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United States General Accounting Office: 
GAO: 

Report to the Chairman, Special Committee on Aging, U.S. Senate: 

September 2002: 

Long-Term Care: 

Availability of Medicaid Home and Community Services for Elderly 
Individuals Varies Considerably: 

GAO-02-1121: 

Contents: 

Results in Brief: 

Background: 

Selected States Varied in Expenditures for and Design of Medicaid Home 
and Community Services: 

Case Managers Predominately Offered Medicaid In-Home Care Services, but 
Number of Hours Offered Varied: 

Case Managers in Some States Offered More In-Home Care, Alternative 
Residential Settings, or Other Supplemental Services: 

Concluding Observations: 

States’ Comments: 

Appendix I: Summary of Hypothetical Individuals Presented to Case 
Managers: 

Appendix II Summary of Care Plans Offered by 16 Case Managers: 

Tables: 

Table 1: Medicaid Expenditures in Four States for Long-Term Care 
Services for the Elderly per State Population Aged 65 or Older, 1999: 

Table 2: Medicaid Home and Community-Based Long-Term Care Services for 
Elderly in Four States: 

Table 3: Number of Care Plans that Recommended that the Individual 
Remain at Home or Move to a Different Residential Setting: 

Table 4: Number of Hours of In-Home Care Offered For Individuals 
Remaining At Home: 

Table 5: Range in Amount of In-Home Care Offered for Individuals 
Remaining at Home, by State: 

Table 6: Number of Care Plans Where Nursing Home or Alternative 
Residential Setting was Recommended: 

Table 7: Care Plans for Abby, an 86-Year-Old Chair-Bound Woman With 
Debilitating Arthritis Who Lives with Her Daughter (Scenario 1): 

Table 8: Care Plans for Abby, an 86-Year-Old Chair-Bound Woman With 
Debilitating Arthritis Who Lives With Her Sister (Scenario 2): 

Table 9: Care Plans for Abby, an 86-Year-Old Chair-Bound Woman With 
Debilitating Arthritis Who Lives Alone (Scenario 3): 

Table 10: Care Plans for Brian, a 70-Year-Old Man With Moderate 
Alzheimer’s Disease Who Lives With His Wife in Fair Health (Scenario 
1): 

Table 11: Care Plans for Brian, a 70-Year-Old Man With Moderate
Alzheimer’s Disease Who Lives With His Wife in Poor Health (Scenario 
2): 

Table 12: Care Plans for Brian, a 70-Year-Old Man With Moderate
Alzheimer’s Disease Who Lives Alone (Scenario 3): 

Abbreviations: 

ADL: activities of daily living: 

CMS: Centers for Medicare & Medicaid Services: 

HCBS: home and community-based services: 

IADL: instrumental activities of daily living: 

[End of section] 

United States General Accounting Office: 
Washington, DC 20548: 

September 26, 2002: 

The Honorable John B. Breaux: 
Chairman, Special Committee on Aging: 
United States Senate: 

Dear Mr. Chairman: 

The aging baby boom generation is anticipated to greatly expand the
demand for long-term care services, with some estimates projecting that
spending for long-term care for the elderly could nearly quadruple by 
2050. Medicaid, the joint federal-state health-financing program for 
low-income individuals, is currently the largest payer for long-term 
care services and is anticipated to face substantial increases in 
spending as demand for long-term care increases. [Footnote 1] While 
coverage of nursing home care has traditionally accounted for the bulk 
of Medicaid long-term care expenditures, the high costs of such care 
and many individuals’ preference to receive care in their homes as long 
as possible has led many states to expand their Medicaid programs to 
provide additional home and community-based services for those who 
would otherwise be eligible for nursing home care. 

Home and community-based services for elderly individuals with 
disabilities can include in-home care involving personal care 
attendants to provide hands-on care with activities such as bathing and 
eating, household support for activities such as laundry and meal 
preparation, or custodial supervision to ensure the safety of someone 
requiring ongoing monitoring. Community options can include adult day 
care, which provides temporary care in a group environment, and 
permanent care in alternative residential settings, such as assisted 
living facilities or adult foster care, for those who are not able to 
remain in their home but who do not require nursing home care. 

Because most home and community-based services are optional elements
of state Medicaid programs, states have discretion in what services are 
covered, who may be eligible, and what services they receive. 
Additionally, local case managers, who screen Medicaid-eligible 
individuals to determine what services they qualify for based on their 
level of disability, often have discretion to customize care plans 
based on the individual’s needs, preferences, and availability of care 
services, including unpaid care provided by family members or other 
informal caregivers. 

The Senate Special Committee on Aging has been examining the current
provision of long-term care to further discussion of what role the 
public sector should play in assuring that long-term care needs will be 
met for the impending surge of persons who will need care—the aging 
baby boom generation. In light of this, you asked us to examine how the 
availability of Medicaid-covered home and community-based care that is 
available for elderly individuals with disabilities varies both across 
and within states. Specifically, we addressed: 

1. the extent to which home and community-based services were available 
within selected states’ programs for Medicaid-covered long-term care 
services for the elderly; 

2. the Medicaid-covered long-term care services that local case managers
would offer for two hypothetical elderly individuals with disabilities
based on the levels of unpaid informal care provided by family members; 
and; 

3. the extent to which care offered to the same hypothetical individual
with the same level of informal support varied among the selected 
states. 

To answer these objectives, we selected four geographically diverse 
states—Kansas, Louisiana, New York, and Oregon— that varied in the 
extent of spending for Medicaid home and community-based services for
individuals who are elderly and disabled. In each of these states, we
interviewed state Medicaid officials and reviewed information about home
and community-based services covered by their Medicaid programs. Based
on data the states reported on Medicaid expenditures to the federal 
Centers for Medicare & Medicaid Services (CMS) for 1999, the most recent
year for which data were available, we also estimated the amount each of
these states spent on several categories of long-term care services for 
the elderly. 

To obtain information about the availability of long-term care for our
hypothetical elderly individuals with disabilities in these states, we 
conducted interviews with 4 case managers responsible for Medicaid
home and community-based services in each state—a total of 16 case
managers. [Footnote 2] We asked the case managers to prepare detailed 
care plans for six hypothetical situations we presented to them using 
the same assessment tools and professional expertise that they would 
with Medicaid-eligible clients they served. The six hypothetical 
situations represented two elderly persons with certain disabilities 
and each with three different scenarios illustrating different levels 
of informal care available from family members. In each scenario, the 
two elderly persons would have been eligible for nursing home care, but 
preferred to receive home or community-based services when possible. If 
the state had a waiting list that would preclude the case managers from 
immediately offering Medicaid home and community-based services to new 
clients, we asked them to assume that the hypothetical individuals had 
exited the waiting list and could receive these Medicaid-covered 
services. Although some case managers also identified non-Medicaid 
services that the hypothetical clients could receive or seek, such as 
Medicare home health services, programs offered through the Older 
Americans Act, or state or locally subsidized programs, other relevant 
services may have been available that the Medicaid case managers did 
not include in their care plans. We did not evaluate the adequacy or 
appropriateness of the care plans offered by the case managers for 
meeting the long-term care needs of our hypothetical individuals. 

The first hypothetical person was a woman who had difficulty performing
everyday activities due to physical limitations, while the second was a 
man who had difficulty due to cognitive limitations. Specifically, our
hypothetical individuals were the following: 

Abby: an 86-year-old woman with debilitating arthritis who is chair-
bound and whose husband, who had previously cared for her, recently 
died. 

* Scenario 1: Abby lives with her daughter who provides most of Abby’s 
care but is overwhelmed by also caring for the daughter’s infant 
grandchild. 

* Scenario 2: Abby lives with an elderly sister who provides most of 
Abby’s care, but the sister has limited strength making her unable to 
provide all care. 

* Scenario 3: Abby lives alone, and her working daughter visits Abby 
once each morning to provide care for about 1 hour per day. 

Brian: a 70-year-old man cognitively impaired with moderate Alzheimer’s
disease, who has just been released from a skilled nursing facility 
after recovering from a broken hip. 

* Scenario 1: Brian lives with his wife who provides most of his care 
and she is in fair health. 

* Scenario 2: Brian lives with his wife who provides some of his care 
and she is in poor health. 

* Scenario 3: Brian lives alone because his wife has recently died. 

Appendix 1 provides additional description of these hypothetical 
Medicaid clients, including their specific limitations and needs for 
additional care services. 

We performed our work from June through September 2002 in accordance
with generally accepted government auditing standards. 

Results in Brief: 

Differences in how states exercised their flexibility in designing their
Medicaid long-term care programs, including the resources devoted to
them, affected the extent to which home and community-based services
were available to elderly individuals with disabilities. The states we
reviewed—Kansas, Louisiana, New York, and Oregon—had all opted to
cover home and community-based services for at least some Medicaid-
eligible elderly individuals with disabilities. These services 
represented larger shares of New York’s and Oregon’s total Medicaid 
long-term care expenditures for the elderly than those of Kansas and 
Louisiana. All Medicaid-eligible elderly individuals needing long-term 
care services could receive home and community-based services in New 
York and Oregon. Most new clients could not immediately receive 
Medicaid-covered home and community-based care in Kansas, which 
initiated a waiting list in April 2002, or in Louisiana, which had more 
than three times as many persons on its waiting list as were being 
served as of July 2002. 

