Bee Weller is my alter ego… a caricature of myself as a bee. Bee Weller likes to tell other people what she has learned about health, about how to have good health. Because health is everything. Bee has learned that if you don’t have your health it doesn’t matter how much money you have because if you aren’t healthy you won’t be able to enjoy your money. If you don’t have your health you won’t be able to fully enjoy the people in your life either. If you asked Bee Weller, “If you had to choose between health or wealth which one would you choose? “, Bee would say “I choose health because if I don’t have my health, if I’m sick or disabled, I won’t be able to enjoy life to the fullest, even if I did have a lot of money. I would rather be healthy and poor, rather than sick and rich.” Of course, if one is sick, money does help one buy things that one needs or that will assist one in one’s sickness and/or disability. In other words, if you are sick, it’s good to have money to pay for things that will alleviate your sickness and/or disability. For example, if you had a stroke and were paralyzed on your left side, and needed help for your every need, you could have a personal assistant 24 seven in your home if you had money. If you didn’t have money you would have to rely on government funds and go to a nursing home to get the help you need. And the help would be on the nursing home’s terms, not yours. The nursing home would be the employer of the person helping you, not you. Here in Kentucky, there is government assistance for people who are disabled and who would like to stay in their homes and in their communities but who can’t afford to pay someone to help them. It’s called the Medicaid Home and Community Based Waiver, but the help is limited to eight hours a day, 40 hours per week, with five hours respite on the weekends. So people who need 24/7 help have to go to a nursing home. I don’t know if you’ve ever stayed the night in a nursing home, or visited one in the middle of the night like I have, but if you have, you will know that they are not good places to sleep. Too many lights, too much noise and the beds are not comfortable. Definitely not like home. The government won’t pay for 24/7 help at home because it’s more expensive than nursing home care. The government has a limit of $200 a day for the care they will pay for. And $200 only pays for eight hours of care per day at home because the care is one on one… in other words, it’s better. In a nursing home it is not uncommon for one person to be responsible for helping 40 people. I firmly believe that every person that needs help, needs one on one care. But I don’t understand why the government won’t pay $200 a day for Home and Community Based Services eight hours a day seven days a week, when they pay for nursing home care $200 a day, seven days a week. The government will only pay for help in one’s home for eight hours a day, FIVE days a week. That’s not fair. That leaves people at home without help on the weekends except for that little bit of five hours of respite that they allow on the weekend. However they don’t reimburse for respite at the same rate and so it’s hard to find anyone to supply that help on the weekend because it doesn’t pay anything. I’m guessing it’s because the nursing home industry has powerful lobbyists that have convinced legislators to tip the scale in their favor so people are forced to go into nursing homes to get the care they need on the weekends.

Agencies like Aging With Grace employ people and supervise them to provide services to people in their homes through the Home and Community Based Waiver. Employees must have their fingerprints taken so that a federal and state background check can be done. Employees must be drug tested, TB tested, and CPR trained. They receive initial training and testing and ongoing training and testing. Training costs are high for agencies for Aging With Grace, especially considering that some employees don’t stay long. Audits are performed by the state regularly to ensure that the agencies that provide services through the Home and Community Based Waivers are compliant. Agencies like Aging With Grace have to provide worker’s comp. insurance to their employees and unemployment insurance. Aging With Grace pays all federal state and local employee taxes. Aging With Grace also offers supplemental health and disability to employees and a superior employee assistance program. Aging With Grace aspires to be known as the gold standard in home and community based services.

In Kentucky, when one desires help at home and one has no money to pay for it, one has to apply at the local Department for Community Based Services …also known as the DCBS or the food stamp office. It is a state program so it doesn’t matter what county’s office you use. Like anything involving the government’s money, there will be lots of forms to fill out and lots of documents to submit. This is a daunting endeavor for someone who is disabled. Take my friend Dottie, for example. She is 91 and frail. She owns her home but has given her car away because she no longer feels safe to drive. She fears falling but doesn’t want to use a walker…she uses a cane. She needs help getting groceries and getting to the doctor for a test that she needs periodically due to a heart problem. I suggested she could have a nurse come to her home to take blood for the test through her insurance but for some reason she would rather get her blood tested at the lab. I just sent Dottie a form to fill out that will give our case managers permission to help Dottie with applying for the home and community based waiver. The government…the Medicaid program …will not reimburse us for the time we spend on helping Dottie or people like Dottie apply to Medicaid. Once she is accepted, we will be reimbursed for authorized services provided. IF she chooses us to provide services. Each Medicaid member is assessed by a nurse individually and that determines their level of care and the amount of services and money needed to pay for that care. Eligible Medicaid members are then given a list of case management agencies from which to choose. It is up to them to call the agency and ask for a case manager. The case manager’s job is to find agencies to provide the services they need according to the assessment done by the nurse. There is a conflict free case management policy in Kentucky and that means that the agency who does the case management cannot be the same agency that provides the services.

So the problems that I have seen with the Medicaid home and community based waiver are:

1.  no money to pay for help on the weekends

2. If people live in a home where someone owns a car they are not eligible for free transportation to the adult day center

3. No procedure or policy or reimbursement to help people apply for the waiver

4. Nursing homes will not tell people about the availability of the Home and Community Based Waiver.

5. Case managers did not do home visits during Covid and are slow to do them again, resulting in some bad situations

6. The state’s electronic visit verification system does not work well resulting in frustration and mistakes and wasted time

7. Adult day services are not encouraged enough. Adult day services are good for people and they save money

The state DID raise our reimbursement rate this legislative session which is a good thing so we can be reimbursed at s level in line with what we are paying our employees. Most people do not realize that in addition to what we pay per hour, we also have to pay workers compensation insurance and unemployment insurance and Medicare and social security and some federal state and local tax per employee, so for an employee earning $14 an hour, we are paying out $16.50 an hour. Plus we have to pay rent, utilities, the managers, billing and payroll agents, nurse and case managers salaries, hiring costs, liability and property insurance, lawyer and accountant fees, and licensing and continuing education costs, etc.

The home and community-based waiver program will also pay for a member to hire their own employee to help them at home. It’s called participant directed services or PDS for short. The PDS program is most popular with family members who want to be paid for the help they are providing for a loved one. As of this writing, the most that could be paid to the PDS employee was $11.27 an hour.