Item 11 of the 2002-2004 Appropriations Act requires a Joint Commission on Health Care (JCHC) evaluation of the personal maintenance allowance (PMA) within the Medicaid Elderly and Disabled Waiver.

When the Medicaid program was established in 1965, it was expected to provide health and nursing home care for low-income Americans; it is unlikely that the scope of Medicaid's current role in long-term care (LTC) was anticipated.

"Today, more than one-third of all Medicaid spending pays for long-term care (Kaiser 1997) ... It is the largest source of financing for nursing home care, constituting 48% of payments (Levit et al. 1997). Medicaid is also a significant, though less dominant, source of funding for home care, paying for 14% of such services in 1996 (Levit et al. 1997)" from AARP Medicaid Financial Eligibility for Older People.

To qualify for Medicaid payment for LTC services a person must:

• Be aged, blind or disabled
• Comply with income and resource limitations
• Meet level of functioning criteria.

Special income and resource requirements are applied in determining eligibility for LTC services. Thus, persons with incomes above the levels usually allowed for Medicaid may be eligible due to the cost of care. In Virginia, the income level is set at 300% of 551 ($545 X 3 =$1,635) and "countable" resources are in general $2,000 for an individual and $3,000 for a couple.

Medicaid waivers must be designed to allow individuals who would otherwise qualify for institutional placement (in a NF, ICF/MR or hospital) to remain in the community. The personal maintenance allowance is the amount the waiver recipient is allowed to deduct from income to account for the basic expenses related to living in the community. Additional deductions are allowed if the waiver recipient has un-reimbursed medical or remedial care expenses or a spouse or dependent children are living in the home.

An AARP survey of the PMA allowed in the elder care waivers in 50 states in 1998 showed:

• PMAs varied from $242 in North Carolina to $1,482 in 14 states (North Carolina increased its PMA to 100% SSI in 1999)
• the average PMA was $881 (178% SSI) and median PMA was $671 (136% SSI)
• 31 states allowed higher PMAs than Virginia.

Virginia has 6 Medicaid home- and community-based services (HCBS) waivers:

• Acquired Immunodeficiency Syndrome (AIDS); 417 individuals
• Elderly and Disabled (E&D); 9,567 individuals
• Consumer-Directed Personal Attendant Services (CD-PAS); 151 individuals
• Individual and Family Developmental Disabilities Support (DD); 323 individuals
• Mental Retardation (MR); 5,056 individuals
• Technology Assistance; 280 individuals

While income eligibility for each of the waivers is set at 300% of SSI, PMAs are set at 100% SSI except for the AIDS waiver.

Advocates indicate that the PMA is not high enough for individuals who receive the Medicaid waivers (other than AIDS waiver). Three Centers for Independent Living provided cost of living estimates for one disabled person:

• $1,914 per month in Northern Virginia
• $1,247 per month in Norfolk
• $1,154 per month in far Southwest Virginia.

DMAS cost estimates to the Centers for Medicare and Medicaid Services showed waiver is less costly than NF care (FY 2001):

E&D Waiver - $14,856/individual; $141 million
NFs - $22,749/individual; $596 million

Actions Taken by JCHC

A number of policy options were offered by the Joint Commission on Health Care regarding the issues discussed in this report. These policy options are listed on pages 21-22. A summary of public comments received regarding the proposed Options are included in Appendix B.

JCHC took the following action with regard to the study Options:

• Introduce budget amendments to increase the allowance from 100 percent ($552 per month) to 150 percent ($828 per month) of Supplemental Security Income.