Medicaid case managers in these four states offered care plans for our 
two hypothetical individuals that relied largely on Medicaid-covered 
home and community-based services that in most situations would provide 
enough hours of in-home care that the case managers would not recommend 
that the individuals move to a nursing home or other residential care 
setting. They typically recommended that Abby, an 86-year-old chair-
bound woman with debilitating arthritis, could stay in her home with 
varying amounts of hands-on assistance with personal care (such as 
bathing) and household support (such as meal preparation) to supplement 
the care provided by her family. However, the amount of in-home care 
that the case managers offered varied significantly. For example, in 
the scenario in which Abby lives with her daughter, case managers 
offered from 4.5 hours per week to 40 hours per week of in-home care. 
For Brian, a 70-year-old man with moderate Alzheimer’s disease, the 
case managers typically recommended that he could remain at home with 
varying amounts of additional in-home support if his wife was also 
available to provide informal unpaid care and supervision. For example, 
if Brian lived with his wife who was in poor health, they would offer 
from 6 hours per week to 35 hours per week of in-home care. If Brian 
lived alone, however, they usually recommended that he move to a 
nursing home or an alternative residential setting, such as an assisted 
living facility, to ensure his safety, although two case managers said 
they could offer him as much as 24-hour-a-day care in his home. 

The home and community-based care that case managers offered to Abby
or Brian sometimes differed due to state policies or practices that 
shaped the availability of their Medicaid-covered services. In Kansas 
and Louisiana, neither Abby nor Brian would have been immediately able 
to receive Medicaid home and community-based services due to a waiting 
list for certain services. Some states also had caps or other practices 
that limited the amount of Medicaid-covered in-home care that could be
offered, as the following examples illustrate. 

* In Louisiana, case managers were limited in the number of hours of in-
home care they could offer due to a cap of $35 per day at the time we
conducted our work; 

* In Kansas, case managers often offered fewer hours of in-home care 
than were offered in other states, which may have been in part 
influenced by Kansas’s supervisory review of more costly care plans and 
cost-consciousness among the case managers who recognized that lower 
costs per client could enable more clients to be served; and; 

* In New York and Oregon, case managers did not have similar cost
restrictions in offering in-home hours, with one case manager in each 
state offering as much as 24-hour-a-day care. 

When out-of-home placements were recommended, Oregon’s case managers 
consistently recommended adult foster care or assisted living 
facilities, whereas case managers in the other states more often
recommended nursing home care. 

We received oral comments from officials of the four states on a draft 
of this report. In response to our findings, they noted that fewer 
hours of in-home care in one state or community did not necessarily 
translate into unmet health and welfare needs for individuals; that 
limits on the number of individuals served or resources available for 
home and community-based care were in some cases due to state funding 
constraints and cost-effectiveness requirements relative to nursing 
home care; and that the local availability of long-term care workers 
and other services vary significantly and influence the care plans that 
case managers offer to individuals seeking care. 

Background: 

Long-term care includes many types of services needed when a person has
a functional disability, whether physical or cognitive. Individuals 
needing long-term care have varying degrees of difficulty in performing 
some activities of daily living without assistance, such as bathing, 
dressing, eating, toileting, and moving from one location to another. 
They may also have trouble with instrumental activities of daily 
living, which include such tasks as preparing food, housekeeping, and 
handling finances. They may have a mental impairment, such as 
Alzheimer’s disease, that necessitates supervision to avoid harming 
themselves or others or need assistance with tasks such as taking 
medications. Although a chronic physical or mental disability may occur 
at any age, the older an individual becomes, the more likely a 
disability will develop or worsen. 

Assistance for such needs takes many forms and takes place in varied
settings, including institutional care in nursing homes or alternative
community-based residential settings such as assisted living 
facilities, in-home care services, and unpaid care from family members 
or other informal caregivers. Approximately 64 percent of all elderly 
individuals with a disability relied exclusively on unpaid care from 
family or other informal caregivers; even among almost totally 
dependent elderly—those with difficulty performing five activities of 
daily living—about 41 percent relied entirely on unpaid care. [Footnote 
3] 

Long-term care is financed through a variety of sources, primarily 
public programs. Nationally, spending from all public and private 
sources for long-term care for all ages totaled about $137 billion in 
2000, accounting for nearly 11 percent of all health care expenditures. 
[Footnote 4] Medicaid, the joint federal-state health-financing program 
for low-income individuals, continues to be the largest funding source 
for long-term care. In 2000, Medicaid paid 46 percent (about $63 
billion) of total long-term care expenditures. Individuals’ out-of-
pocket payments represented the second largest source of payments for 
long-term care—a larger part of long-term care spending than for other 
types of health care services such as physicians and hospitals. These 
out-of-pocket payments accounted for 23 percent (about $31 billion) of 
total long-term care expenditures in 2000. Medicare, private insurance, 
and other public or private sources financed the remaining shares of 
these expenditures. 

States share responsibility with the federal government for Medicaid,
paying on average approximately 43 percent of total Medicaid costs.
Within broad federal guidelines, states have considerable flexibility in
determining who is eligible and what services to cover in their Medicaid
program. Among long-term care services, states are required to cover
nursing facilities and home health services for Medicaid beneficiaries.
States also may choose to cover additional services that are not 
mandatory under federal standards, such as personal care services, 
private-duty nursing care, and rehabilitative services. For services 
that a state chooses to cover under its CMS-approved state Medicaid 
plan, enrollment for those eligible cannot be limited but benefits may 
be. For example, states can limit the personal care service benefit 
through medical necessity requirements and utilization controls. 

States may also cover Medicaid home and community-based services (HCBS) 
through waivers of certain statutory requirements under section 1915(c) 
of the Social Security Act, thereby receiving greater flexibility in
the provision of long-term care services. [Footnote 5] These waivers 
permit states to adopt a variety of strategies to control the cost and 
use of services. For example, states may obtain CMS approval to waive 
certain provisions of the Medicaid statute, such as comparability, 
which generally requires states to make all services available to all 
eligible individuals statewide. 

With a waiver, states can target services to individuals on the basis of
certain criteria such as disease, age, or geographic location. Further, 
states may limit the numbers of persons served to a specified target, 
requiring additional persons meeting eligibility and need criteria to 
be put on a waiting list. Limits may also be placed on the costs of 
services that will be covered by Medicaid. To obtain CMS approval for a 
HCBS waiver, states must demonstrate that the cost of the services to 
be provided under a waiver (plus other state Medicaid services) is no 
more than the cost of institutional care (plus any other Medicaid 
services provided to institutionalized individuals). These waivers 
permit states to cover a wide variety of nonmedical and social services 
and supports that allow people to remain at home or in the community, 
including personal care, personal emergency response systems, 
homemakers’ assistance, chore assistance, adult day care, and other 
services. 

Medicare—the federal health financing program covering nearly 40 million
Americans who are aged 65 or older, disabled, or have end-stage renal
disease—primarily covers acute care, but it also pays for limited 
postacute stays in skilled nursing care facilities and home health care.
Medicare spending accounted for 14 percent (about $19 billion) of total
long-term care expenditures in 2000. During the early and mid-1990s,
Medicare became an increasingly significant funding source for 
individuals receiving continuing home health care, including home 
health aide services that may at times substitute for other long-term 
care services. The adoption of an interim payment system in 1997 to 
better control spending growth was followed by a sharp reduction in the 
number of home health visits and spending covered by Medicare. A new 
home health prospective payment system was implemented in October 2000 
that was intended to more closely align Medicare payments with patient 
needs. While it provides funding that allows a higher number of home 
health visits per user than under the interim payment system, it also 
provides incentives to reward efficiency and control use of services. 
The number of home health visits declined from about 29 visits per 
episode immediately prior to the prospective payment system being 
implemented to 22 visits per episode during the first half of 2001. 
[Footnote 6] Most of the decline was in home health aide visits. 

Selected States Varied in Expenditures for and Design of Medicaid Home 
and Community Services: 

Each of the states we reviewed—Kansas, Louisiana, New York, and 
Oregon—covered home and community-based services in their Medicaid
programs, but differed in how much of their Medicaid spending for long-
term care for the elderly they dedicated to home and community-based
care and how they designed their programs for these services. In 
general, Kansas and Louisiana spent a smaller portion of their Medicaid 
long-term care expenditures on home and community-based services than 
the other two states, and many of these services had recently not been 
available to new clients because both states had waiting lists. New 
York had the highest Medicaid spending on long-term care services for 
the elderly, with per capita spending nearly two-and-a-half times the 
national average. In addition, most of New York’s home and community-
based services were covered through its state Medicaid plan, making the 
services available to all eligible Medicaid beneficiaries. Oregon spent 
much less on nursing home care than other states, with a higher share 
of its long-term care expenditures for the elderly dedicated to home 
and community-based care. 

The four states we reviewed allocated different proportions of Medicaid
long-term care expenditures for the elderly to federally required long-
term care services, such as nursing facilities, and to state optional 
home and community-based care, such as in-home personal support, adult 
day care, and other home and community services. (See table 1.) New 
York’s expenditures for Medicaid long-term care services (including 
nursing facilities, home health, personal support, and other care) for 
the elderly was $2,463 per person aged 65 or older in 1999—much higher 
than the national average of $996. [Footnote 7] While nursing home care 
represented 68 percent of New York’s expenditures, New York also spent 
more than the national average on long-term care services provided at 
the state’s option, such as personal support services. Kansas and 
Louisiana spent near the national average of $996 per person aged 65 or 
older ($935 and $1,012, respectively), but nursing home care accounted 
for a higher portion of these expenditures in Louisiana (93 percent) 
than the national average (81 percent). Oregon spent $604 on Medicaid 
long-term care services per elderly individual. In contrast to the 
other states, Oregon spent much less per capita on nursing home care, 
and spent a larger portion for other long-term care services such as 
care in alternative residential settings. 

