Analysis of the 2008-09 Budget Bill: Health and Social Services

In–Home Supportive Services (5180)

The In–Home Supportive Services (IHSS) program provides various services to eligible aged, blind, and disabled persons who are unable to remain safely in their homes without such assistance. An individual is eligible for IHSS if he or she lives in his or her home—or is capable of safely doing so if IHSS is provided—and meets specific criteria related to eligibility for the Supplemental Security Income/State Supplementary Program. In August 2004, the U.S. Department of Health and Human Services approved a Medicaid Section 1115 demonstration waiver that made about 93 percent of IHSS recipients eligible for federal financial participation. Prior to the waiver, about 25 percent of the caseload were not eligible for federal funding and were served in the state–only “residual” program.

The budget proposes about $1.6 billion from the General Fund for support of the IHSS program in 2008–09, an increase of $2.8 million (0.2 percent) compared to estimated expenditures in the current year. This slight increase is attributable to increases in the IHSS caseload and provider wages, which is largely offset by the Governor’s proposal to reduce IHSS domestic and related care service hours.

Reducing Domestic and Related Care Hours For IHSS Recipients

The Governor’s budget proposes to reduce the hours of domestic and related services provided to the In–Home Supportive Services recipients by 18 percent, resulting in estimated General Fund savings of about $110 million in 2008–09. Additionally, the budget includes a proposal to reduce county administrative funding and workload by 10 percent, resulting in estimated General Fund savings of about $10 million in the budget year. We provide background on domestic care service hours, highlight key features of the Governor’s proposals, present some concerns with the estimated savings, and provide alternatives for achieving savings.

Background

After the needs of an IHSS recipient are assessed by a social worker, the recipient is authorized to receive a specific number of hours of care each month for a variety of services. This care is allocated among certain tasks to create a package of services to assist recipients in remaining in their own homes thereby potentially avoiding being placed in a residential care or nursing facility. Figure 1 provides a list of the tasks for which IHSS recipients may receive service hours.

Who Receives Domestic Services? As shown in Figure 1, domestic and related services include general housekeeping activities, meal preparation, meal clean–up, shopping for food, and errands. For 2008–09, the IHSS caseload is estimated to be about 408,000 persons. Over 95 percent of these recipients are estimated to receive some level of domestic and related care service. Currently, the average number of hours authorized for IHSS domestic services is 37 hours per month, and the average number of hours for all other tasks is about 50 hours per month. In other words, for an average IHSS recipient, domestic and related services make up about 43 percent of their total care hours each month.

The Current Assessment Process. The IHSS program relies on county social workers to conduct individualized assessments to determine the number of hours of each type of IHSS service that a recipient needs in order to remain in his/her home. Recently, social workers have received training in order to implement a standardized assessment process throughout the state.

Reassessment Process. Current law requires social workers to reassess most recipients’ need for service every 12 months. The length of time between assessments can be extended for an additional 6 months (to a total of 18 months between assessments) if recipients meet certain criteria relating to their health and living conditions.

IHSS Appeals. Currently, if IHSS recipients disagree with the hours authorized by the social worker, they have a right to request a reassessment, and if still not satisfied, they can appeal their hour allotment by submitting a request for a state hearing to the Department of Social Services (DSS).

Governor’s Proposals

County Administration Proposal

The Governor’s budget proposes to reduce county administrative funding by about $10 million General Fund (about 10 percent) in 2008–09. He also proposes to reduce the workload for county social workers by extending the interval between IHSS recipient assessments from 12 months to 18 months. The Governor’s proposal allows for assessments more frequently than 18 months if recipients meet certain criteria relating to their condition or at any time that a recipient requests an assessment.

Domestic and Related Care Reduction

The Governor’s budget proposes to reduce the number of hours provided for IHSS domestic and related services by 18 percent in 2008–09. This reduction is estimated to save $110 million General Fund in the budget year. Because most recipients receive domestic care services, this reduction will have an effect on nearly all IHSS recipients and providers. As seen in Figure 2, the average IHSS recipient will go from having 37 hours of domestic and related services to 30.4 hours per month, and their total services will be reduced from 86.6 hours to 80 hours per month.

