2016 Impact of Consolidation on Long-Term Services & Supports 25
E. Consumers Paying for LTSS Through Medicaid
The Medicaid program146 is the primary public payer for both nursing home care and home- and community-based LTSS.147 “Medicaid is the largest single purchaser of LTSS in the United States, with cumulative spending of more than $130 billion annually on behalf of more than four million individuals. This spending surpasses both Medicare and commercial insurance spending combined.”148 Historically, with the notable exception of the Department of Veterans Affairs’ Aid and Attendance and Housebound program,149 individuals who were dependent on public funding for their LTSS were subject to important choices about the who, what, when, where, and how details of their service plan being determined and directed by the funding agency (usually the state’s designated Medicaid agency).150 Institutional—mainly nursing home— services were favored for many years under the terms of the Medicaid statute, but in the last couple of decades, an array of home- and community-based (HCB) alternatives have become increasingly available to consumers on Medicaid through a slew of state-specific waiver programs.151 Although originally the HCB alternatives were built around an agency-directed model, more recently a variety of opportunities for consumer-directed LTSS have been opened up for Medicaid-dependent people, by moving from an
146. 42 U.S.C. §§ 1396-1396w- 5 (2014); see generally Laura Snyder & Robin Rudowitz, Medicaid Financing: How Does It Work and What Are the Implications?, HENRY J. KAISER FAM. FOUND. 1 (May 2015), http://files.kff.org/attachment/issue-brief-medicaid-financing- how-does-it-work-and-what-are-the-implications. 147. Erica L. Reaves & MaryBeth Musumeci, Medicaid and Long-Term Services and Supports: A Primer, HENRY J. KAISER FAM. FOUND. 1 (Dec. 2015), http://files.kff.org/ attachment/report-medicaid-and-long-term-services-and-supports-a-primer. 148. Dennis G. Smith et al., Proposed Rule Creates Challenges for Managed Long-Term Services and Supports, DENTONS (July 8, 2015), http://www.dentons.com/en/insights/alerts/ 2015/july/8/proposed-rule-creates-challenges-for-managed-long-term-services. 149. See Pension: Aid & Attendance and Housebound, U.S. DEP’T VETERANS AFF., http://www.benefits.va.gov/pension/aid_attendance_housebound.asp (last updated Dec. 8, 2015). 150. See KAREN TRITZ, CONG. RESEARCH SERV., LONG-TERM CARE: CONSUMER- DIRECTED SERVICES UNDER MEDICAID 9 (Aug. 31, 2006), http://congressionalresearch. com/RL32219/ document.php (comparing agency-directed versus consumer-directed LTSS in terms of program structures and policies); Mary J. Clark et al., A Longitudinal Comparison of Consumer-Directed and Agency-Directed Personal Assistance Service Programmes Among Persons with Physical Disabilities, 30 DISABILITY & REHABILITATION 689, 689 (2008) (“Agency-directed models offer few choices over who is hired, daily scheduling, the types of services to be performed, or how the services are performed.”). 151. See generally Hermer, supra note 6, at 62 (“This article examines efforts states are making to expand access to community-based services for elderly and disabled Medicaid beneficiaries and suggests several options that might improve such access nationally.”); Molly O’Malley Watts et al., Money Follows the Person: A 2015 State Survey of Transitions, Services, and Costs, HENRY J. KAISER FAM. FOUND. (Oct. 16, 2015), http://kff.org/medicaid/ report/money-follows-the-person-a-2015-state-survey-of-transitions-services-and-costs/.