November 24, 2022
  • November 24, 2022

Make the protections against the impoverishment of spouses permanent

By on December 7, 2021 0


The Medicare Catastrophic Coverage Act of 1988 included the addition of spousal impoverishment protections to the Medicaid program. These protections apply when a spouse requests Medicaid coverage for long-term services and supports (LTSS) and the other spouse plans to continue to reside in the community (the community spouse). Prior to the enactment of these spousal impoverishment protections, the community spouse of a Medicaid recipient often found themselves with few resources due to strict income and asset limits, forcing a difficult choice between care needs. a spouse’s long-term and basic financial needs. the other.

Protections against spousal impoverishment are rooted in the belief that it is unreasonable to allow one spouse to be reduced to poverty to provide long-term care services to the other spouse. For married couples, one of the spouses would have to live with the consequences of lower spending in poverty. Spouse impoverishment protections allow the community spouse to retain a significantly greater share of income and assets than would otherwise be allowed to allow the other spouse to qualify for Medicaid eligibility. However, without a comprehensive and affordable solution for long-term care needs in the United States, spending almost all of your savings to access Medicaid coverage remains the only option for many people.

Under current protections, when a spouse applies for Medicaid LTSS, the income of the requesting spouse is considered alone, but the couple’s assets are considered jointly owned. If the community spouse has a minimum income, spousal impoverishment protections allow a portion of the income of the spouse seeking Medicaid coverage to be allocated to the community spouse. In addition, the protections allow the community spouse to keep a defined share of jointly owned assets, rather than spending almost all of the shared assets to fund the long-term care of the spouse in need of LTSS (see Exhibit 1 below). below).

Each year, the minimum and maximum allowable income (known as the Minimum Monthly Maintenance Needs Allowance or MMMNA) and assets (known as the Spouse Community Resource Allowance or CSRA) are adjusted to accommodate into account changes in the rate of Federal Supplementary Security Income and the Consumer Price Index. Income and resource protections have been included in the 1988 law. From 2021, MMMNA is at least $ 2,177 in all states except Alaska and Hawaii and cannot exceed $ 3,259. The minimum CSRA is $ 26,076 and the maximum is $ 130,380. The table below provides examples of CSRAs under different resource scenarios.

Exhibit 1: Community resource allowance for spouse in practice

Source: Authors’ analysis based on 42 USC Section 1396r-5.

As promulgated in 1988, protections against spousal impoverishment were limited to those seeking services in an institutional setting, such as a nursing home. States also had the option of extending spousal impoverishment protections to certain individuals eligible for Home and Community Services (HCBS) under the 1915 waiver authorization. Decades later, Section 2404 of the Affordable Care Act (ACA) extended spousal impoverishment protections to all major categories of Medicaid HCBS beneficiaries for a five-year period, from January 2014 to December 2018. This change reflects a trend towards decreased emphasis on institutionalization. in Medicaid and increasing availability of LTSS home and community services. Between 1988 and 2018, the share of Medicaid LTSS expenditure devoted to institutional care went from around 90 percent to just 44 percent, and HCBS spending increased from 10% to 56% over the same period.

Over the years, Congress has added a number of new HCBS authorities to Medicaid law, creating new options for states to expand HCBS offerings. In 1981, states were permitted to serve people who would otherwise require an institutional level of care in the community under the 1915 (c) waiver authority. Today, all states offer some form of HCBS to Medicaid registrants, and 48 states have at least one 1915 (c) waiver in effect. These 1915 (c) waivers were the largest share of $ 92 billion in Medicaid HCBS spending in 2018. The 2005 Deficit Reduction Act and ACA created and enhanced opportunities for states to offer HCBS through the State Plans Authority, allowing states to add services Medicaid electives without going through the waiver approval process. In 2018, state plan services accounted for about 32% of total Medicaid HCBS spending.

A majority of adults have a strong preference for aging in place rather than going into institutional care. According to 2018 survey data, at least 68% of adults want to stay in the community, and 63% of adults want to stay in their current residence as long as possible. To make community living sustainable as individuals age and require higher levels of care, a variety of home and community services are needed, including home modifications and assistance with carrying out activities of daily living such as than to wash, dress and eat.

Since they were originally adopted as part of the ACA and were due to expire in 2018, the HCBS spousal impoverishment protections have been brought back from the brink of expiration by Congress on several occasions. Those short-term renewals keeping protections in place lasted as little as seven days and as long as almost two years. The legislative language proposed in the Build Back Better Act is the latest proposal to permanently expand the HCBS spousal impoverishment provisions.

Since 2014, there have been eight Congressional extensions of the HCBS spousal impoverishment protections, and all of them were passed with bipartisan support. It is true that there are costs associated with protecting eligible spouses from financial ruin. Until there, spousal impoverishment protections cost between $ 200 million and $ 300 million per year between 2014 and 2019. While not insignificant, these costs are paltry compared to the huge investment Congress has made in rebalancing long-term care spending to allow seniors to age in place. We believe that the extension of the 32-year-old spousal impoverishment provisions granted to spouses of relatives who are placed in nursing homes or who continue to live in the community reflects both political platforms and the core values ​​of the majority of Republicans, Democrats, and Independents.

Allowing the expiration of the HCBS spousal impoverishment protections would not only harm those currently dependent on those protections, but would also be a step backwards for the Medicaid program, which has spent decades striving to deliver. better access to HCBS options. As with any policy, enforcement and compliance are critical to ensuring that the program protects those it is meant to protect, while eliminating fraud and abuse. Regardless of the outcome of the federal budget proposals for fiscal 2022 and the survival of certain provisions of the Build Back Better Act, Congress should accept the reality of the need for sustained investment in spousal impoverishment protections. HCBS and make them permanent.