Medicare Compliance & Reimbursement

Flexible LTC options could end up costing benes access to Medicaid coverage

Millions of aging baby boomers, combined with escalating budgetary pressures, have federal and state governments trading in long-term care quality-of-care initiatives for cheaper--and controversial--"flexible" coverage options.

One of these flexible alternatives is the Medicaid Home and Community-Based Services waiver. The HCBS waiver gives beneficiaries the option to choose assisted-living or home-based care over nursing home care and other institutional care settings. But the waiver lacks quality-of-care standards, argues Edward C. King, executive director for the National Senior Citizens Law Center. He cites a 2003 Government Accountability Office report as proof. In addition, only 40 percent of health care opinion leaders are in favor of providing Medicaid benes with vouchers to purchase their own LTC services, according to a recent Commonwealth Fund survey.

Increasing budgetary restrictions are forcing states to curb Medicaid spending and improvise more cost-effective LTC solutions. For instance, some states--including Florida, Vermont, Kentucky, Idaho, South Carolina and New Hampshire--are proposing demonstration waivers as an alternative "flexible" Medicaid LTC option. Upon permission from the Centers for Medicare & Medicaid Services, these demonstration waivers allow states to establish experimental LTC programs that don't necessarily comply with Medicaid statute. While affording states more Medicaid flexibility, demonstration waivers threaten to deny Medicaid coverage to benes who have no other way to pay for LTC services. "Demonstration waivers can be used broadly to eliminate beneficiaries' entitlements to particular forms of care, including nursing home care; increase cost sharing; or cap state or federal expenditures for beneficiaries or for particular kinds of services," King warns.

At the very least, to provide optimum coverage and flexibility without sacrificing benes' entitlement and quality-of-care, LTC Medicaid waivers must neither eliminate nor restrict a Medicaid beneficiary's entitlement to long-term care. In addition, waivers must set meaningful quality-of-care standards for LTC services, notes King.

"As the baby boom population approaches young-old status, we should be rethinking our long-term care system in a comprehensive way, rather than devising waivers that may deny older Americans their right to high-quality long-term care," King proposes. "In refusing to provide for such care, we simply shift the costs to the most vulnerable adults in our society or to their families."