Table 1: Medicaid Expenditures in Four States for Long-Term Care 
Services for the Elderly per State Population Aged 65 or Older, 1999: 

Services required under federal law, Nursing facility: 
Kansas, $ per capita: 737; 
Kansas, % of total: 79; 
Louisiana, $ per capita: 938; 
Louisiana, % of total: 93; 
New York, $ per capita: 1,665; 
New York, % of total: 68; 
Oregon, $ per capita: 352; 
Oregon, % of total: 58; 
U.S., $ per capita: 806; 
U.S., % of total: 81. 

Services required under federal law, Home health: 
Kansas, $ per capita: 14; 
Kansas, % of total: 2; 
Louisiana, $ per capita: 3; 
Louisiana, % of total: 0; 
New York, $ per capita: 153; 
New York, % of total: 6; 
Oregon, $ per capita: 0; 
Oregon, % of total: 0; 
U.S., $ per capita: 24; 
U.S., % of total: 2. 

Services covered at state option, Personal support: 
Kansas, $ per capita: 174; 
Kansas, % of total: 19; 
Louisiana, $ per capita: 9; 
Louisiana, % of total: 1; 
New York, $ per capita: 502; 
New York, % of total: 20; 
Oregon, $ per capita: 10; 
Oregon, % of total: 2; 
U.S., $ per capita: 88; 
U.S., % of total: 9. 

Services covered at state option, Other care services (includes adult 
day care and alternate residential care settings): 
Kansas, $ per capita: 10; 
Kansas, % of total: 1; 
Louisiana, $ per capita: 62; 
Louisiana, % of total: 6; 
New York, $ per capita: 143; 
New York, % of total: 6; 
Oregon, $ per capita: 242; 
Oregon, % of total: 40; 
U.S., $ per capita: 77; 
U.S., % of total: 8. 

Total: 
Kansas, $ per capita: 935; 
Kansas, % of total: [Empty]; 
Louisiana, $ per capita: 1,012; 
Louisiana, % of total: [Empty]; 
New York, $ per capita: 2,463; 
New York, % of total: [Empty]; 
Oregon, $ per capita: 604; 
Oregon, % of total: [Empty]; 
U.S., $ per capita: 996; 
U.S., % of total: [Empty]. 

Notes: Per capita expenditures represent the ratio of Medicaid 
expenditures for services for the elderly to the state population aged 
65 or older. 

We adjusted Medicaid expenditures for the state’s health care costs in 
relation to national average health care costs for 1997 to 1999 to at 
least partially account for geographic cost differences. 

Percentages may not add to 100 and expenditure categories may not add 
to the total due to rounding. 

Sources: GAO calculations based on CMS Medicaid expenditure data; 
Bureau of the Census, Population Estimates for the U.S., Regions, and 
States by Selected Age Groups and Sex: Annual Time series, July 1, 1990 
to July 1, 1999 [hyperlink, 
http://eire.census.gov/popest/archives/state/st-99-09.txt] (downloaded 
Sept. 13, 2002); and health care services cost data from the Department 
of Labor’s Bureau of Labor Statistics and the Department of Housing and 
Urban Development. 

[End of table] 

The states also differed in how they designed their home and community-
based services, influencing the extent to which these services were
available to elderly individuals with disabilities. In some instances, 
as the following examples illustrate, not all services were available 
to all clients, with Kansas and Louisiana having waiting lists for HCBS 
waiver services for new clients. 

* Kansas: Most home and community-based services for the elderly in
Kansas were offered under HCBS waivers. These services included in-home
help such as personal care, household support, night supervision,
assistive devices (such as shower seats), personal emergency response
systems, adult day care, and respite care. As of June 2002, 6,300 
Kansans were receiving these HCBS waiver services. Because Kansas 
recently initiated a waiting list for these services in April 2002, 
they were not currently available to new recipients, with 290 people on 
the waiting list as of June 2002. 

* Louisiana: Most home and community-based services available in
Louisiana for the elderly and disabled were offered under HCBS waivers,
allowing the state to limit the number of recipients and cap the dollar
amount available per day for services. One waiver, which includes such
services as personal care, environmental modifications to the home (such
as wheelchair ramps), and personal emergency response systems, served
approximately 1,500 people in July 2002 with a waiting list of 5,000 
people. The dollar cap on services provided through this waiver 
increased in September 2002 from $35 per day to $55 per day. The other 
waiver, which is exclusively for adult day health care, [Footnote 8] 
served approximately 525 people, with 201 individuals on the waiting 
list as of July 2002. 

* New York: New York relied less on HCBS waivers for home and
community-based care for the elderly and disabled than other states
because these services were largely available through the state Medicaid
plan. Although New York had higher spending on Medicaid long-term care
services per capita than the other states in 1999, including about $500 
per capita on personal support services for the elderly, spending for 
HCBS waiver services was a small part of Medicaid spending—$9 per 
elderly person. [Footnote 9] As a result, home and community-based 
services were largely available to all eligible Medicaid beneficiaries 
needing them through the state Medicaid plan without caps. [Footnote 
10] Services offered through the state plan included in-home help, such 
as hands-on assistance and household support, and personal emergency 
response systems. Through a waiver, New York also offers such services 
as home-delivered meals, adult day care, environmental modifications, 
and nutritional counseling. 

* Oregon: Oregon had HCBS waivers that covered in-home care,
environmental modifications to homes, adult day care, respite care, and
care in alternate residential settings such as assisted living 
facilities and adult foster homes. Oregon’s waiver services did not 
have a waiting list and were available to elderly and disabled clients 
based on functional need, and served about 12,000 elderly and disabled 
individuals as of June 2002. Oregon has established a priority system 
for providing services based on eligible Medicaid beneficiaries’ needs 
with assistance for activities of daily living. Were a waiting list to 
become necessary in Oregon, officials told us that the state would 
allocate services based on its priority categories so that those 
categorized as being more dependent on assistance would receive help 
first. 

Table 2 summarizes the home and community based services offered in
the four states we reviewed either through their Medicaid state plan or 
a home and community-based services waiver. Generally, many home and
community-based services are covered in each of the states, but in 
Kansas and Louisiana they may be limited in their level of coverage and 
the number of individuals served. 

Table 2: Medicaid Home and Community-Based Long-Term Care Services for
Elderly in Four States: Home and community-based services (includes 
services offered in state plans and through waivers): 

In-home help with daily activities: Personal care, providing hands-on
assistance with activities of daily living such as eating, bathing, 
dressing, using the toilet, and grooming: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

In-home help with daily activities: Household support, providing 
assistance with instrumental activities of daily living, such as 
housekeeping and meal preparation: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

In-home help with daily activities: Home-delivered meals: 
Kansas: [Empty]; 
Louisiana: [Empty]; 
New York: Available services; 
Oregon: Available services. 

In-home help with daily activities: Standby assistance during day or 
night: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

Adaptive items or changes to facilitate independence, mobility, or 
safety: Environmental modifications, such as wheelchair ramp, or 
assistive devices or technology, such as bathtub lift or shower seat: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

Adaptive items or changes to facilitate independence, mobility, or 
safety: Personal emergency response system: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

In-home medical care or counseling: Periodic nursing evaluation: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: Available services; 
New York: Available services; 
Oregon: Available services. 
 
In-home medical care or counseling: Home health services/medical 
equipment assistance: 
Kansas: Available services; 
Louisiana: Available services; 
New York: Available services; 
Oregon: Available services. 

In-home medical care or counseling: Nutritional counseling: 
Kansas: [Empty]; 
Louisiana: [Empty]; 
New York: Available services; 
Oregon: [Empty]. 

In-home medical care or counseling: Case management: 
Kansas: Available services; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

Help outside of home: Adult day care: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: State had a waiting list for these services as of June 2002; 
New York: Available services; 
Oregon: Available services. 

Help outside of home: Help provided in community residential settings, 
such as assisted living facility, adult foster care, boarding home: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: [Empty]; 
New York: Available services; 
Oregon: Available services. 

Help outside of home: Transportation: 
Kansas: [Empty]; 
Louisiana: Available services[A]; 
New York: Available services; 
Oregon: Available services. 

Help outside of home: Moving assistance: 
Kansas: [Empty]; 
Louisiana: [Empty]; 
New York: Available services; 
Oregon: [Empty]. 

Care for Caregiver: Respite care in-home or out of home: 
Kansas: State had a waiting list for these services as of June 2002; 
Louisiana: [Empty]; 
New York: Available services; 
Oregon: Available services. 

Note: Services are only included in the table if the state Medicaid 
plan or HCBS waivers cover these services specifically for the elderly 
and/or disabled. In some cases, other services (such as respite care or 
transportation) may not be specifically included in the state plan or 
the waiver but could be provided indirectly through personal care 
attendants or other support services that are covered. 

[A] In Louisiana, the HCBS waiver covers transportation to medical 
appointments only. 

Source: GAO interviews with state Medicaid officials and review of 
state Web sites, 2002. 