Implementing the Reduction. The Governor’s proposal assumes that the reduction in domestic and related care hours would become effective on July 1, 2008. This assumes enactment by the Legislature of the necessary statutory changes by March 1, 2008. Currently, information regarding recipient hour authorizations is stored in the state operated Case Management Information and Payrolling System (CMIPS). The Governor’s proposal does not include any administrative or reprogramming costs to enable the reduction. The DSS states that CMIPS will be reprogrammed to automatically apply the 18 percent reduction to existing hour assignments for domestic and related services. At the time this analysis was prepared, it was not clear if CMIPS could make this change within its existing resources or whether additional costs will be incurred for computer reprogramming.

The Assessment Process. The DSS states that there will be no change in the assessment process at the county level. Social workers will continue to use their training and existing guidelines to perform an individualized assessment and determine the amount of care that they believe a recipient should receive to avoid institutionalization.

Pursuant to the proposed trailer bill language, after their hours are reduced by 18 percent, all IHSS recipients will receive a notice in the mail with information about (1) the amount of hours the recipient received prior to the reduction and the number of hours the recipient will receive as a result of the reduction, (2) the reason for the reduction, (3) when the reduction will be effective, and (4) how all or part of the reduction may be restored if the recipient believes he/she will be at serious risk of out–of–home placement if the care is not restored.

Changes to the Appeals Process. Current law states that IHSS recipients do not have the right for a state hearing if they are appealing a reduction in hours that occurred as a result of a change in federal or state law. However, when describing how all or part of the 18 percent reduction in domestic and related care service hours may be restored, the trailer bill language implementing the Governor’s proposal refers to a section in current law that allows IHSS recipients to apply to have their hours restored through an IHSS care supplement, which is designed to provide additional hours of service. If the recipient disagrees with the county’s determination regarding the need for a care supplement, the recipient may then request a hearing on that determination. Additionally, under the Governor’s proposal, recipients retain the right to request a social worker reassessment and to appeal their reassessment if not satisfied.

Projected Savings May Not Be Achieved

Although it is likely that this proposal will lead to some General Fund savings, we are concerned that the estimated savings in the Governor’s budget may be overstated. The Governor’s budget assumes that by increasing the allowable time between social worker assessments, county workloads will decrease by 10 percent. Additionally, the Governor’s plan assumes that all IHSS domestic and related care hours will be reduced by 18 percent for all recipients in 2008–09. Below we present our concerns with the estimated savings included in the Governor’s budget.

Administrative Cost Reduction May Not Lead to Equivalent Workload Reduction. Although the proposal to reduce funding for county administration by 10 percent results in savings, there is the potential that it will not result in a 10 percent reduction to county workload. Although the proposal extends the allowable time between reassessments, it does not change the recipient’s ability to request a reassessment at any time. As more time passes between assessments, recipients may experience changes in their conditions and request a social worker reassessment. This may require social workers to perform more assessments than would be budgeted under the Governor’s proposal.

Implementing Hour Reduction Proposal. Although the 18 percent reduction in domestic and related care service hours will be applied automatically by CMIPS, it is not clear whether there will be administrative or reprogramming costs to enable the reduction. The Governor’s budget does not include any administrative or reprogramming costs that may be required for CMIPS to apply the reduction. To the extent that these costs exist, some of the savings in this proposal will erode.

Appeals for Additional Hours. As recipients become aware of the 18 percent reduction in domestic and related services, there will likely be an increase in the number of recipient requests for hour restorations (whether through reassessments or requests for an IHSS care supplement). This is because the proposal does not change the ability of the recipient to request these reevaluations, and the notice they receive will inform them of their ability to restore hours if they believe that they are at serious risk of out–of–home placement. If these reassessments or appeals result in restored domestic and related care services for recipients, the savings due to this proposal will be less than estimated in the Governor’s budget.

Additionally, increased reassessments and appeals would raise administrative costs. This is because it will take a social worker time to process the increase in the requests and appeals.

