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Get top deals, latest trends, and more. Email address. Sign up. New flexibilities combined with funding provided through the American Rescue Plan Act helped states enact new policies to address those issues during the pandemic, but many of those policies are ending and federal funding will expire.

The data come from the 21 st KFF survey of officials administering Medicaid HCBS programs in all 50 states and the District of Columbia, which states completed between May and August The survey was sent to each state official responsible for overseeing the administration of HCBS benefits including home health, personal care, and waiver services for specific populations such as people with physical disabilities.

All states except Florida responded to the survey, but response rates for certain questions were lower. Key takeaways include:. HCBS are one type of long-term services and supports LTSS , which encompass a broad range of paid and unpaid medical and personal care services. LTSS assist with activities of daily living such as eating, bathing, and dressing and instrumental activities of daily living such as preparing meals, managing medication, and housekeeping.

Services provided in non-institutional settings are usually referred to as HCBS and include a wide range of services such as adult daycare, home health, personal care, transportation, and supported employment.

A wide variety of workers provide HCBS, and most positions require minimal training and education see Box 1. In , Medicaid was the primary payer for LTSS, covering over half of all spending in in the U. The HCBS workforce is diverse and encompasses individuals with a variety of job titles.

Depending on the state and the specific services offered, the people who provide HCBS include personal care aides, direct support professionals, home health aides, certified nursing assistants, and independent providers.

Different types of providers are paid differently and are subject to different training and certification requirements. Home health aides and certified nursing assistants are the only types of providers that must comply with federal training and certification standards.

Most have less than an associate degree and although over half work full time, many receive public assistance such as Medicaid or food and nutrition assistance.

If services are provided through a state plan, they must be offered to all eligible individuals. In contrast, services provided under waivers, such as s or c s, may be restricted to specific groups based on geographic region, income, or type of disability.

Waivers may also include a wider range of service types than can be provided under state plans. Many HCBS are now available through Medicaid state plans and available to all enrollees in the state. KFF estimates that over 4 million Medicaid enrollees use HCBS, and that the numbers of people using HCBS through the state plan are similar to the numbers using HCBS through waivers.

States are required to offer home health through their Medicaid state plan and 34 states also offer personal care through the state plan. Most c waivers serve specific populations, with 47 states having waivers for people with intellectual or developmental disabilities and 42 states having waivers for people who are ages 65 and older or have physical disabilities.

Ohio was the only state to report a new c waiver in , serving people under age 21 who have complex behavioral health needs that would require an inpatient level of psychiatric care. Over half of states use managed care to provide at least some HCBS, particularly for benefits provided through the state plan or waivers.

In managed care, states pay managed care plans a set fee—often called a capitation payment—for each person enrolled and the managed care plans are responsible for providing all services to enrollees.

Use of managed care to provide HCBS has been growing over time , with states using managed care to make their Medicaid spending more predictable and to help coordinate the services enrollees use.

Among the 14 states with waivers, 10 use managed care plans to provide at least some of the HCBS and over half of states use managed care plans to provide at least some home health and personal care. Managed care was much less common under the c waivers, particularly for waivers serving people with intellectual or developmental disabilities—of the 47 states with such waivers, only 6 provided any of the benefits through managed care.

All responding states reported workforce shortages in , with the most common shortages being among direct support professionals 50 states , personal care attendants 49 states , and nursing staff 49 states Figure 3, Appendix Table 3. States were asked if they had shortages of each type of provider but were not provided with a definition of shortage.

Most states also reported shortages in home health aides 47 states , case managers 45 states , community-based mental health providers 38 states , and occupational, physical, and speech therapy providers 35 states. In some cases, states may not have reported a shortage of a particular type of provider because that type of service is not offered through the HCBS program.

All states but one Nebraska reported shortages for more than one type of provider and 48 states reported shortages among five or more provider types. Such shortages may reflect ongoing effects from the pandemic, but also low levels of compensation coupled with increasing requirements of providers.

The federal requirement took effect in January for personal care and in January for home health services. Within the last year, 43 states experienced permanent closures of HCBS providers, which were most common among adult day health programs 32 states , group homes 29 states , and assisted living facilities 27 states Figure 4, Appendix Table 4.