[End of table] 

Case Managers Predominately Offered Medicaid In-Home Care Services, but 
Number of Hours Offered Varied: 

Most often, the 16 Medicaid case managers we contacted in Kansas,
Louisiana, New York, and Oregon offered care plans for our hypothetical
clients—Abby, an 86-year-old chair-bound woman with debilitating
arthritis, and Brian, a 70-year-old man with moderate Alzheimer’s
disease—that aimed at allowing them to remain in their homes. The
number of hours of in-home care that the case managers offered and the
types of residential care settings recommended depended in part on the
availability of services and the amount of informal family care 
available. In a few situations, especially when the individual did not 
live with a family member who could provide additional support, case 
managers were concerned that the client would not be safe at home and 
recommended a nursing home or other residential care setting. 

Most case managers offered in-home services for Abby and Brian except
for the one scenario when Brian lives alone and requires constant
supervision to ensure his safety due to his moderate Alzheimer’s 
disease. Several case managers noted that they would attempt to honor 
individuals’ preferences to remain at home unless it was unsafe to do 
so. For Abby, most case managers offered in-home personal care (hands-
on assistance with activities such as bathing, toileting, and eating), 
household support (such as preparing meals and laundry), and other 
supplemental services (such as household modifications or an emergency 
response system) that would supplement the care she received from her 
family. When Abby lived with her daughter or elderly sister, all but 1 
of the 16 case managers offered in-home care. When Abby lived alone 
with her daughter able to come by only once per day before going to her 
job, 12 case managers still offered in-home services to provide most of 
her care while 4 recommended that she relocate to a nursing home or 
other residential care setting. Similarly, in the scenarios when Brian 
lived with his wife, all but one case manager offered in-home care 
services for Brian. Most of the care plans continued to rely on Brian’s 
wife to provide much of the supervision of Brian’s safety and reminders 
for him to bathe, eat, and use the bathroom, but the care plans also 
offered additional in-home support to provide some hands-on care and 
household support. However, when Brian would otherwise have to live 
alone, 13 of the 16 care plans would have him move to a nursing home or 
other residential care setting. (See table 3.) 

Table 3: Number of Care Plans that Recommended that the Individual 
Remain at Home or Move to a Different Residential Setting: 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 1: Abby lives with her daughter 
(who also cares for infant grandchild): 
Number of plans in which individual remains at home: 15; 
Number of plans in which individual moves to a residential care 
setting: 1. 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 2: Abby lives with her sister 
(who has limited strength): 
Number of plans in which individual remains at home: 16; 
Number of plans in which individual moves to a residential care 
setting: 0. 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 3: Abby lives alone (her 
daughter visits once a day): 
Number of plans in which individual remains at home: 12; 
Number of plans in which individual moves to a residential care 
setting: 4. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 1: Brian lives with his wife (wife in 
fair health): 
Number of plans in which individual remains at home: 16; 
Number of plans in which individual moves to a residential care 
setting: 0. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 2: Brian lives with his wife (wife in 
poor health): 
Number of plans in which individual remains at home: 15; 
Number of plans in which individual moves to a residential care 
setting: 1. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 3: Brian lives alone: 
Number of plans in which individual remains at home: 3; 
Number of plans in which individual moves to a residential care 
setting: 13. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

When the case managers recommended that the individuals remain at
home, the number of hours of in-home services offered varied. The care
plans generally provided more paid in-home care when less informal
family support was available, especially when Abby or Brian lived alone,
as shown in the following examples. 

* When Abby lived with her daughter who was overwhelmed due to also
caring for an infant grandchild, the case managers recommending in-home
care offered a median of 28 hours per week. However, the number of
hours of in-home care in this scenario varied by case manager from 4.5
hours to 40 hours per week. In this scenario, four case managers
recommended that Abby attend adult day care—which serves to both
provide additional hours of care to Abby and provide her daughter with
some respite. [Footnote 11] 

* When Abby lived with an 82-year-old sister who had difficulty helping 
with some tasks due to limited strength, the case managers offered a 
median of 16 hours per week, with a range across case managers of 6 to 
37 hours per week. In this scenario, one case manager also recommended 
that Abby receive most of her care (56 hours per week) through adult 
day care. 

* When Abby lived alone with her daughter visiting for an hour each
morning, the number of offered hours of in-home care was highest—a
median of 32 hours per week and as many as 49 hours per week. 

For Brian, the number of hours of care offered more consistently 
reflected the amount of informal help that was available to him, as the 
specific examples illustrate. 

* When Brian lived with his wife who was in fair health, the case 
managers offered a median of 18 hours per week of in-home care, ranging 
from 11 to 35 hours per week. Two case managers also offered adult day 
care in addition to or instead of in-home care. 

* If Brian’s wife were in poor health, the case managers offered in-home
care for a median of 22 hours per week, ranging from 6 to 35 hours per
week. One care manager recommended that Brian move to a residential
care facility. 

* When Brian lived alone, two of the three care managers who had Brian
remain at home offered round-the-clock in-home care—168 hours per
week. Table 4 summarizes the numbers of hours of in-home care offered 
by care managers for each scenario. 

Table 4: Number of Hours of In-Home Care Offered For Individuals 
Remaining At Home: 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 1: Abby lives with her daughter 
(who also cares for infant grandchild): 
Median amount of in-home help offered (hours per week): 28; 
Range in amount of in-home help offered (hours per week): 4.5 to 40. 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 2: Abby lives with her sister 
(who has limited strength): 
Median amount of in-home help offered (hours per week): 16; 
Range in amount of in-home help offered (hours per week): 6 to 37. 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 3: Abby lives alone (her 
daughter visits once a day): 
Median amount of in-home help offered (hours per week): 32; 
Range in amount of in-home help offered (hours per week): 12 to 49. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 1: Brian lives with his wife (wife in 
fair health): 
Median amount of in-home help offered (hours per week): 18; 
Range in amount of in-home help offered (hours per week): 11 to 35. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 2: Brian lives with his wife (wife in 
poor health): 
Median amount of in-home help offered (hours per week): 22; 
Range in amount of in-home help offered (hours per week): 6 to 35. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 3: Brian lives alone: 
Median amount of in-home help offered (hours per week): 168; 
Range in amount of in-home help offered (hours per week): 35 to 168. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Consistent with the hypothetical individuals’ preferences to remain at
home as long as possible, case managers less often recommended that the
hypothetical individuals move out of their homes to a nursing home or an
alternative residential care setting such as an assisted living 
facility, adult foster home, or adult boarding home. The case managers 
typically recommended the individual move only if they believed that 
she or he would be unsafe in their homes or, in two instances, if they 
were concerned that the family caregiver was at risk due to the demands 
of providing extensive informal care. Of the 16 case managers, 13
recommended that Brian move to a residential care setting if he lived
alone, with most noting that they were concerned about his safety 
living at home alone or were unable to provide a sufficient number of 
hours of in-home supervision. Four case managers also recommended that 
Abby needed to move if she did not have a family member or paid 
caregiver who could remain with her at nighttime and assist her with 
using the toilet or in an emergency. In two instances when the 
hypothetical individuals did have a family member living with them, 
case managers were concerned that providing care would be too demanding 
either for Abby’s daughter (who also had an infant grandchild to care 
for) or Brian’s wife (who was in poor health) and recommended that the 
client move to an adult foster home. For example, one case manager was 
concerned that Brian’s wife, who was in poor health, would ultimately 
also need care if she continued to provide Brian with most of his 
support. 

In some situations, two case managers in the same locality offered 
notably different care plans. For example, across the eight localities 
where we interviewed case managers, four case managers offered in-home 
care while their local counterpart recommended a nursing home or 
alternative residential setting for Abby when she lived alone. This 
contrast also occurred three times when Brian lived alone and once each 
when Abby lived with her daughter and Brian lived with his wife who was 
in poor health. In a few cases, the case managers in the same locality 
both offered in-home care but offered significantly different numbers 
of hours. For example, one case manager offered 42 hours per week of in-
home care for Abby when she lived alone, while another case manager in 
the same locality offered 15 hours per week of in-home care for this 
scenario. 

Appendix II provides a summary of the care plans provided by each case
manager for each of the six hypothetical scenarios. 

Case Managers in Some States Offered More In-Home Care, Alternative
Residential Settings, or Other Supplemental Services: 

The care plans the case managers offered for the hypothetical 
individuals, Abby and Brian, sometimes varied as a result of state-
specific policies or practices for Medicaid home and community-based 
services. In particular, neither Abby nor Brian would be able to 
immediately receive HCBS waiver services in Kansas and Louisiana due to 
a waiting list. When case managers developed care plans based on HCBS-
waiver services for our hypothetical individuals, Louisiana’s cap on 
the amount of dollars that could be spent per day limited the number of 
hours of in-home care that could be offered in scenarios where Abby or 
Brian needed more extensive care. Also, Kansas’s case managers may have 
been more cost-sensitive due to state review thresholds and their 
awareness that maintaining lower average costs per client may help 
other clients to be served. When out-of-home placements were 
recommended, case managers in Oregon consistently recommended 
alternatives to nursing homes (either adult foster care or assisted 
living) whereas case managers in Louisiana were more likely to 
recommend a nursing home. Other state-specific differences in the care 
plans included that Louisiana case managers did not offer adult day 
care in any of the care plans, and New York and Louisiana case managers 
often considered how Medicare home health services would expand or 
offset the Medicaid home and community-based services offered. 