Social Worker Incentives May Reduce Savings. As social workers become aware of the 18 percent reduction, there may be an incentive to increase the hours in nondomestic categories of care, or inflate the assessed hours for domestic care, to make up for the lost hours. Social workers might do this in order to avoid requests for reassessments and appeals which take additional social worker time. It should be noted that these additional hours could be assigned to domestic or nondomestic services. This is because IHSS recipients typically use their hours as if they are a block grant. Although social workers assign a certain number of hours for each task, recipients often reallocate hours among tasks. (For a more complete discussion of how recipients treat their hours as a block grant, see “Enhancing Program Integrity” in the “IHSS” section of the Analysis of the 2007–08 Budget Bill.)

State Plan Amendment May Be Required for Both Proposals. The DSS indicates that a Medi–Cal state plan amendment, approved by the federal Centers for Medicare and Medicaid Services, may be needed in order to implement the extension of time between recipient assessments and the 18 percent reduction in domestic and related care hours. If it is determined that a state plan amendment is required, and the amendment is not approved prior to July 1, 2008, the implementation date will be delayed and the proposed savings will be reduced.

Other Means of Achieving Savings

The administration’s proposals reduce service hours without changing the underlying statutory or regulatory criteria for assigning hours. Based on our review, we conclude that some of the estimated savings are likely to be offset by increased appeals and hour restorations, reassessments, and potential administrative costs.

In order to make meaningful changes to service hours, the Legislature could consider changes in statute to the standards for authorizing hours in the program, rather than reduce the hours once they have already been assessed, as the Governor’s budget proposes. Below we present some options to consider.

Cap Hours for Certain IHSS Services. Although the Governor’s proposal reduces the number of hours assessed by social workers by 18 percent, it does not limit the number of hours which may be assessed. In order to achieve meaningful savings by reducing IHSS hours, the underlying criteria for providing hours could be changed. To achieve this, the Legislature could place caps on the hours authorized for certain IHSS services. Such caps, with exceptions, currently exist for services provided in the IHSS program. For example, the maximum number of hours that recipients can receive for certain domestic services is limited to 6 hours per month, unless there is an exception because the needs of the recipient require additional time. Thus, as an alternative approach, the Legislature could cap the hours for this service at five hours and not allow exceptions.

We believe that it is reasonable to place caps, without exceptions, on certain domestic services where the condition of the recipient is not likely to lead to a variance in the need for service hours. The savings associated with this proposal would depend upon the number of services that are capped without exceptions and the number of hours at which they are capped.

Consider Living Situation When Assessing Hours. The Legislature could also establish differential hours based on the recipient’s living situation. In other words, the Legislature could cap the number of domestic hours available to a recipient who lives with their family at a level that is lower than for someone living independently. For example, the current maximum number of hours that recipients may receive for food shopping is one hour per week. The Legislature could consider continuing to allow one hour per week for recipients who live on their own, but authorize only one–half hour per week for recipients who live with relatives.

When assessing hours for certain domestic services, it seems appropriate to consider the living situation of the recipient. As part of the current assessment process, social workers do consider whether the recipient has access to voluntary assistance and other resources. However, there is no formal distinction made between the maximum authorized hours for those who live with family members and those who live independently. Recipients living with relatives may need less hours for domestic services than individuals living independently. This is because family members would likely be performing domestic tasks, such as food shopping, regardless of whether or not they were living with a recipient of IHSS. In such a situation, it would not be necessary to provide the same number of IHSS service hours for recipients living with relatives as are provided for those living independently. The savings attributable to this type of reduction would depend upon the number of services selected for the establishment of differential hour caps, and the amount of the hour differential.

State Plan Amendment. Similar to the Governor’s proposal, prior to implementing these types of IHSS hour reforms, a Medi–Cal state plan amendment (with federal approval) may be necessary.

Conclusion

We believe that the Governor’s proposal to reduce domestic and related care hours will result in some savings in the budget year. However, due to the concerns mentioned above, it is likely that the savings will be less than estimated by the Governor’s budget. To the extent that the Legislature wants to achieve savings by reducing service hours, the preferred approach is to change the statute regarding actual standards for assigning hours, rather than reduce the hours after the need has been assessed.

