Oklahomans and their families prefer in-home supports over institutionalization and we know these supports offer marked savings with much better outcomes. Over two decades, Oklahoma developed five in-home support Medicaid programs (i.e., 1915C Waivers) now serving 31,000 eligible citizens, and 2 more are in the works. Yet, in-home programs are increasingly squeezed by nearly eight years of stagnant reimbursement.

One way to generate new funds is through Medicaid provider assessments. Through assessments, fees levied on “classes” of services generate revenues matched with federal funds to help cover provider costs. Provider assessments on institutions like nursing facilities allow them to average annual 10% increases even while operating at 65% occupancy.

To investigate in-home provider assessments, the Home and Community-Based (H&CB) Services Council joined Representative Peters to organize an Interim Study (2009H-080) on Provider Assessment Options for Home & Community-Based 1915C Waiver programs. In-home support recipients, advocates, and providers endorsed the study in the belief that Oklahoma should lead through stewardship and prevention across the lifespan for disabled and aging populations, and with measures that assure cost-effective, quality-proven programs. In-home programs save Oklahoma nearly half of a billion dollars annually by preventing costly institutionalization, promoting individual responsibility, self-determination, and full participation in the community –all with better outcomes, including help with employment and a full life in the community no matter how complex the disability.

Medicaid experts spoke with legislators and agency heads on implications for in-home programs if assessments are not passed. According to consultants, CMS (the federal agency overseeing Medicaid), has not updated assessment classes since 1981, preventing states from assessing fees on in-home programs like other providers. National advocacy is underway to change this omission. Missouri and Texas passed bills pursuing in-home assessments, Kentucky has an assessment with the knowledge of CMS, Michigan created an in-home assessment in managed care, and Maine adopted an assessment through allowed taxation. Clearly, preventive, cost-saving opportunities through in-home programs are motivating states to pursue assessments. Conversely, as California cut citizen choice for in-home programs, families/advocates filed a lawsuit under the Olmstead Supreme Court Decision, one that mandates services in the most integrated setting possible.

Additional considerations:

• Oklahoma’s in-home programs support citizens, ages 3 through late adulthood and all are deemed “nursing-facility-level-of-care.” Without in-home programs, these Oklahomans are forced into more costly options, including emergency rooms, nursing and intermediate institutions;

• Oklahoma’s legislated Rate Review recommends a rate adjustment to sustain in-home services.

• Estimates suggest that over 100,000 Oklahomans are employed in in-home programs providing a range of proprietary and non-profit supports. Experts agree that rate stagnation lowers preventive, quality services, and employment for Oklahoma citizens.

• Oklahoma’s Health Care Authority received Oklahoma’s 2nd Freedom Initiative grant for over $45M to bring over 2,000 citizens out of institutions due to recognized benefits of community living. With CMS ‘ strong encouragement, the state is writing two additional waivers for children and adults with disabilities and seniors to advance use of in-home supports.

With the age wave upon us, increasing numbers of Oklahomans with disabilities across the lifespan, and when recognizing the place Medicaid holds in state budgets–the chief funding for long-term care–it seems logical to endorse in-home support programs to save Oklahoma substantial dollars, assure better outcomes, and serve individuals and families as desired–in their own homes and communities.

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