Designing a Medicare Help at Home Benefit: Lessons from Maryland’s Community First Choice Program

ISSUE: Medicare does not cover home- and community-based services (HCBS) that help beneficiaries function independently at home. The financial burden of uncovered personal care services puts beneficiaries with physical or cognitive impairment at risk of nursing home placement. GOAL: Analyze trends in paid and unpaid personal care and expenditures under a model Medicaid Community First Choice (CFC) program in Maryland. METHODS: Trends were analyzed using Maryland Medicaid claims data and standardized assessment information. Quantitative analysis was supplemented by interviews with Maryland officials and experts. FINDINGS: Maryland introduced CFC in 2014. By the end of 2016, enrollment had reached 11,573. The majority of participants were over age 65 (55%) and dually eligible for both Medicare and Medicaid (65%). Expenditures per person per year were stable at $21,000 between 2014 and 2016. Mean hours of paid personal assistance per participant averaged 29 hours per week, with slightly higher levels of utilization for dually eligible enrollees than for Medicaid-only enrollees. Weekly mean hours of informal support declined slightly. Unpaid informal care continued at a high rate, even though payment is permitted for personal care from family members and other previously unpaid caregivers. CONCLUSION: Maryland’s experience points to: a targeted benefit that will augment support from family members and other unpaid caregivers, a stable per-person cost, and increased take-up rates of eligible enrollees over time.