Home Care Options for Seniors: Alternatives to Nursing Homes
by Lesley M. Mehalick
Pennsylvania is the 4th “oldest” State in our country, and caring for our senior population is a growing concern. It has been estimated that 80% of the dollars spent on elders goes toward institutional, or nursing home, care. However, services that can be provided in one’s home and community are generally both more cost-effective and more desirable by consumer. As a result, we are starting to see a shift to expand funding and options for home and community based services (HCBS). Through HCBS, seniors can experience increased independence, choice, control, and dignity as they age.
Home and Community Based Services provide funding to allow aged or disabled persons to remain in their community and live independently in their homes. HCBS include services designed to prevent nursing home care, such as personal care, assistance with activities of daily living, homemaker services, protective supervision, home nursing, therapeutic services, home health aides, adult day programs (including transportation), respite care, certain home modifications, and case management services.
Many of the HCBS for seniors are offered through Pennsylvania’s “Waiver” programs, which are funded by both Federal and State monies. Specifically, the Aging Waiver, the Attendant Care Waiver and the LIFE program are all in this category.
The Pennsylvania Aging Waiver provides services to keep persons in their homes instead of requiring nursing home care. To be eligible for the Aging Waiver, one must be a Pennsylvania resident, age 60 or older, who is medically eligible and financially eligible. To be medically eligible, one must qualify as Nursing Facility Clinically Eligible (NFCE), which means that a physician certifies that due to diagnosed illness, injury or disability, the person requires the level of care and services that is typically provided by an institution. Of course, the person must still be able to be appropriately cared for in the home.
To be financially eligible for the Aging Waiver, one must have limited income (below $2,163 per month in 2014) and have resources below $2,000.00. Ironically, a person can have slightly higher income and resources and still qualify for nursing home care paid by Medicaid; however, for services through the Aging Waiver, there is a lower income and resource limit. The traditional Medicaid planning and gifting rules apply, meaning that many persons must engage in elder law planning before they are eligible for these services.
Another program is the Living Independent for the Elderly (LIFE) Waiver, which is a managed care program that provides a comprehensive all-inclusive package of medical and supportive services. In the LIFE program, services are generally provided at Adult Day Centers. To be eligible for LIFE, the applicant must be age 55 or older, Nursing Facility Clinically Eligible, financially eligible, and able to be safely served in community. For those who may have too high of an income level to be financially eligible, LIFE is also available for private pay. LIFE is only available in certain areas in Pennsylvania, so an applicant must reside in a LIFE service area.
The Attendant Care Waiver is an option that provides services to persons with physical disabilities in order to prevent institutionalization and remain independent. The Attendant Care Waiver is generally for persons between the ages of 18 to 59, but if a person receives the Attendant Care Waiver before her 60th birthday, she can opt to remain in after age 60 or move to Aging Waiver if that Waiver would better meet her needs. To qualify for the Attendant Care Waiver, a person must have a physical impairment that is expected to last 1 year or more, and be mentally alert and capable of directing her own care (managing own finances, supervising attendants). Additionally, the applicant must be Nursing Facility Clinically Eligible and financially eligible.
Both the Aging and Attendant Care Waivers allow certain family members to be paid as caregivers for the elder in need. It is important to note, however, that legally responsible individuals, who include the spouse and parent or stepparent of minor cannot be paid for their services under these waivers. Similarly, neither a guardian nor a POA may be paid. Otherwise, any family member who is over 18, can provide the needed service and passes a criminal and abuse clearance can qualify. Signed time sheets of the work performed must be regularly submitted.
Because the Waivers are funded through Medicaid, the Estate Recovery Act will be implicated for persons who receive Waiver services. The Estate Recovery Act is Pennsylvania’s right to recover against a decedent’s probate estate for Medical Assistance provided to that person after age 55. This recovery is currently limited to the “probate estate,” which includes all real and personal property titled in the person’s own name.
In addition to the waivers explained above, there are also several programs that are funded through state monies alone, instead of through Medicaid. As such, the Estate Recovery Act does not apply to these State funded programs. These programs include the OPTIONS Program, Act 150, the Domiciliary Care Program, and the Family Caregiver Support Program (FCSP).
Persons who do not qualify for Aging Waiver may explore the OPTIONS Program. This is a Pennsylvania operated program that provides similar services as the Aging Waiver but is not funded by Medicaid; it is funded through the Pennsylvania lottery. To be eligible for the OPTIONS program, one must be age 60 or older, but there is no resource limit , nor is there any income limit. Depending upon one’s income, however, there may be a cost-sharing requirement, and if one’s income is high enough, then the applicant will cover the entire cost. It is also not a requirement that an applicant to OPTIONS be Nursing Facility Clinically Eligible. Thus, for a person who does not qualify for the Aging Waiver based on either financial or medical reasons, then the OPTIONS program may be a viable choice. The OPTIONS program does have some limitations in that many Counties have waiting lists, and there is a monthly cap on the amount of services that will be covered.
Another state funded program is ACT 150, which provides the same services as the Attendant Care Waiver, but is not funded through Medicaid. As with the Attendant Care Waiver, applicants must be between the ages of 18 to 59, with a physical impairment expected to last a year or more and be mentally alert. Unlike the Attendant Care Waiver, there is no resource or income limit for Act 150, nor must one be Nursing Facility Clinically Eligible as certified by a physician.
The State also funds the Caregiver Support Program, which provides financial assistance for out of pocket care-giving expenses of the caregiver. The program is designed to help support caregiver, not replace the care provided. To be eligible, one must be the unpaid primary caregiver for a functionally dependent person over 60 or who has chronic dementia. This program provides a maximum benefit of $500.00 per month to the caregiver (for demonstrated need) as well as a lifetime limit of $2,000.00 for home modifications or assistive devices.
Lastly, there is a Domiciliary Care Program that provides a homelike living arrangement in the community for adults age 18 and older who need assistance with activities of daily living and are unable to live independently. In this program, a Domiciliary Care Provider opens his own home to a resident and the two parties enter into a contract for the resident to pay the home provider on a monthly basis for the entirety of the Dom Care residential service. The payment amount is determined annually by the State. To be eligible, a senior must be incapable of living independently, but should not be Nursing Facility Clinically Eligible. They must be mobile or semi-mobile so that they would be able to evacuate the home in the event of an emergency. The applicant also must be willing to live with a family.
Preserving our dignity and independence is a central goal as we age, and for many of us, this means being able to safely remain in our home as long as reasonably possible. It is important to be aware that there are alternatives to nursing homes, and that home and community based services may be a way for your loved one to be safely cared for in the home. Obviously, the options are varied and their eligibility requirements differ significantly, and as such, it is prudent to contact an elder law attorney to determine what program may be best for your situation.