Aug 16, 2010

Alzheimer's Caregiving and Medicaid

By Carole B. Larkin
Alzheimer's Reading Room

I promised Carol Wright some information about Medicaid in response to the article -- The Cost of the War on Alzheimer's Terrorism -- $24 a Day.

First a “Cliff Notes” (abbreviated) version of the relationship between government and caregiving of elders.



On the first day, (Wait! I’m going back too far! Never mind that.) OK, starting when man had progressed from tribal government to a larger and more comprehensive types of government in civilizations established around the world, like China (dynasties), Egypt (Pharaohs) South America (Mayans), the family was the designated caregiving unit for older adults. Governments had nothing to do with caregiving elders.

This concept continued unabated until fairly recent times. In the United States, the first significant government program to help with care of an older adult (this is sort of a stretch) was the act which created the Social Security Administration in 1936. FDR set up mechanisms so that there would be funds available to care for older adults. The older adults could access them when they turned 65.

In 1965 Medicare was begun to vastly increase the amount of medical care given to elders. Note none of this money was ever devoted to paying family caregivers, as it was still conceived as not being in government’s assigned duties.

The Medicaid program was created by the same act in 1965, but wasn’t really extended to the elderly in any significant way until 1972, when SSI (elderly welfare recipients) were automatically included in Medicaid.

The only purpose for Medicaid was to pay nursing home costs for poor elderly people; nothing else. Finally, in 1981 came the Home and Community Based Waiver program which allowed Medicaid to pay for some people to leave nursing homes and return to their homes (or to assisted living, which cost less than nursing homes) with caregivers. It was a small program started on a trial basis. That basically leads us to where we are today.

Medicaid is a federal government program (meaning that the federal government pays over half of the costs of the program) but is administered by the states.

There are “core” rules and regulations that each state must adhere to, but states are free to deviate or experiment a little with the approval of the federal government. That is why you will find differences in rules and programs from state to state.

For example, a “core” rule is that a single individual cannot have more than $2,000 in total assets (not counting the values of their home and one car) to be eligible for Medicaid.

Another “core” rule is that they have to have income at or below the poverty level, as defined every year by the federal government. The federal government intended Medicaid to be for “poor” people, not the middle class.

In recent years, Medicaid is trying to cut costs where it can (I didn’t say it is cutting costs, but that it is trying to). Because it is always cheaper for the government to pay for assisted living or for a certain number of hours a week for caregivers to come in rather than for nursing home costs, those types of programs have grown a little. But those programs remain a very small proportion of total Medicaid payments.

I will give you some examples from Texas, where I live, because those are the rules that I know best. Keep in mind that the rules may not be exactly the same in your state, but chances are that they are similar.

Elders now can have income up to 300% of the federal poverty level and still qualify for Medicaid to pay for nursing homes. It sounds like a lot of money, but really it isn’t.

There is an “interest list” of people on Medicaid waiting to be on the Community Based Alternative Waiver program. For people on Medicaid and not in a nursing home (i.e. cared for by relatives at home) the wait is about two years. People on Medicaid in nursing homes who want to go home or to assisted living, are added to the top of the interest list, not the bottom. After all, the purpose is to take people out of nursing homes, if possible.

Texas pays for 40 hours a week of caregiving, and the caregiver cannot be a relative. The caregiver comes from home care agencies that contract with the state. I’m guessing that Vermont runs their Community Based Alternative Waiver program, slightly differently, allowing relatives, (but not the spouse) to be paid after getting a certain amount of training and contracting with the state to do the care. Always paperwork when you deal with the state- right? At least that’s what I read when I looked over Vermont’s Medicaid rules. Remember all this is in relation to POOR people, not the middle class.

Will the middle class ever be paid to caregive their loved ones in the United States? I, for one, doubt it. The United States has never defined the Federal Government’s role as providing care giving for elders, except for the poor. Advocating for this benefit is good. It may get it put on the “interest list” for additional benefits. Others may disagree with my opinion. I’m just saying…


Carole Larkin MAG, CMC, DCP, EICS is a geriatric care manager who specializes in helping families with Alzheimer’s and related dementias issues. She also trains caregivers in home care companies, assisted livings, memory care communities, and nursing homes in dementia specific techniques for best care of dementia sufferers. ThirdAge Services LLC, is located in Dallas, TX.

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Original content Carole B. Larkin, the Alzheimer's Reading Room