Improving the IHSS Workforce Through Tiered State Participation in Wages

Although the In–Home Support Services (IHSS) wages represent a significant cost to the state, current law grants local county boards of supervisors the authority to set wage levels and the conditions under which potential providers may list themselves as available to recipients. In order to improve the IHSS labor force, and control growing wage costs, we recommend enactment of legislation, before 2010–11, which modifies the structure for state participation in wages to reflect the training and tenure of IHSS providers.

Background

IHSS Recipients and Providers. In 2008–09, the IHSS program is estimated to provide in–home care to approximately 408,000 recipients. The IHSS care is primarily delivered by an average of 325,000 individual providers located throughout the state. About 58 percent of IHSS providers are related to the IHSS recipient for which they provide care.

Recipient Control. In the IHSS program, the recipient is considered to be the employer, and has the responsibility to hire, supervise, and fire their provider. Although the recipient is the employer, they do not set IHSS wages, which are collectively bargained between counties (generally represented by “public authorities” discussed below) and employer representatives. As the employer, IHSS recipients have few restrictions on who they are permitted to hire. Specifically, the only restrictions on IHSS recipients is that they may not hire individuals who in the last ten years have been convicted of Medi–Cal fraud, child abuse, or elder abuse.

The Role of Public Authorities. For purposes of collective bargaining over IHSS provider wages and terms of employment, all but two counties in the state have established public authorities (other counties have established different entities for this purpose). The public authorities essentially represent the county in provider wage negotiations. Besides collective bargaining, the primary responsibilities of public authorities include (1) establishing a registry of IHSS providers who have met various qualification requirements, (2) investigating the background of potential providers, (3) establishing a system to refer IHSS providers to recipients, and (4) providing training for providers and recipients.

Funding for Provider Wages and Benefits. The federal, state, and local governments share in the cost of IHSS wages. Specifically, the federal government funds 50 percent of the cost, and the remaining, nonfederal share of costs is funded 65 percent by the state and 35 percent by the counties.

Funding Criminal Background Investigations. Among other things, Chapter 447, Statutes of 2007 (SB 868, Ridley–Thomas), provides, if funds are appropriated, for state participation in the cost of performing criminal background investigations (CBIs) on registry and nonregistry IHSS providers. Prior to enactment of this legislation, the state did not share in the cost of CBIs. Pursuant to Chapter 447, if over 50 percent of those on a public authorities registry have received a CBI, the county is eligible for state reimbursement of 65 percent of the nonfederal cost. Additionally, if funds are appropriated in the annual budget act, recipients may request a CBI be conducted on their provider at no cost to the recipient or provider. No such appropriation was made in 2007–08, and the Governor’s budget does not include funding for 2008–09. Thus under current practice, there is no state participation in the cost for CBIs.

Flexibility Leads to County Variance

Local county boards of supervisors have used their discretion to implement public authority registry requirements and wage structures that vary throughout the state, as discussed below.

Wages Vary Among Counties. Pursuant to Chapter 108, Statutes of 2000 (AB 2876, Aroner), the state participates in combined wage and benefit levels of up to $12.10 per hour for IHSS providers. Although the state participates in wages of up to $12.10 per hour, as seen in Figure 3, county combined wages and benefits range from $8 per hour to $14.43 per hour. A county, such as Santa Clara, with an established wage over the state participation cap of $12.10 per hour, shares the cost of the portion of the wage that is over the $12.10 with the federal government. In other words, the additional $2.33 above the $12.10 is shared 50 percent by the federal government and 50 percent by Santa Clara County.

Currently, the average statewide IHSS wage and benefit level is about $9.98 per hour. County decisions to raise wages to this level have resulted in state costs of $281 million more than they would have been if counties had continued paying minimum wage ($8 per hour as of January 2008). If all counties decide to raise wages and benefits to the authorized maximum ($12.10 per hour), state costs would increase by about $316 million annually.