Waiting Lists in Two States Would Prevent New Clients from Immediately 
Receiving Medicaid Home and Community-Based Waiver Services: 

As new clients, our hypothetical elderly individuals with disabilities 
would not have been able to immediately receive most Medicaid home and
community-based services in Kansas or Louisiana due to waiting lists for
the HCBS waiver services. As a result, our hypothetical individuals 
would often have fewer services available to them, only those available 
through other state or federal programs, until Medicaid HCBS waiver 
services became available or they would have to receive Medicaid-
covered nursing home care. The average length of time individuals wait 
for Medicaid waiver services was not known in either state. However, 
one case manager in Louisiana estimated that elderly persons for whom 
he had developed care plans had spent about a year on the waiting list 
before receiving services. In Kansas, as of July no one had yet come 
off the waiting list, which was instituted in April 2002. 

When case managers in Kansas developed care plans based only on what
services were currently available from sources other than Medicaid home
and community-based services, they tended to offer fewer in-home hours
and to recommend out-of-home placements twice as often as they did
when the waiver services were available. Service availability also 
varied more widely across the state when case managers could not offer
Medicaid HCBS waiver services. For example, in one area of the state, 
in-home help was offered using Older Americans Act funds while in 
another
area those services were not available due to budget constraints. 
[Footnote 12] 

According to Louisiana officials, since Medicaid HCBS waiver services
have a waiting list, persons needing immediate assistance who call the
state help line may be referred to local councils on aging or they can
contact another organization that would help them complete an
application for nursing home care. In general, however, the case 
managers we interviewed in the four states indicated that few services 
were typically available outside of the Medicaid program. 

Number of Hours of In-Home Care Varies Partly Due to State Policies: 

The number of hours of in-home care offered to our hypothetical 
individuals through Medicaid could be as much as 168 hours per week (24
hours per day) in New York and Oregon while case managers in Kansas
and Louisiana offered at most 24.5 and 37 hours per week, respectively. 

The number of hours of in-home care offered was often lowest in Kansas,
and in Louisiana case managers tended to change the amount of in-home
help offered little even as the hypothetical scenarios changed, such 
that our hypothetical individuals presumably would require more 
assistance because there was less unpaid care available from family 
caregivers. (See table 5.) This variation reflects several factors case 
managers took into consideration when determining the amount of care to 
offer. These factors included the local availability of personal care 
attendants and other care services, the cost of the care that was 
allowed under their state’s Medicaid program, and the state’s review 
requirements for approving care plans. 

Table 5: Range in Amount of In-Home Care Offered for Individuals 
Remaining at Home, by State: 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 1: Abby lives with her daughter 
(who also cares for infant grandchild): 
Offered in-home care (hours per week), Kansas: 5 to 22; 
Offered in-home care (hours per week), Louisiana: 28 to 37; 
Offered in-home care (hours per week), New York: 4.5 to 40; 
Offered in-home care (hours per week), Oregon: 7[A]. 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 2: Abby lives with her sister 
(who has limited strength): 
Offered in-home care (hours per week), Kansas: 6 to 14; 
Offered in-home care (hours per week), Louisiana: 24.5 to 37; 
Offered in-home care (hours per week), New York: 15 to 35; 
Offered in-home care (hours per week), Oregon: 9 to 16. 

Amount of informal care available: Abby (86-year-old chair-bound woman 
with debilitating arthritis), Scenario 3: Abby lives alone (her 
daughter visits once a day): 
Offered in-home care (hours per week), Kansas: 12 to 24.5; 
Offered in-home care (hours per week), Louisiana: 24.5 to 35; 
Offered in-home care (hours per week), New York: 42 to 49; 
Offered in-home care (hours per week), Oregon: 15 to 42. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 1: Brian lives with his wife (wife in 
fair health): 
Offered in-home care (hours per week), Kansas: 11 to 14.75; 
Offered in-home care (hours per week), Louisiana: 21 to 35; 
Offered in-home care (hours per week), New York: 11 to 20; 
Offered in-home care (hours per week), Oregon: 16 to 25. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 2: Brian lives with his wife (wife in 
poor health): 
Offered in-home care (hours per week), Kansas: 14 to 21; 
Offered in-home care (hours per week), Louisiana: 21 to 28; 
Offered in-home care (hours per week), New York: 6 to 35. 
Offered in-home care (hours per week), Oregon: 22 to 29. 

Amount of informal care available: Brian (70-year-old man with moderate 
Alzheimer’s disease), Scenario 3: Brian lives alone: 
Offered in-home care (hours per week), Kansas: N/A[B]; 
Offered in-home care (hours per week), Louisiana: N/A[B]; 
Offered in-home care (hours per week), New York: 168[C]; 
Offered in-home care (hours per week), Oregon: 35 to 168. 

Note: Table does not include adult day care services. 

[A] Only one case manager offered in-home care for this scenario. Two 
other Oregon case managers recommended that Abby stay at home and the 
family caregiver become licensed for a relative foster home and receive 
a payment that she could use to hire in-home or respite care for an 
unspecified number of hours. 

[B] All four case managers recommended care in a residential care 
setting, such as a nursing home or assisted living facility. 

[C] Only one case manager offered in-home care for this scenario. The 
other New York case managers recommended a residential care setting. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

The number of hours of in-home care case managers in Louisiana could
offer was limited by a dollar cap on waiver services of $35 per day at 
the time we conducted our work. [Footnote 13] Case managers in 
Louisiana tended to offer as many hours of care as they could offer 
under the cost limit. Therefore, as the amount of informal care changed 
in the different scenarios, the hours of in-home help offered in 
Louisiana did not change as much as they did in the other states. For 
example, when Brian’s wife was in poor health, the case managers in 
Kansas, New York, and Oregon usually either offered more in-home care 
(from 1.5 to 13.5 additional hours per week) or else offered more help 
through adult day care than they offered when his wife was in better 
health. In contrast, case managers in Louisiana did not prescribe any 
more hours of in-home care per week when Brian’s wife was in poor 
health because they could not cover more hours within the cap. 

Case managers in Kansas often offered the fewest hours of in-home care
across all of the states we reviewed. The state had a review process
whereby higher cost care plans were more extensively reviewed than
lower cost care plans. Case managers recognized that Kansas’s Medicaid
HCBS waiver program and other state programs providing long-term care
services had recently been largely closed to new clients due to budget
constraints. As one Kansas case manager told us, offering fewer hours of
care may reflect the case managers’ sensitivity to the waiting list and 
an effort to serve more clients by keeping the cost per person low. 

In contrast, case managers in New York and Oregon did not indicate
similar cost concerns in offering in-home care hours. When the costs of
services were above the cost limit for waiver services in New York, case
managers could offer most in-home care through services provided in the
state plan, which were not subject to a cost limit. Further, while 
three case managers in Oregon expressed concern about finding live-in 
help or providers for lower-paying custodial services, one case manager 
in New York and one in Oregon offered the most in-home care possible—24 
hours a day, 168 hours a week. 

When Residential Care Was Recommended, Oregon Relied on Alternatives 
Other Than Nursing Homes: 

When recommending that our hypothetical individuals could be better
cared for in a residential care setting, case managers offered 
alternatives to nursing homes to varying degrees across the states, 
with those in Louisiana relying most heavily on nursing home care and 
those in Oregon using exclusively alternative residential settings. 
Case managers in Louisiana recommended nursing home care in three of 
the four care plans for Abby or Brian in which care in another 
residence was recommended. A Louisiana state official noted that care 
in alternative residential care settings is generally not covered 
through the Medicaid waiver. In contrast, case managers in Oregon never 
recommended nursing home care for our hypothetical individuals. 
Instead, case managers in Oregon exclusively recommended either adult 
foster care or an assisted living facility in the five care plans 
recommending care in another residence. (See table 6.) 

Table 6: Number of Care Plans Where Nursing Home or Alternative 
Residential Setting was Recommended: 

Residential care settings: 
Type of residential care setting (number of care plans), Kansas: 
Nursing home (2), Assisted living (3); 
Type of residential care setting (number of care plans), Louisiana: 
Nursing home (3), Group home (1); 
Type of residential care setting (number of care plans), New York: 
Nursing home (3), Boarding home (2); 
Type of residential care setting (number of care plans), Oregon: 
Nursing home (0), Assisted living (1), Adult foster care (4). 

Total out-of-home placements: 
Kansas: 5; 
Louisiana: 4; 
New York: 5; 
Oregon: 5. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Case managers in Oregon twice recommended that our hypothetical
individuals obtain care in other residential care settings when case
managers in other states would have had them stay at home. Case 
managers in Kansas, Louisiana, and New York only recommended out of
home placement for Abby or Brian in scenarios when they lived alone. In
Oregon, however, two different case managers recommended that Abby
and Brian move into an adult foster home in scenarios when they lived
with a family member, expressing concern that continuing to provide care
to Abby or Brian would be detrimental to the family. 

States Also Varied in Use of Adult Day Care and Medicare Home Health 
Services: 

State differences also were evident in how case managers used other
services to supplement in-home or other care. For example, across all 
care plans the case managers developed for Abby and Brian (24 care 
plans in each state), adult day care was offered four times in New York 
and Oregon and three times in Kansas. When adult day care was offered 
in the other states, it often served to provide additional hours of 
care for Abby or Brian as well as some relief for their caregiver. 
However, none of the care plans developed by case managers in Louisiana 
included adult day care despite the state’s Medicaid waiver for these 
services. [Footnote 14] Case managers may not have offered adult day 
care services because Louisiana covers these services under a separate 
HCBS waiver from the waiver that covers in-home assistance and, in 
general, individuals cannot receive services from two separate waiver 
programs concurrently. 

