Medicaid-funded in-home services were working. " The four states in our sample -- California, Kansas, Maine, and Oregon -- have extensive interest in or experience with consumer-directed personal care. Despite differences in their consumer-direction models, all four states have confronted similar issues surrounding the availability and quality of consumer-directed services: (1) ensuring a qualified pool of personal caregivers for what are typically relatively low-wage positions that often attract individuals with little or no training and (2) balancing state concerns regarding consumer safety with the consumers' right to self-direct their own care." The information below is taken from the GAO report.

California relies on the Personal Care Services benefit primarily as a means of providing attendant services to individuals with long-term care needs

Under California's county-based system, 96 percent of attendant (and related services) is self-directed, with consumers having various levels of access to supportive services.

State officials told General Accounting Office researchers that regulations require that all counties evaluate consumers regarding their ability to self-direct and, if counties determine consumers are incapable, they are "referred for special assistance."

Of California's 58 counties, 16 offer service delivery models other than self-direction that are based upon county assessments of consumers' needs. In these 16 counties, consumers may also select providers from either the contracting agency or the counties' contracted providers.

Twenty-three counties offer supported individual provider services, which use state funds to provide additional administrative and support services for consumers using independent providers. Supported individual provider services enhance service delivery through recruitment, provider list development and maintenance, orientation classes, supervision assistance, and consumer-to-independent- provider matching services.

Six counties have opted to form public authorities. Public authorities are relatively new; the San Francisco Public Authority first met in Oct. 1995, and Los Angeles passed its ordinance in Oct. 1997. These are considered which are enhanced independent provider models, and provide additional client assistance and increased compensation for providers. In California, counties exercise control over many aspects of personal care. Not only do they administer the attendant services program, they are also responsible for 17.5 percent of costs and decide what supportive services will be available to consumers. In other counties where there are no public authorities, few such services are available.

Counties have the option of increasing the personal attendant's hourly wage using local revenues, without any state contribution to the increase. Only San Francisco has augmented the wage level. Several other counties are currently considering increases. In addition, California has chosen to use state revenues to pay relatives for providing attendant services to people who are otherwise eligible for Medicaid reimbursement, because HCFA generally prohibits Medicaid payments to spouses or parents of beneficiaries who provide care.

The degree of self-direction in Kansas ranges from a low of 10 percent of people with developmental disabilities to a high of 70 percent of those with physical disabilities. The "frail elderly" fall in between, with 30 percent self-directing their care. Consumers choosing self-direction manage all aspects of their care except paying personal attendants, which is generally the responsibility of community organizations that serve as payroll agents. Consumers are given lists of payroll agents from which they may choose. Consumers may consult with independent living centers for help with determining "how comfortable they are with living independently in the community and with self-direction."

In Kansas, under the HCBS waiver for people with physical disabilities, attendants are paid between $8.25 and $13.25 per hour. The specific amount is determined by the consumer and his or her independent living counselor and reflects in part the severity of the consumer's disability. These amounts are essentially ceilings; attendants are typically paid at lower levels.

For services arranged through the Topeka Independent Living Center, wages range from $7 to $10. an hour. Part of the reason for the difference between these rates and the maximum allowed by the state is that the Center pays for workers' compensation and unemployment insurance from the remainder of the state allowance.

Kansas' "frail elderly" HCBS waiver reimburses between $12.00 and $13.25, depending on the level of care the consumer requires. The waiver for people with developmental disabilities offers a flat hourly rate of $10.40.

These amounts are then subject to withholding and insurance, resulting in the attendant's receiving approximately $6 to $8.

Maine gives consumers an initial choice regarding self-direction. Consumers choosing to self-direct must then decide between two models. Under one model, all consumers must agree to participate in the most extensive consumer-directed program we reviewed, which requires clients to be responsible for training and developing job descriptions for their attendants as well as for performing actual payroll management functions. These consumers receive a voucher check twice a month from the state based on time sheets that they submitted. (A voucher check is a two-party check that the consumer signs over to the attendant.) Personal attendants are hired by the consumers and trained on the job by the consumers to assist with daily activities. Under the second model, consumers may choose between more limited self-direction and agency provision of service.

In Maine, 479 consumers collectively employ over 2,000 "personal caregivers." Maine limits eligibility to individuals with chronic or permanent disabilities.

Maine officials told the GAO researchers they were concerned about the implications of the lawsuits that had been filed requiring services be provided in the community, as well as about the U.S. Dept. of Justice's "most integrated setting" regulation. "State officials' concerns center on states' ability to limit participation in their waiver programs. Maine officials noted that it is crucial that the state have the authority to define eligibility for services and to implement programs consistently with financial budgets, especially given the large number of individuals who have ADL limitations."

In Oregon, consumer-directed providers, over whom clients have ultimate hiring and firing authority, provide over 91 percent of in-home services. These providers are paid directly by a state agency, and, thus, consumers have minimal involvement in the payroll process. However, consumers of Medicaid in-home care do verify that the authorized hours of work were performed by signing workers' time sheets.

In Oregon, case managers play a significant role in ensuring a successful community-based placement. Consumers work with case managers to obtain the set of services that best meets their functional needs. Oregon reports a staffing standard of one case manager for each 69 in-home clients‹approximately one-half of the staffing standard for nursing facility clients. Case managers can also arrange for in-home agency providers to assist in case of an emergency. Oregon has a "Client Employed Provider Guide for Employees" that helps clients select, hire, and direct their attendants.

Hourly wages for attendant services provided under consumer-directed (nonagency) arrangements