Registry Requirements Vary. Each public authority maintains a registry of IHSS providers who have met various background and qualification requirements implemented by the counties. The names of providers listed on the registry are distributed to IHSS recipients to aid them in the hiring process. The IHSS recipients are not required to hire their providers from the registry. Current law grants broad discretion to counties when establishing criteria for providers to qualify for IHSS registry placement. Failure to meet registry requirements does not prohibit a person from working as an IHSS provider, but instead renders them ineligible from being placed on the registry. Below we list some of the requirements that some counties have implemented in order for a person to be placed on the registry.

• Attend provider training,
• Pass a drug screening test,
• Pass a criminal background investigation,
• Provide personal and professional references,
• Participate in an interview with the public authority,
• Provide employment history.

The requirements established for qualification for the provider registry vary by county. Not all counties have implemented all of the registry requirements listed above, and some counties have implemented requirements that are not included. Additionally, counties with similar requirements may implement them in a variety of ways. For example, two counties may require that registry providers attend training, but one county may require more hours of training than another county.

County Experience With Tiered Wages

Although there is wide variation among county registry requirements, with very few exceptions, IHSS workers within each county are paid the same hourly wage. However, at least two counties have used their authority to consider or implement variable wage rates within their counties. Below we discuss a differential wage approach in Los Angeles County and a proposal for tiered wages in Lake County.

The Los Angeles County Back–Up Attendant Program. Los Angeles County has utilized the flexibility in current law to implement a back–up attendant program. The Back–Up Attendant program was set up to ensure that IHSS recipients in Los Angeles County receive their authorized care even if their regular provider is not available. The program provides a wage of $12 per hour for providers who are willing to be listed on the registry as back–up providers, and $9 per hour for all other providers. The back–up providers are used when eligible IHSS recipients have an urgent but temporary need for assistance, and their regular provider is unable to provide that assistance. The requirements to become a back–up provider are the same as the requirements to be listed on the registry, but in addition to those requirements, back–up providers must complete a 12‑hour training course or pass a proficiency test to evaluate their skills. The DSS concurred that counties have the authority to set wage levels and approved this differential wage structure, as it was implemented at no additional cost to the state. The Los Angeles Back–Up Attendant program provides an example of how counties have used their authority to make differential wage decisions.

Lake County Two–Tier Wage Proposal. Recently, Lake County proposed to implement a two–tiered wage structure that would pay higher wages to IHSS providers who were willing and able to qualify for the Lake County Public Authority registry. Individuals who did not wish to sign up for the registry, or did not qualify for the registry, could still be hired as an IHSS provider, but would be paid a lower wage. The Lake County Board of Supervisors indicated that the purpose of this tiered wage proposal was to use a monetary incentive to encourage a heightened standard for IHSS providers. They maintain that a tiered wage structure would provide IHSS recipients with the opportunity to make more informed decisions when searching for a provider. To qualify for the registry in Lake County, a provider would have to pass a criminal background investigation, pass a drug screening, and participate in first–aid training. The DSS has concluded that current law permits counties to negotiate tiered wage structures as long as it is done at no cost to the state. Lake County is currently in the process of providing DSS with the details of how it plans to implement a tiered wage structure at no additional state cost.

Tiered Wage Automation Considerations. Both the Los Angeles County Back–Up Attendant Program and the Lake County tiered wage proposal require a payrolling system that is able to accommodate multiple wages within a county. Each county’s payroll claim is processed by the state’s CMIPS. Currently, CMIPS is only capable of accommodating a single wage for all workers in a given county. Thus, Los Angeles County must use “work arounds” and manual inputs by county workers to operationalize the wage differential for the Back‑up Attendant program. Similarly, DSS is requiring Lake County to address the data entry issue at no state cost. However, a new payroll processing system, CMIPS II, is currently being developed, and this new system will be able to accommodate multiple wage levels within a single county. The system should be fully operational by summer of 2011.

Opportunity for the Legislature to Condition State Participation in Wages

Because multiple wages within a county are permissible under current law, and CMIPS II will be able to accommodate multiple wages within a county, more counties may begin to propose differential wage structures. This will provide the Legislature with the opportunity to consider whether it wishes to link the level of state participation in wages to the skills, training, and experience of IHSS providers. Differential wage structures are common in the public and private sectors. Valuing the experience and training of IHSS providers should improve the IHSS labor force and thus the quality of services for recipients. Below we present several alternatives for creating pay differentials among workers.