Case managers in New York and Louisiana also often considered the effect
that the availability of Medicare home health services could have on the
Medicaid in-home care. For example, one case manager in New York
noted that she maximizes the use of Medicare home health before using
Medicaid home health or other services. Several of the case managers in
New York included the amount of Medicare home health care available in
their care plans, and these services offset some of the Medicaid 
services that would otherwise be offered. In Louisiana, where case 
managers faced a dollar cap on the amount of Medicaid in-home care 
hours they could provide, two case managers told us that they would 
include the additional care available under Medicare’s home health 
benefit in their care plans, thereby increasing the number of total 
hours of care that Abby or Brian would have by 2 hours per week. While 
six Kansas and Oregon case managers also mentioned that they would 
refer Abby or Brian to a physician or visiting nurse to be assessed for 
potential Medicare home health care, they did not specifically include 
the availability of Medicare home health care in the number of hours of 
care provided by their care plans. 

Concluding Observations: 

Many states have found that offering home and community-based services
through their Medicaid programs can help low-income elderly individuals
with disabilities remain in their homes or communities when they
otherwise would be likely to go to nursing homes. States differ, 
however, in how they designed their Medicaid programs to offer home and
community-based long-term care options for elderly individuals and the
level of resources they devoted to these services. As a result, as
demonstrated by the care plans offered by case managers for our
hypothetical elderly individuals in four states, the same individual 
with certain identified disabilities and needs would often receive 
different types and intensity of home and community-based care for 
their long-term care needs across states and even within the same 
community. These differences often stemmed from case managers’ attempts 
to leverage the availability of both publicly financed long-term care 
services as well as the informal care and support provided to 
individuals by their own family members. 

States’ Comments: 

We requested comments on a draft of this report from Kansas, Louisiana,
New York, and Oregon officials. On behalf of these states, we received
oral comments from the Program Manager, Kansas Department of Aging;
the Waiver Manager, Louisiana Bureau of Community Supports and 
Services; the Health Program Administrator, Bureau of Long-Term Care,
Office of Medicaid Management, New York Department of Health; and the
Manager of Community-Based Care Licensing, Office of Licensing and
Quality of Care for Seniors and People with Disabilities, Oregon
Department of Human Services. 

Two states commented on our findings concerning the extent of services 
case managers offered to our hypothetical individuals. The Kansas 
official noted that our finding that the Kansas case managers’ care 
plans often offered among the fewest hours of in-home care does not 
necessarily reflect that the care plans would not meet their health and 
welfare needs. She emphasized that Kansas case managers are trained to 
ensure that the care plans are sufficient to meet clients’ health and 
welfare needs and that the state reviews the care plans to provide 
further assurances that they are sufficient. We clarified the report to 
indicate that we did not evaluate the adequacy or appropriateness of 
the care plans offered by the case managers in meeting the hypothetical 
individuals’ long-term care needs. The Louisiana official commented 
that the state was covering as many eligible enrollees in its HCBS 
waivers as funding allowed, and that Louisiana’s daily cap for in-home 
HCBS waiver services reflects the state’s budget constraints as well as 
the need to be cost-effective relative to nursing home care, which had 
a reimbursement rate of about $85 per day as of September 2002. 

Two states commented on the importance of individuals’ preferences and
the local availability of long-term care service providers in shaping 
case managers’ care plans. The Oregon official commented that case 
managers will develop their care plans to best reflect the preferences 
of their clients to receive care in their home or in community-based 
settings. The New York official commented that the availability of 
certain long-term care services, such as workers to provide in-home 
care and adult day care settings, varies within the state and can be an 
additional factor influencing the number of hours of in-home care 
offered in case managers’ care plans. 

Officials from the four states also provided technical comments that we
incorporated as appropriate. 

We did not seek comments on this report from CMS because we did not
evaluate CMS’s role or performance with respect to the availability of
Medicaid home and community-based services. 

As agreed with your office, unless you publicly announce this report’s
contents earlier, we plan no further distribution until 30 days after 
its date. At that time, we will send copies of this report to other 
interested congressional committees and other parties. We will also 
make copies available to others on request. Copies of this report will 
also be available at no charge on GAO’s Web site at [hyperlink, 
http://www.gao.gov]. 

Please call me at (202) 512-7118 or John E. Dicken at (202) 512-7043
if you have any questions. Major contributors to this report include
JoAnne R. Bailey, Romy Gelb, and Miryam Frieder. 

Sincerely yours, 

Signed by: 

Kathryn G. Allen: 
Director, Health Care—Medicaid and Private Health Insurance Issues: 

[End of section] 

Appendix I: Summary of Hypothetical Individuals Presented to Case 
Managers: 

To obtain information about the availability of long-term care for our
hypothetical elderly individuals, we asked 16 Medicaid case managers in
Kansas, Louisiana, New York, and Oregon to prepare detailed care plans
for two elderly persons with physical or cognitive disabilities. For 
each hypothetical individual, we presented the case managers with three
different scenarios illustrating different levels of informal care 
available from family members. The first hypothetical person was a 
woman, “Abby,” who had difficulty performing everyday activities due to 
physical limitations, while the second was a man, “Brian,” who had 
difficulty due to cognitive limitations. We contacted each case manager 
and presented detailed information, as summarized below, regarding the 
hypothetical individuals’ conditions, needs for assistance, and 
availability of informal unpaid care from family. We also provided any 
clarifying information that the case managers requested to be able to 
develop the care plans. With this information, the case managers used 
state-specific uniform assessment instruments and their professional 
expertise to develop care plans as they would with other Medicaid-
eligible clients. [Footnote 15] 

Summary of Abby: 

The first hypothetical Medicaid-eligible individual we presented was 
Abby, an 86-year-old woman with physical limitations due to debilitating
arthritis. She also has type II diabetes. Specifically, Abby is chair-
bound, has developed a pressure ulcer, and has some degree of 
difficulty with all activities of daily living (ADL) and instrumental 
activities of daily living (IADL) tasks as well as with taking an oral 
medication. [Footnote 16] She also needs her glucose levels checked 
daily to monitor her diabetes. She is alert and oriented, without any 
cognitive impairment. Her prognosis is for little or no recovery, with 
decline in her current condition possible. Abby’s husband, who served 
as her primary caregiver, recently died. 

We presented three scenarios to the case managers in which Abby’s
conditions and needs for assistance remained the same, but the 
availability of unpaid informal care provided by her family varied: 

* Scenario 1: Abby has moved in with her 51-year-old daughter who also
cares for her own infant grandchild. [Footnote 17] Abby’s daughter 
provides assistance with Abby’s ADL and IADL needs, but the daughter 
reports feeling overwhelmed caring for both her mother and grandchild. 
In addition, the daughter is unable to help with Abby’s diabetes 
testing because she does not know how to do so. 

* Scenario 2: Abby has moved in with her 82-year-old sister who provides
assistance with Abby’s ADL and IADL needs. However, the sister has
limited strength and therefore is unable to provide assistance with some
ADLs and IADLs, such as helping Abby to the toilet and transferring her 
to and from her wheelchair. During the week, the sister is also unable 
to fully meet Abby’s needs for bathing, laundry, and housekeeping. In 
addition, the sister cannot assist Abby with her diabetes testing. 

* Scenario 3: Abby lives alone, and her 51-year-old daughter visits 
once each morning for 1 hour to provide assistance but is unable to 
provide additional assistance at other times because she works two jobs 
and lives in another home. As a result, Abby does not receive 
assistance with grooming and dressing her upper and lower body. During 
the day and night, she does not receive assistance with planning and 
preparing meals, toileting, eating, and transferring to and from her 
wheelchair to the toilet or bed. Each week, she does not receive 
assistance with transportation, bathing, laundry, and using the 
telephone in case of an emergency. In addition, the daughter is unable 
to assist with Abby’s diabetes testing. 

Summary of Brian: 

The second hypothetical Medicaid-eligible individual we presented to the
case managers was Brian, a 70-year-old man with moderate Alzheimer’s
disease who has been in a skilled nursing facility for 90 days following
hospitalization for a hip fracture. [Footnote 18] During his stay in 
the skilled nursing facility, he has become physically weakened and 
will need physical therapy. Brian takes medication for his hip fracture 
and for anxiety and temporarily uses a cane when walking, but otherwise 
is in good physical health. Brian needs supervisory help with most ADLs 
and IADLs and taking his oral medication—that is, he can perform tasks 
such as eating and toileting if he is reminded and monitored. Due to 
dementia resulting from Alzheimer’s disease, he is alert but not 
oriented and is unable to shift attention and recall directions more 
than half the time. Further, he is confused during the day and evening, 
but not constantly. He cannot be left unsupervised. 

As with the first hypothetical individual, we presented three scenarios 
to the case managers in which Brian’s conditions and needs for 
assistance remained the same, but the availability of unpaid informal 
care provided by his family varied: 

* Scenario 1: Brian lives with his 65-year-old wife, who is his primary
caregiver and is in fair health but has recently suffered health 
problems. [Footnote 19] She supervises Brian with all ADLs and she 
performs many of his IADLs herself, but is having increasing difficulty 
doing these tasks due to her declining health. During the day, she 
would like additional assistance reminding Brian to toilet and bathe as 
well as with planning and preparing meals and transportation. Each 
week, she would like additional assistance with laundry, housekeeping, 
and shopping. 

