Lack of Retroactive Coverage for HCBS Pushes Seniors into Institutional Care: MACPAC

McKnight’s Home Care / By Adam Healy
Determining a beneficiary’s eligibility for Medicaid home- and community-based services can be a lengthy ordeal. And while states have options to streamline the process, most lack options for retroactive coverage, which can allow for the quickest access to HCBS, experts at the Medicaid and CHIP Payment and Access Commission discussed during a meeting Thursday.
“Timely access to HCBS is essential to ensure individuals receive care in the setting of their choice,” Asmaa Albaroudi, a senior analyst at MACPAC, said during the meeting. “States have several options to streamline Medicaid enrollment for people who need HCBS.”
Eligibility offerings
The most common way states streamline Medicaid eligibility processes is through presumptive eligibility. This system allows beneficiaries to begin receiving HCBS immediately as their eligibility is determined over a two-month period. Nine states use presumptive eligibility. 
Four states use expedited eligibility when making Medicaid HCBS determinations. While there is no uniform definition for expedited eligibility, it typically involves fast-tracking beneficiaries’ applications for HCBS so that they may begin receiving services sooner.
Only one state, Connecticut, offers retroactive coverage for Medicaid HCBS. This method allows people who are eligible for services, but not yet enrolled, to get coverage for care received up to three months prior to the start of their enrollment. This type of coverage is commonplace for nursing home care, but not for Medicaid HCBS, in other states, according to Patti Killingsworth, senior vice president of long term services and supports strategy at CareBridge and MACPAC commissioner.
Institutional bias 
As a result, nursing home care is often more financially viable for older adults as they can be reimbursed for care received before they enrolled in Medicaid. On the other hand, if one chose to receive Medicaid home care, they are fully responsible for the bill until they become enrolled.
“That is the reason why so many people end up in nursing homes that don’t need to,” Killingsworth said. “And I think it is a fundamental institutional bias — one of many in the federal regulations — that results in people being institutionalized when they don’t want to be and need to be.”
And while other tools including presumptive eligibility can still help beneficiaries receive HCBS, without retroactive coverage, many are still forced to rely on institutional care.
“I appreciate the fact that presumptive eligibility is available to states,” Killingsworth said. “I do not appreciate the fact that retroactive coverage of nursing facility benefits is available to people, while home- and community-based services are not.”