States were asked if there were any permanent closures of providers within each type of setting that provides HCBS. Arizona and Tennessee reported that closures were unknown to the state. Most states reported closures among more than one type of provider: 37 states reported closures among two or more provider types, 23 states reported closures among 4 or more provider types, and 1 state Maine reported closures among all eight provider types.

The services are intended to support independence and socialization while also providing family caregivers with a break during the day.

All responding states reported taking actions to address provider shortages, with 48 states increasing payment rates, 42 states developing or expanding worker education and training programs, and 41 states offering incentive payments to recruit or retain workers Figure 1, Appendix Table 1.

Less common initiatives included establishing or raising the state minimum wage 20 states and offering paid sick leave for workers 19 states.

States also reported several other types of initiatives to strengthen the workforce, including creating platforms or support systems to connect job seekers with employers and positions, launching a social media campaign, and providing outreach to prospective employees.

Some states have permanent payment rate increases in place for providers, but 13 states reported that payment rate increases for at least some of the workers were temporary. Only 14 states have payment formulas that automatically increase with the costs of living, but those formulas do not apply across all types of workers.

KFF asked states to report their average dollar rate per visit paid to two types of HCBS provider agencies personal care agencies and home health agencies and three types of specific HCBS providers personal care providers, home health aides, and registered nurses , but many states were unable to report all rates Figure 5, Appendix Table 5.

The number of states that did not provide payment rates or reported that payment rates were unknown was 8 for personal care agencies and 24 for home health agencies. Even more states did not provide payment rates for specific provider types: For each specific type of provider, nearly half of states did not provide payment rate information or reported that payment rates were unknown.

If provisions of a proposed Biden Administration rule are finalized, states would be required to report such detailed payment rates see Box 2.

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Reducing the Cost of Care

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However, these programs could help. Medicaid , a joint federal and state health insurance program for low-income Americans, offers several important benefits for seniors, like certain home care services. But depending on where you live, Original Medicaid could help offset some of the costs of in-home care for elderly adults.

The OAA is a federal program available to adults 60 and older with a significant need. It funds different state and local service programs that promote the independence of frail and disabled older adults.

These benefits can help offset various costs of in-home care for elderly adults, such as:. SHIP provides free counseling to Medicare recipients, their families, and caregivers. This guidance helps cover or lower the cost of in-home care for elderly adults by making it much easier to navigate Medicare and understand benefits, coverage, and eligibility for various programs.

PACE , a joint Medicare-Medicaid program, allows seniors to age in place by providing financial assistance to meet their health and care needs at home.

This program includes all covered services available through Medicare and Medicaid, non-medical in-home and home health care services. Visit Medicare. gov to find out which programs are available in your state.

HCBS refer to various types of person-centered care delivered in the home and community. In addition, HCBS waivers, or c waivers , help offset some of the costs of self-directed home care. These programs are available through the state and can include assistance for various home care services, such as:.

HCBS waivers are available in nearly every state. This monthly stipend helps cover various long-term care costs, including home care. Seniors who self-direct their care, hire a caregiver, or pay for a family member to care for them could qualify for the medical care tax deduction. This benefit allows qualifying adults 65 and older to itemize eligible medical expenses that exceed 7.

Qualified expenses include those prescribed by a licensed practitioner, long-term care, and nursing services. Cash and counseling programs help lower the cost of in-home care for elderly adults by providing cash stipends to help them meet their needs at home.

Beneficiaries can use this benefit to pay a family caregiver, purchase assistive devices, and cover home modifications. Rather, they help offset the cost of home remodels such as wheelchair ramps, stair lifts, or even an accessory apartment.

For this reason, these loans are ideal for family caregivers whose loved one lives with them in their home. Rural Repair and Rehabilitation Grants or the Section Home Repair program are available to very low-income rural homeowners. Interested applicants can visit USDA to find a home loan specialist, ask questions, and get started.

At adult day programs , seniors can receive care, enjoy healthy meals, and participate in activities that support social and cognitive wellbeing. Plus, many provide transportation to assist those who need reliable transportation.

Breaking up in-home care with adult day services a few days a week ensures that seniors receive full-time support without paying as much. Official 99 Cent Only Store Wholesaler Over 10, Retailers Served Since ! Call Us: How BW Works Sign In or Register. BARGAIN WHOLESALE.