Higher State Participation in Wages for Experienced Providers. Currently, with very few exceptions, virtually all IHSS providers within a county are paid the same amount in wages and benefits regardless of experience. Typically, wage structures in the public and private sectors are designed to pay those with more experience at a higher level than those new to the job. The Legislature could consider implementing a “training wage” for new IHSS providers, and therefore participate in higher wages for IHSS providers with more experience. In other words, new IHSS providers would receive less state participation than providers with at least six months of experience. This would reward skilled providers, and result in some savings to the state with potential county costs or savings. Whether counties will experience savings is dependent upon county behavior. If counties decide to reduce wages to the level of state participation, they will also receive some savings from the training wage. However, those counties that maintain wages despite decreased state participation will experience additional costs.

Higher State Participation for Trained Workers. Similarly, the Legislature could authorize state participation in higher wages for providers who obtain training. For example, the Los Angeles City College currently offers a free IHSS provider training course. This particular training course is designed to provide IHSS providers with the skills needed to be an effective in–home care provider. Upon completion of the course, participants receive a certificate of completion.

Blending Training and Experience Rules. Another alternative for the Legislature to consider would be to allow IHSS providers to substitute successful completion of a training course for up to six months of on–the–job training. The Legislature would specify the number of hours of training needed to substitute training for experience, as well as require provider documentation of course completion in order to receive state participation in the higher wage.

The Legislature would ultimately determine the details of the training wage. For purposes of illustration, if the Legislature creates a wage differential whereby the state participates in $0.50 cents less for a six month training wage for new providers, this would result in General Fund savings of about $1 million annually.

Higher State Participation in Wages for Providers Who Complete a Criminal Background Investigation. The Legislature could provide greater state participation for providers who are willing to have a CBI conducted. Under this approach, workers desiring the higher wage level would apply to the Department of Justice (DOJ) for a CBI. The results of the CBI would be provided to the IHSS recipients and the county. The information in the CBI would assist recipients in making informed decisions during the hiring process. Unless the CBI reveals that the provider was convicted of fraud or abuse as previously described, the state would participate in a higher wage level for providers who complete a criminal background investigation and are hired by an IHSS recipient.

Implementing this criteria would result in some savings to the state, as it is unlikely that all IHSS providers would participate in the CBI. For example, if 10 percent of all providers opt not to participate in a CBI within the timeframe established, and the Legislature decides to participate in $0.50 cents less per hour for those providers, the state would save about $5.7 million annually.

Other Considerations. The options described above would improve the IHSS labor force. Additionally, encouraging training and increasing the recipient’s knowledge of the provider through a CBI, may result in reduced fraud in the IHSS program. These options would not prevent counties from maintaining or increasing current wages, as it only affects state participation in those wages. Failure to comply with the criteria established in these differential wage options would not prevent an individual from becoming an IHSS provider.

Analyst’s Recommendation

In order to improve the IHSS labor force, we recommend enactment of legislation that conditions state participation in IHSS wages on the provider’s experience, training, and willingness to have a criminal background investigation conducted. Because the current version of CMIPS is only able to accommodate one wage level per county, we recommend that variable state participation in wages only become operational when CMIPS II is fully implemented (in 2010–11).

The precise policy mix of state participation in wages would be up to the Legislature. Variants to the options mentioned above could include increases or decreases to the amount of the wage differentiation and the length of time new providers receive the training wage. In other words, the Legislature may decide to participate in $1 less per hour for providers who have not completed a CBI, rather than the $0.50 differential we used in our example, or they may decide to participate in a training wage for three months rather than six months. All of these decisions will influence the amount of savings associated with tiered wages. Adopting all of the options described above ($0.50 wage differentials and six months of the training wage) would result in annual General Fund savings of about $6.7 million. In addition, we believe linking pay to experience and training will improve the IHSS labor force and services for recipients.