- Report Published -
|Medicaid-Funded Consumer-Directed Personal Assistance Services|
|Department of Medical Assistance Services|
|HJR 125 (Regular Session, 1996)|
|A heightened interest in consumer-directed personal assistance services by consumers with disabilities and providers prompted legislators to investigate the possibilities of providing consumer-directed services in Virginia. Consumer-directed personal assistance service is based upon the principle that individuals should have the primary responsibility for making decisions regarding the assistance they receive. Personal assistance services provide the elderly or disabled consumer with assistance with basic health-related services, such as helping with activities of daily living (eating, bathing, grooming, dressing, ambulation, and toileting); reporting changes in the recipient's conditions and needs; assisting with normally self-administered medications; and/or providing household services essential to health in the home. These services do not include the performance of skilled nursing services.|
In 1995, the General Assembly passed House Joint Resolution 539, which requested the evaluation of the feasibility and advisability of amending the existing Elderly and Disabled waiver to allow individuals to hire their own personal attendants. For the purposes of the study, a workgroup, representing the major stakeholders, was convened to evaluate the impact of offering a consumer-directed model of personal care on consumers, providers and other agencies in the community. The results of the workgroup were reported in House Document 18 (1996), entitled "A Study of Consumer-Directed Services."
Based upon the recommendations of this study, the 1996 General Assembly passed House Joint Resolution 125, which requested the Department of Medical Assistance Services to "examine existing and available waivers or other options to provide personal assistance services through a consumer-based model of service delivery." The resolution further directed the Department of Medical Assistance Services to "with all due haste, request a waiver or a waiver amendment from the federal government and implement with all due haste consumer-directed personal assistance services, in conjunction with the agency-directed model currently available, to Virginians who are elderly or who have disabilities."
In accordance with the resolution, the Department of Medical Assistance Services reviewed the "Study of Consumer-Directed Services" (House Document 18, 1996) and other state consumer-based models and waivers (Pennsylvania, Maine and Massachusetts). The Department of Medical Assistance Services also continued to meet with the Centers for Independent Living and the Department of Rehabilitative Services to identify ways to overcome concerns previously identified in the "Study of Consumer-Directed Services." These issues include quality assurance, reimbursement issues, utilization control, employment tax and benefit liability issues, and the impact on the long-term care system.
In order to meet the mandate of the 1996 General Assembly to implement a consumer-directed alternative to the agency-directed model of personal care services already in place, DMAS is requesting language in the budget during the 1997 General Assembly session to provide the agency with the authority to promulgate emergency regulations. If this language is approved by the General Assembly, the consumer-directed personal assistance services program can be implemented effective July 1, 1997. Without the authority to promulgate emergency regulations, DMAS must promulgate regulations via the full regulatory process prior to implementing the program. The full regulatory process takes an average of 14 months to complete. Emergency regulations will shorten the process by at least six months. HCFA waiver guidelines require that the State's regulatory process be complete prior to the final approval of the Waiver. Therefore, DMAS' waiver submission will coincide with the regulatory process.
The Department of Medical Assistance Services has developed a proposed model for Medicaid-funded consumer-directed personal assistance services. This new service will be provided as a separate waiver but in conjunction with the agency-directed model currently available to eligible individuals in the Elderly and Disabled Waiver. Consumers will be eligible to receive personal assistance services under either waiver, except in the consumer-directed model, the consumer will be allowed to hire their own personal attendant after demonstrating their ability to manage and supervise the performance of the attendant.
Both the agency-directed and the consumer-directed personal assistance models are designed to be cost-effective alternatives to institutionalization. Thereby, both models save the Commonwealth money in the provision of long-term care services. The purpose of the consumer-directed waiver will be to offer another cost-effective community-based alternative to the consumer at risk of institutionalization, not to demonstrate that one model is more cost effective than the other.
Comments Received from the Stakeholders on a Draft of this Report
The Department of Medical Assistance Services recently circulated a draft of this report to the stakeholders involved in the provision of personal assistance services to the elderly and consumers with disabilities to solicit comments on the proposed model for consumer-directed personal assistance services. The comments received indicated that there are still issues that require resolution as DMAS develops the regulations and waiver application. Those involved with the frail elderly are concerned that the proposed model is too open for abuse and puts the elderly consumer at risk. Those involved with the consumers with disabilities are concerned that the proposed model is still too restrictive and does not really afford the consumer the autonomy and independence to oversee the assistance needed. A summary of the major issues that still are a concern to the various stakeholders are described in Table 1.
Summary Comparison of the Elderly and Disabled Waiver and the Proposed Consumer-Directed Personal Assistance Waiver
The proposed model represents our best thinking to date on the issues and the program features of the consumer-directed personal assistance model. We have reviewed numerous approaches to the provision of consumer-directed personal assistance programs and have attempted to draw on the best aspects of all of those approaches, while avoiding some of the pitfalls of the past. We present this document now, not because we believe we have resolved all of these issues or because we are firmly committed to every feature. To the contrary, we present this document in the hope that we can continue to solicit the thoughts of all those with a stake in the future of consumer-directed services.
DMAS has had a successful personal assistance services program under the Elderly and Disabled Waiver program since 1982. Many features of this agency-directed model have been retained in the proposed consumer-directed personal assistance services waiver. This similarity will allow the consumers flexibility to choose which program suits their needs and to easily switch programs if desired. However, in order to recognize the principles of consumer-directed services which increase the consumer choice and ability to manage the services they receive, some aspects of the program are different from the agency-directed program. These similarities and differences are summarized in Table 2.