* Scenario 2: Brian’s 65-year-old wife is in poorer health than 
described in scenario 1, and can offer supervisory help with ADLs but 
cannot perform most IADLs. As a result, Brian does not receive all of 
the reminders he needs for bathing and toileting nor all of the 
assistance he needs with planning and preparing meals, transportation, 
laundry, housekeeping, and shopping. 

* Scenario 3: Brian lives alone because his wife recently died. He needs
constant supervision with most ADLs and help with several IADLs. He
cannot be left unsupervised and does not receive reminders for bathing,
dressing, grooming, toileting, eating, and taking his medications. He 
also does not receive assistance with planning and preparing meals,
transportation, shopping, laundry, and housekeeping. 

[End of section] 

Appendix II: Summary of Care Plans Offered by 16 Case Managers: 

We obtained care plans from 16 Medicaid case managers in Kansas,
Louisiana, New York, and Oregon that detailed the long-term care 
services that they would offer to two hypothetical Medicaid-eligible 
elderly individuals—Abby, an 86-year-old woman with debilitating 
arthritis and who was chair-bound, and Brian, a 70-year-old man with 
moderate Alzheimer’s disease. Each case manager developed six care 
plans, representing three different levels of unpaid informal care 
provided to Abby and Brian by their family. The case managers we 
contacted were specifically responsible for Medicaid home and community-
based services. While most also were familiar with other local public 
services available, clients could receive different care options if 
they sought care through other approaches, such as physician referrals 
or contacting local councils on aging. The care plans were based on the 
information presented by telephone to the case managers we selected to 
interview in a small town (a population of less than 15,000 people) and 
a large city (a population of more than 250,000 people) in each of the 
four states and should not be generalized to indicate what care plans 
other case managers in these localities or other states would likely 
offer. We did not evaluate the adequacy or appropriateness of the care 
plans offered by the case managers for meeting the long-term care needs 
of our hypothetical individuals. 

Tables 7 through 12 summarize key components of the care plans offered
by each of the case managers, designated in the tables as case managers 
A through P, for each of the six care plans. [Footnote 20] The tables 
summarize the number of in-home hours of care offered by the case 
manager or whether a nursing home or other alternate residential care 
setting was recommended. The tables also provide other aspects of care 
offered to Abby or Brian, including whether the care manager would 
offer adult day care to supplement or replace in-home or other care, 
whether the case manager noted the availability of a nurse or home 
health services available from Medicare and/or Medicaid, and examples 
of other services (such as personal emergency response systems, 
assistive devices such as transfer seats, or companionship services) 
that may be offered through Medicaid or other federal, state, or local 
programs. 

Table 7: Care Plans for Abby, an 86-Year-Old Chair-Bound Woman With 
Debilitating Arthritis Who Lives with Her Daughter (Scenario 1): 

Case manager: A; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Adult foster home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: B; 
Amount of in-home care offered (hours per week): Relative foster 
home[A]; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Grief Counseling; 
Other non-Medicaid services: 
* Companionship; 
* Caregiver support for daughter; 
* Respite care for daughter. 

Case manager: C; 
Amount of in-home care offered (hours per week): Relative foster 
home[A]; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 24; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: D; 
Amount of in-home care offered (hours per week): 7; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Home-delivered meals; 
Other non-Medicaid services: [Empty]. 

Case manager: E; 
Amount of in-home care offered (hours per week): 40; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Respite care; 
Other non-Medicaid services: [Empty]. 

Case manager: F; 
Amount of in-home care offered (hours per week): 32; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Lift/transfer seat for bathing; 
Other non-Medicaid services: 
* Wheelchair ramp. 

Case manager: G; 
Amount of in-home care offered (hours per week): 4.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Senior companion; 
* Home-delivered meals. 

Case manager: H; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 18; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: I; 
Amount of in-home care offered (hours per week): 5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 12; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: J; 
Amount of in-home care offered (hours per week): 22; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Respite care. 

Case manager: K; 
Amount of in-home care offered (hours per week): 12; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Unspecified[B]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Adult diapers; 
* Home meal delivery. 

Case manager: L; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 8; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Senior companion. 

Case manager: M; 
Amount of in-home care offered (hours per week): 28; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: N; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Unspecified[B]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: O; 
Amount of in-home care offered (hours per week): 37; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals; 
* Family counseling. 

Case manager: P; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Companionship. 

[A] The care plan recommended that the family caregiver become licensed 
for a relative foster home to allow Abby to remain living in the home 
and the family caregiver would receive payment that could be used to 
hire additional in-home or respite care for an unspecified number of 
hours. 

[B] The care plan recommended a referral for home health care but did 
not specify whether this service would by covered through Medicare or 
Medicaid. 

Note: Abby’s daughter also cares for an infant grandchild and, though 
meeting the care needs of both her mother and grandchild, reports 
feeling overwhelmed by her responsibilities. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Table 8: Care Plans for Abby, an 86-Year-Old Chair-Bound Woman With 
Debilitating Arthritis Who Lives With Her Sister (Scenario 2): 

Case manager: A; 
Amount of in-home care offered (hours per week): 9; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Grief counseling; 
Other non-Medicaid services: 
* Transportation; 
* Caregiver support for sister. 

Case manager: B; 
Amount of in-home care offered (hours per week): Relative foster 
home[A]; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Grief Counseling; 
Other non-Medicaid services: 
* Companionship. 

Case manager: C; 
Amount of in-home care offered (hours per week): 16; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 24; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: D; 
Amount of in-home care offered (hours per week): 14; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
* Home-delivered meals; 
Other non-Medicaid services: [Empty]. 

Case manager: E; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Assistive devices; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: F; 
Amount of in-home care offered (hours per week): 15; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare and Medicaid; 
Other Medicaid services: 
* Lift/transfer seat for bathing; 
* Wheelchair ramp; 
Other non-Medicaid services: [Empty]. 

Case manager: G; 
Amount of in-home care offered (hours per week): 17; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: H; 
Amount of in-home care offered (hours per week): 28; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 18; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Adult diapers; 
* Personal emergency response system; 
Other non-Medicaid services: 
* Equipment to help with eating. 

Case manager: I; 
Amount of in-home care offered (hours per week): 10; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 12; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: J; 
Amount of in-home care offered (hours per week): 6; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 56; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: K; 
Amount of in-home care offered (hours per week): 14; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Unspecified[B]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Adult diapers; 
* Home-delivered meals. 

Case manager: L; 
Amount of in-home care offered (hours per week): 6; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 8; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Minor home repairs; 
Other non-Medicaid services: 
* Transportation. 

Case manager: M; 
Amount of in-home care offered (hours per week): 24.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
* Wheelchair ramp; 
Other non-Medicaid services: [Empty]. 

Case manager: N; 
Amount of in-home care offered (hours per week): 36.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Unspecified[B]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: O; 
Amount of in-home care offered (hours per week): 37; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: P; 
Amount of in-home care offered (hours per week): 28; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Companionship. 

[A] The care plan recommended that the family caregiver become licensed 
for a relative foster home to allow Abby to remain living in the home 
and the family caregiver would receive payment that could be used to 
hire additional in-home or respite care for an unspecified number of 
hours. 

[B] The care plan recommended a referral for home health care but did 
not specify whether this service would by covered through Medicare or 
Medicaid. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Table 9: Care Plans for Abby, an 86-Year-Old Chair-Bound Woman With 
Debilitating Arthritis Who Lives Alone (Scenario 3): 

Case manager: A; 
Amount of in-home care offered (hours per week): 15; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Transportation; 
* Caregiver support for daughter; 
* Grief support for Abby. 

Case manager: B; 
Amount of in-home care offered (hours per week): 42; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
* Grief Counseling; 
Other non-Medicaid services: 
* Companionship. 

Case manager: C; 
Amount of in-home care offered (hours per week): 36; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 24; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: D; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Adult foster home; 
Adult day care (hours per week): 8; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* large-button speaker phone. 

Case manager: E; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Boarding home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare and Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: F; 
Amount of in-home care offered (hours per week): 49; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare and Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
* Lift/transfer seat for bathing; 
Other non-Medicaid services: 
* Wheelchair ramp; 

Case manager: G; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: H; 
Amount of in-home care offered (hours per week): 42; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 18; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Adult diapers; 
* Personal emergency response system; 
Other non-Medicaid services: 
* Equipment to help with eating. 

Case manager: I; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Assisted living 
facility; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: J; 
Amount of in-home care offered (hours per week): 24.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare and Medicaid; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: K; 
Amount of in-home care offered (hours per week): 21; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Unspecified[B]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Adult diapers. 

Case manager: L; 
Amount of in-home care offered (hours per week): 12; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 8; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Transportation; 
* Home-delivered meals. 

Case manager: M; 
Amount of in-home care offered (hours per week): 24.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
* Wheelchair ramp; 
Other non-Medicaid services: [Empty]. 

Case manager: N; 
Amount of in-home care offered (hours per week): 34; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Unspecified[B]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: O; 
Amount of in-home care offered (hours per week): 30; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: P; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals; 
* Companionship. 

[A] The care plan recommended a referral for home health care but did 
not specify whether this service would by covered through Medicare or 
Medicaid. 

