A Tool for All Citizens
Since its founding in 1986,
the Indiana Home Care Task Force has coordinated the public policy
efforts to build a consumer driven system of quality and affordable home
and community based services (HCBS) in the state. Those efforts resulted
in the passage of the Community and Home Options to Institutional Care
for the Elderly and Disabled Act (CHOICE) in 1987, Senate Enrolled Act
493 in 2003, and many more HCBS laws in between.
What follows is a briefing
from the Task Force that can be used as a tool for any and all citizens
to advance cogent arguments regarding the importance of implementing SEA
493 and maintaining the CHOICE home care program. SEA 493 and CHOICE will
remain in 2006 and beyond the lynchpins and hope for the type of home and
community based services that Hoosiers want and need. Consequently,
readers of the Task Force paper will find the history, program
information, policy discussion, principles, and action steps they need to
effectively talk to the public officials and fellow citizens about the
importance of SEA 493 and CHOICE.
SEA 493 Implementation and Related Issues
An Advocacy Education Paper from
the Indiana Home Care Task Force
The implementation of Senate
Enrolled Act 493, commonly called SEA 493, is the primary concern of the
Indiana Home Care Talk Force. Its member organizations believe there is
no greater priority today in Indiana
regarding programs and services for senior citizens and persons with
disabilities. Citizens and organizations are encouraged to use the
following briefing paper to enhance their abilities to effectively
communicate with other Hoosiers, public officials and lawmakers regarding
the importance of SEA 493 and CHOICE.
In 1987 the General Assembly
passed by a vote of 149-1 the Community and Home Options to Institutional
Care for the Elderly and Disabled Act, or CHOICE. CHOICE remains the most
popular and visible form of quality and consumer driven home care
services today for seniors and persons with disabilities. CHOICE is
administered locally by the 16 Area Agencies on Aging with all services
delivered by private providers. CHOICE remains very cost effective and
Since CHOICE only uses state
tax dollars, its funding base has proven to be finite. Additionally,
while CHOICE is a very flexible program it is not a substitute for
programs that specifically provide for assisted living, adult foster (or
family) care, and adult day care.
Beginning in 1991, Indiana began to
employ a series of Medicaid waivers for home and community based services
(HCBS) that are similar to CHOICE in order to bring federal dollars for
those services. However, the combination of CHOICE and the waivers did
not create a comprehensive, integrated and balanced long-term care
system. That happened with the unanimous passage of SEA 493 in the 2003
SEA 493 is comprehensive
because the law establishes a long-term care (LTC) system that requires
individuals to have the choice of any form of LTC they need including any
form of HCBS. The implementation of SEA 493 must maintain that feature of
SEA 493 is integrated because
it establishes a global budget for all long-term care and allows dollars
to follow individuals receiving Medicaid nursing home services to
Medicaid HCBS if they choose the latter.
SEA 493 is balanced because
it equalizes income eligibility between Medicaid nursing home care and
HCBS waivers by raising the latter to 300 percent of the federal
Supplemental Security Income level, or $1,810 per month for individuals.
The implementation of SEA 493
and the ongoing administration of CHOICE must be in accordance with the
consumer driven features of those laws.
SEA 493 and CHOICE encourage
and are compatible with the optimal use of federal Medicaid waivers,
Medicaid, Medicare and other federally funded HCBS. Neither should be
denigrated by the state in the process of trying to optimize the use of
federal dollars. (As used in this briefing paper, “state” refers to the
Indiana Division of Aging and its supervisory agency, the Indiana Family
and Social Services Administration.)
SEA 493 and CHOICE are based
on consumer-driven market place solutions. These laws are specifically
designed to use neutral case management services and advocacy for
consumers provided in local communities through the Area Agencies on
Aging in order to make market place choices viable. This structure is
commonly called the “single point of entry system” and is a nationally
recognized model. That system protects consumers, and brokers the best
and most effective services from private providers. Those local market
mechanisms should stay in place.
As a whole the AAAs operate
case management services, nutrition programs, and federally mandated
advocacy services that result in best health and outcomes for seniors and
persons with disabilities. Nonetheless, the AAAs have
indicated their willingness to work in partnership with consumer groups
and the state to improve what they do. Recent threats and actions by the
state to cut AAA budgets, to alter Medicaid waiver and CHOICE provider
rates, to threaten AAA nutrition programs, and to take away their senior
employment programs only make it harder for the AAAs to do their work.
Such actions by the state will make it difficult to implement SEA 493 in
a humane and cost effective manner.
Rates set by the state for HCBS services must be adequate to
ensure participation of quality providers, and to generate local
competition between providers wherever possible.
The AAAs must be sustained through adequate staff and funding,
and should continue to serve as the independent, single point of entry,
one-stop resource for consumers in need of long-term care.
The AAAs should continue to be locally controlled and
accountable within the context of existing state and federal laws.
Contracts with the state should reflect those parameters. New performance
standards for the AAAs must be mutually agreed upon by the state, the
AAAs, and consumer representatives.
The CHOICE program must be funded at a level to insure
sufficient services for those waiver-eligible consumers who have not yet
transitioned onto an HCBS waiver, and to insure sufficient services to
all CHOICE eligible consumers who do not quality for the waiver.
The state should work with the Area Agencies on Aging to
calculate the number of persons who should be receiving Medicaid waiver
services under the provisions of SEA 493 including persons currently
being served by CHOICE, persons in other long-term care settings, and
persons on waiting lists. These calculations should include estimates of
the number who can be served on the waivers in the current fiscal year,
estimates of the persons to be served in the next biennium in all
long-term care venues, and calculations regarding funding and appropriate
All consumers entering the long-term care system or changing
services within that system should receive independent counseling about
all the available options from a professional AAA case manager, and have
freedom of choice among all options for which they are eligible as
defined by SEA 493 and CHOICE.
Consumers may not be forced to move or relocate against their
will as the result of a “bed buy-out” in any nursing facility and these
transactions must be transparent. (The state has offered to literally pay
nursing homes $10,000 or more per bed to close Medicaid certified nursing
facility resident beds in order to take them off the market. Since bed
buy-outs are done with public funds the transactions should be entirely
open to public review.)
The array of services within Indiana’s long-term care system must
include a true diversity of facility and community based options, with an
emphasis on non-institutional providers of long-term care services per
the directives contained in SEA 493.
The state must maintain in its administrative code a standard
for adult family/foster care providers of a maximum of three individuals
in each home-like setting.
To act on the concerns raised
in this memorandum state officials and legislators have three options:
Utilizing public hearings by
standing legislative commissions or committees, or by committees during
the 2997 session, to hear public concerns and to secure commitments from
the state to address the concerns that are raised in this paper.
Pass legislation to address
the concerns listed in this paper.
Pass funding in the state
budget act to address the funding needed for HCBS under SEA 493 and
CHOICE, and to address the administrative and case management needs of the
Area Agencies on Aging.
The Indiana Home Care Task
Force stands ready to work with the state and the members of the General
Assembly to draft solutions to the concerns raised
in this paper. Citizens who share these concerns are also urged to
communicate with state officials and their elected representatives.