By Sheryl Allenson, J.D.
Analyzing data and experience from Maryland’s Community First Choice (CFC) benefit, the Commonwealth Fund discussed the feasibility of a Medicare Help at Home program in a June 2018 Issue Brief. The Commonwealth Fund concluded that Maryland’s experiences with a Help at Home program are encouraging. Maryland’s CFC benefit was authorized by Section 2401 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Currently, Medicare does not cover home and community-based services, which puts a segment of the population at risk of being placed in long-term nursing homes.
Maryland’s CFC benefit does not substitute informal support from family members and other caregivers but rather supplements that care. This experience suggests a targeted benefit to augment support from family members and other unpaid caregivers. The Issue Brief explains individual eligibility for a CFC benefit, noting that Maryland was one of the first to implement the benefit. The benefit is designed to cover personal care services through qualified organizations that employ providers, including family members. Under the CFC, these personal attendant services can be covered by the states under their Medicaid plans. They then can receive the enhanced federal medical assistance percentage (FMAP) of six percentage points for enrollees that would be otherwise eligible for institutional nursing care. The Issue Brief explained that unlike other long-term services and support programs, the CFC does not limit the enhanced FMAP to a specific time period, thus allowing the six percentage point match for CFC services.
The Commonwealth Fund highlighted the enrollment trends and demographics of the Maryland CFC benefit, which was introduced in 2014. From that point through the end of 2016, enrollees grew to more than 11,500, which included some individuals who had been previously covered under a Medicaid home-and community-based services benefit (HCBS) and some who were newly eligible for Medicaid and Medicare. Based on Maryland’s experiences, that enrollment in a Medicare benefit would likely grow over time. Moreover, the cost-per-participant, based on Maryland’s CFC costs, appear to be stable. In considering whether a Medicare Help at Home is viable, this is reassuring, according to The Commonwealth Fund. The greatest expense is for personal assistance services.
Although Maryland’s experience with the CFC bodes well for a Medicare Help and Home Program, the Commonwealth Fund still highlighted the limitations on the data to be drawn from the state’s program, noting that Maryland’s CFC is still in its early stages. As a result, the Issue Brief questions whether the data actually foretells trends in various areas. "On the key issue of whether the program substitutes for unpaid service, the analysis does not permit conclusive evidence of causality. Eligible participants were not randomly assigned to receive benefits; only trend data pre- and post-adoption are available."
Nonetheless, Maryland’s experience with the CFC benefit is "encouraging," according to the Issue Brief. Specifically, the CFC addresses concerns arising from the implementation of a Help at Home Medicare benefit, including concerns that the benefit would supplant informal care, finding this concern unfounded. Instead, targeted benefits, for example 20 hours per week, will likely augment unpaid informal support. Maryland’s CFC unveiled a significant unmet need for personal care among Medicaid beneficiaries. If Medicaid added a similar benefit, it could help minimize "spend-down to Medicaid," Finally, Maryland’s CFC demonstrates "that it is possible to define eligibility, assess functional status and hours of needed care, establish per-person budgets appropriately, and stabilize spending per person."
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