Note: Abby’s working daughter visits once each morning for 1 hour to 
provide informal care for Abby. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Table 10: Care Plans for Brian, a 70-Year-Old Man With Moderate 
Alzheimer’s Disease Who Lives With His Wife in Fair Health (Scenario 
1): 

Case manager: A; 
Amount of in-home care offered (hours per week): 18; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Home-delivered meals; 
Other non-Medicaid services: [Empty]. 

Case manager: B; 
Amount of in-home care offered (hours per week): 16; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Counseling; 
Other non-Medicaid services: 
* Caregiver support group. 

Case manager: C; 
Amount of in-home care offered (hours per week): 25; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 16; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: D; 
Amount of in-home care offered (hours per week): 25; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Bath/shower grab bar; 
Other non-Medicaid services: [Empty]. 

Case manager: E; 
Amount of in-home care offered (hours per week): 20; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Home-delivered meals; 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: F; 
Amount of in-home care offered (hours per week): 11; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: G; 
Amount of in-home care offered (hours per week): 14.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: H; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 30; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: I; 
Amount of in-home care offered (hours per week): 11; 
Other housing – nursing home or alternate housing: [Empty]. 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]. 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: J; 
Amount of in-home care offered (hours per week): 14.75; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals; 
* Respite (2 hours/week); 
* Caregiver support group. 

Case manager: K; 
Amount of in-home care offered (hours per week): 13; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Companionship. 

Case manager: L; 
Amount of in-home care offered (hours per week): 14; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 8; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Caregiver support group; 
* ID bracelet (in case Brian wanders). 

Case manager: M; 
Amount of in-home care offered (hours per week): 21; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Caregiver support group. 

Case manager: N; 
Amount of in-home care offered (hours per week): 34; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals; 
* Housekeeping. 

Case manager: O; 
Amount of in-home care offered (hours per week): 25; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: P; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Table 11: Care Plans for Brian, a 70-Year-Old Man With Moderate 
Alzheimer’s Disease Who Lives With His Wife in Poor Health (Scenario 
2): 

Case manager: A; 
Amount of in-home care offered (hours per week): 26.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Home-delivered meals; 
Other non-Medicaid services: [Empty]. 

Case manager: B; 
Amount of in-home care offered (hours per week): 22; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: 
* Counseling; 
Other non-Medicaid services: 
* Caregiver support group. 

Case manager: C; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Adult foster home; 
Adult day care (hours per week): 24; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Home-delivered meals; 
Other non-Medicaid services: [Empty]. 

Case manager: D; 
Amount of in-home care offered (hours per week): 29; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: E; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Home-delivered meals; 
* Personal emergency response system; 
Other non-Medicaid services: [Empty]. 

Case manager: F; 
Amount of in-home care offered (hours per week): 24.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: G; 
Amount of in-home care offered (hours per week): 16; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 15; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: H; 
Amount of in-home care offered (hours per week): 6; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 30; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: I; 
Amount of in-home care offered (hours per week): 15; 
Other housing – nursing home or alternate housing: [Empty]. 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]. 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: J; 
Amount of in-home care offered (hours per week): 21; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Home-delivered meals. 

Case manager: K; 
Amount of in-home care offered (hours per week): 19; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: L; 
Amount of in-home care offered (hours per week): 14; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): 8; 
Medicare or Medicaid nurse or home health care: Medicare; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Caregiver support group; 
* ID bracelet (in case Brian wanders). 

Case manager: M; 
Amount of in-home care offered (hours per week): 21; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicare and Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: 
* Caregiver support group. 

Case manager: N; 
Amount of in-home care offered (hours per week): 28; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Personal emergency response system; 
Other non-Medicaid services: 
* Home-delivered meals; 
* Housekeeping. 

Case manager: O; 
Amount of in-home care offered (hours per week): 25; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: P; 
Amount of in-home care offered (hours per week): 27.5; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: Medicaid; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

Table 12: Care Plans for Brian, a 70-Year-Old Man With Moderate 
Alzheimer’s Disease Who Lives Alone (Scenario 3): 

Case manager: A; 
Amount of in-home care offered (hours per week): 35; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: 
* Home-delivered meals; 
* Counseling; 
Other non-Medicaid services: [Empty]. 

Case manager: B; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Assisted living 
facility; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: C; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Adult foster home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: D; 
Amount of in-home care offered (hours per week): 168; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: E; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Boarding home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: F; 
Amount of in-home care offered (hours per week): 168; 
Other housing – nursing home or alternate housing: [Empty]; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: G; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: H; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: I; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Assisted living 
facility; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]. 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: J; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Assisted living 
facility; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]. 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: K; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: L; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: M; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: N; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: O; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Group home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Case manager: P; 
Amount of in-home care offered (hours per week): [Empty]; 
Other housing – nursing home or alternate housing: Nursing home; 
Adult day care (hours per week): [Empty]; 
Medicare or Medicaid nurse or home health care: [Empty]; 
Other Medicaid services: [Empty]; 
Other non-Medicaid services: [Empty]. 

Source: GAO interviews with case managers in Kansas, Louisiana, New 
York, and Oregon. 

[End of table] 

[End of section] 

Footnotes: 

[1] See U.S. General Accounting Office, Long-Term Care: Aging Baby Boom 
Generation Will Increase Demand and Burden on Federal and State 
Budgets, GAO-02-544T (Washington, D.C.: Mar. 21, 2002). 

[2] In each state, we selected two case managers in a county with a 
small town (less than 15,000 people) and two in a county with a large 
city (at least 250,000 people) based on a list of all local Medicaid 
case managers provided by state or county officials. 

[3] Calculations based on Korbin Liu et al, Changes in Home Care Use by 
Older People with Disabilities: 1982-1994, prepared for the AARP Public 
Policy Institute (Washington, DC.: AARP, Jan. 2000). 

[4] Based on our analysis of data from the CMS Office of the Actuary 
and The MEDSTAT Group. These figures include long-term care for all 
people, regardless of age. Amounts do not include expenditures for 
nursing home and home health services provided by hospital-based
entities, which are counted with other hospital services. 

[5] 42 U.S.C. § 1396n(c) (2000). 

[6] U.S. General Accounting Office, Medicare Home Health Care: Payments 
to Home Health Agencies Are Considerably Higher Than Costs, GAO-02-663 
(Washington, D.C.: May 6, 2002). 

[7] Medicaid expenditures for these long-term care services for the 
elderly include both federal and state shares and are in relation to 
the state or national population aged 65 or older. Also, we adjusted 
Medicaid expenditures for a state’s health care costs as a percentage 
of the national average health care costs for 1997 to 1999 to at least 
partially account for geographic cost differences. 

[8] In Louisiana, “adult day health care” for the elderly and disabled 
is distinguished from “adult day care” for individuals with mental 
retardation or developmental disabilities. For the purposes of this 
report, “adult day care” is used to describe care for the elderly and
disabled to be consistent with terminology across states. 

[9] HCBS waiver services served about 25,000 New Yorkers as of July 
2002. 

[10] In New York, spending on HCBS waiver services provided in-home 
cannot exceed 75 percent of Medicaid’s average annual nursing home 
costs for most individuals, but these costs may be up to 100 percent of 
average annual nursing home costs for individuals with certain 
diagnoses, including Alzheimer’s disease. 

[11] Many of the care plans recommending that Abby or Brian remain at 
home also recommended other supplemental services, including Medicaid-
covered personal emergency response systems or assistive devices for 
bathtubs such as grab bars or transfer seats; Medicaid and/or Medicare 
home health care; or other federal or state-subsidized services such as 
meal deliveries or transportation services. 

[12] Funding from the Older Americans Act provides for supportive in-
home and community-based services, including such services as 
nutrition, transportation, senior centers, health promotion, and 
homemaker services. 42 U.S.C. §§3001-3058ee (2000). 

[13] The cap was increased from $35 per day to $55 per day effective 
September 1, 2002. The cap includes the cost of in-home care as well as 
a case management fee. According to a state official, Louisiana’s daily 
cap for in-home HCBS waiver services reflects the state’s budget 
constraints as well as the need to be cost-effective relative to 
nursing home care. 

[14] The Louisiana adult day care waiver served approximately 525 
people with a waiting list of 201 people as of July 2002. 

[15] We presented information about the hypothetical individuals by 
phone, whereas case managers would typically assess clients in person. 

[16] ADLs include grooming, dressing upper and lower body, bathing, 
toileting, transferring (such as to and from a bed or wheelchair), 
walking (ambulation), and eating. IADLs include planning and preparing 
meals, transportation, laundry, housekeeping, shopping, and using a 
telephone. 

[17] In this scenario, Abby’s granddaughter is a single mother who 
works long hours and therefore depends on her mother (Abby’s daughter) 
for child care. 

[18] Brian is not a military veteran and is therefore not eligible for 
health or long-term care services covered by the Department of Veterans 
Affairs. 

[19] In this scenario, Brian’s wife has a history of high blood 
pressure and type II diabetes, and she underwent an angioplasty in the 
past 6 months. 

[20] While some case managers suggested alternative care plans or noted 
that clients could choose among different care options, the care plans 
summarized in this report represent the care plans that the case 
managers identified as the best alternative or indicated were most 
likely to be selected by clients who generally preferred to remain at 
home if possible. The recommended care plans represented the services 
offered at the time of the assessment, could be subject to supervisory 
review, and could be reassessed if the plan did not meet the 
individuals’ care needs or if the individuals’ conditions or 
availability of informal care changed. 

[End of section] 

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