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Temporarily Sold Out. Athlete's Foot Cream, 1. Add To Cart. States also reported several other types of initiatives to strengthen the workforce, including creating platforms or support systems to connect job seekers with employers and positions, launching a social media campaign, and providing outreach to prospective employees.

Some states have permanent payment rate increases in place for providers, but 13 states reported that payment rate increases for at least some of the workers were temporary. Only 14 states have payment formulas that automatically increase with the costs of living, but those formulas do not apply across all types of workers.

KFF asked states to report their average dollar rate per visit paid to two types of HCBS provider agencies personal care agencies and home health agencies and three types of specific HCBS providers personal care providers, home health aides, and registered nurses , but many states were unable to report all rates Figure 5, Appendix Table 5.

The number of states that did not provide payment rates or reported that payment rates were unknown was 8 for personal care agencies and 24 for home health agencies.

Even more states did not provide payment rates for specific provider types: For each specific type of provider, nearly half of states did not provide payment rate information or reported that payment rates were unknown.

If provisions of a proposed Biden Administration rule are finalized, states would be required to report such detailed payment rates see Box 2. Among the states that were able to report payment rates, only 15 could report payment rates for personal care agencies, home health agencies, personal care providers, and home health aides, all of which would be required under the rule.

Those 15 states include states that reported a mix of time-based and visit-based rates, which makes comparisons between provider and agency rates more complicated. Given the challenges for states in collecting such data, federal guidance might be required to achieve consistent reporting across states.

On May 3, , the Biden Administration released a proposed rule aimed at ensuring access to Medicaid services, which has several notable provisions aimed at addressing HCBS workforce challenges.

States would be required to report payment rates for personal care, home health aide, and homemaker services to increase transparency around payment rates. For services provided through c waivers and through the state plan authorities, the proposed rule has additional requirements related to the HCBS workforce, including the following.

The proposed rule also includes provisions that would strengthen requirements around person-centered planning and needs assessment, create new requirements around incident management, establish requirements for people to file grievances if they are receiving HCBS from the state Medicaid program, and require states to report on nationally-standardized quality measures.

Provisions would take effect on a rolling basis, between 2 and 4 years after the rule is finalized. States reported many reasons why it was difficult to report payment rates, including the following.

In addition to having difficulty reporting payment rates, many states reported different payment rates for personal care across different waivers and the waiver payment rates often differ from the payment rates for personal care provided through the state plan.

When states reported multiple payment rates for personal care, KFF used the median of those payment rates in the analysis. Although KFF asked states to report the average dollar rate per visit, states varied in their reporting of payment rates, with most states reporting payment rates by time either 15 minutes or one hour , and a smaller number of states reporting rates that were per visit or per day.

Rates for home health aides are somewhat higher, reflecting the additional training requirements for such workers. Among the states with payment rates in the highest category, some reported that the rates were per visit or per day.

Others did not indicate whether their rates were based on time or another basis, but it is likely that most payment rates in the highest category are per visit or per day.

Payment rates to home health agencies are generally larger than those to personal care agencies, but there is considerable variation in both Figure 6. The payment rates to HCBS providers also show considerable variation and are somewhat higher than those reported by other organizations on account of differences in reporting and provider categorization Figure 6.

It is difficult to compare those numbers to those of other organizations for the following reasons. Among states that deliver HCBS through managed care , 20 states reported that the fee-for-service payment rate is the minimum amount MCOs could pay providers.

Out of the 36 states that use managed care to provide at least some HCBS, none of the states reported that fee-for-service rates were the maximum amount that managed care plans could pay providers.

There were 20 states that reported fee-for-service rates were the minimum payment rates, 12 states that reported there was no relationship between the fee-for-service and managed care rates, and 4 states that reported the answer was unknown or did not respond to the question.

Even among states that do not directly tie fee-for-service rates to managed care rates, the fee-for-service rates may affect negotiations between health plans and HCBS providers, thereby, affecting the managed care rates.

Furthermore, it is common for provider reimbursement contracts that are directly tied to the Medicaid fee schedule i. How does the workforce shortage for Medicaid HCBS fit in with the broader staffing challenges for long-term services and supports LTSS?

Recent analysis on the Peterson-KFF Health System Tracker shows that, as of June , the number of workers in LTSS settings was measurably lower than in early Shortages and high turnover among LTSS workers reflect demanding working conditions and relatively low wages.

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