MAY 2023 FACT SHEET Chapman Consulting In-Home Supportive Services (IHSS) 101: Opportunities and Challenges Under CalAIM T hrough its CalAIM (California Advancing and With the implementation of CalAIM and shifts in the Innovating Medi-Cal) initiative, the California Medi-Cal LTSS delivery system, policymakers and Department of Health Care Services (DHCS) other stakeholders will need to consider both oppor- seeks to offer a more equitable, coordinated, and per- tunities and challenges for the IHSS program, given son-centered approach that prioritizes whole-person its outsized role in the LTSS landscape and its unique care. One component of CalAIM includes building the operating model. infrastructure over time to provide managed long-term services and supports (MLTSS) statewide by 2027. This shift is intended to increase coordination, reduce siloes, In-Home Supportive Services and improve access to LTSS. (More information is avail- Program Basics able in the California Health Care Foundation report California's IHSS program provides personal care ser- Medi-Cal Managed Care and Long-Term Services and vices and other supports to Medi-Cal enrollees of all Supports: Opportunities and Considerations Under ages to enable them to remain safely in their own CalAIM.1) While a limited number of LTSS have been homes rather than living in a nursing home or other integrated into Medi-Cal managed care plan (MCP) facility. It is the largest LTSS program in California, in contracts, In-Home Supportive Services (IHSS) - by terms of both numbers served and spending. In fiscal far the largest Medi-Cal LTSS program and one that year (FY) 2021–22, the IHSS program had an aver- is expected to grow over time - remains outside of age monthly caseload of over 586,000 care recipients managed care. statewide,2 dwarfing other Medi-Cal LTSS programs. (See Table 1.) Key Takeaways $ IHSS is the largest program in the complex Medi-Cal LTSS delivery system. $ CalAIM offers some limited opportunities to increase coordination of IHSS through the development of statewide MLTSS (including Enhanced Care Management and Community Supports) and Population Health Management strategies. $ TheIHSS program's regulatory, operational, and financial structure operates independently of Medi-Cal MCP benefits. $ Policymakers and stakeholders can consider ways to encourage increased and improved data sharing, commu- nication, and care coordination between different parts of the Medi-Cal delivery system, including Dual Eligible Special Needs Plans (D-SNPs), MCPs, IHSS providers, and IHSS care recipients. $ Additional options for coordination and support can be explored through pilots and targeted use of contract- mode IHSS, which could further inform future IHSS program and policy decisions. Table 1. Enrollment/Caseload for Select California LTSS Programs PROGRAM ENROLLMENT SOURCE(S) AIDS Waiver Maximum waiver capacity is 1,948. George P. Failla Jr. (director, Division of HCBS Operations and Oversight, CMS) to Jacey Cooper (Medicaid director, DHCS), Approval for a §1915(c) Home and Community-Based Services Waiver [Program Title: Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS)] (PDF), California Department of Health Care Services (DHCS), accessed April 17, 2023. Assisted Living Waiver Maximum waiver capacity is 12,744. Application for a §1915(c) Home and Community- Based Services Waiver [Program Title: California Assisted Living Waiver] (PDF), DHCS, accessed April 3, 2023; and Request for an Amendment to a 1915(c) Home and Community-Based Services Waiver [Program Title: California Assisted Living Waiver] (PDF), DHCS, January 24, 2022. California Community 592 Medi-Cal beneficiaries transitioned back Custom data request, DHCS, received March 6, 2023. Transitions into the community between January 1, 2022, and October 1, 2022. Community-Based Adult 36,374 Community-Based Adult Services: Participants Services (CBAS) Characteristics Aggregate Data, Reporting Period: December 31, 2022 (Excel file), California Department of Aging, accessed April 3, 2023. Home and Community-Based Maximum waiver capacity is 9,871. George P. Failla Jr. (director, Division of HCBS Alternatives (HCBA) Waiver Operations and Oversight, CMS) to Jacey Cooper (Medicaid director, DHCS), Approval for a §1915(c) Home and Community-Based Services Waiver [Program Title: Home and Community Based Alternatives Waiver] (PDF), DHCS, February 8, 2023. Home and Community- Approximately 150,000 Henrietta Sam-Louie (associate regional administrator, Based Services for the Division of Medicaid & Children's Health Operations, CMS) to Mari Cantwell (chief deputy director, Health Developmentally Disabled Care Programs, DHCS), Approval and Application for a (HCBS-DD) §1915(c) Home and Community-Based Services Waiver [Program Title: HCBS Waiver for Californians with Developmental Disabilities] (PDF), December 7, 2017. In-Home Supportive Services 586,627 (average monthly caseload Caseload Projections [from 2023-24 Governor's in Fiscal Year 2021–22) Budget] (PDF), California Department of Social Services, accessed April 3, 2023. Multipurpose Senior Services Maximum waiver capacity is 11,370. "Multipurpose Senior Services Program," DHCS, last Program modified June 27, 2022. Program of All-Inclusive Care 17,483 "Medi-Cal Managed Care Enrollment Report" (January for the Elderly (PACE) 1, 2023), CalHHS, last updated April 5, 2023. Notes: HCBS is home and community-based services, CMS is Centers for Medicare & Medicaid Services, CalHHS is California Health and Human Services Agency. California Health Care Foundation www.chcf.org 2 IHSS is jointly funded by the federal, state, and county $ IHSS providers provide direct services to care governments, and administration of the program recipients. includes a complex combination of roles as described $ Care recipients hire, fire, and direct the work of below. providers. $ As the state Medicaid agency, DHCS main- tains the state-level contract/Medi-Cal State IHSS Program History and Plan authority to operate IHSS with the federal Centers for Medicare & Medicaid Services (CMS). Design IHSS allows care recipients to direct their own care, $ The California Department of Social Services including selecting and hiring their own service pro- (CDSS) administers the program at the state viders, which can include family members or friends. In level, providing fiscal and policy direction, over- fact, 71.4% of IHSS providers are relatives, spouses, or sight, and systems management through the parents of the person needing care.3 These program Case Management Information and Payrolling features are deeply ingrained in IHSS history: While System. the program was officially established in California $ Counties/Public Authorities provide day-to- State Statute in 1973,4 it stemmed from a community day program administration, including eligibility movement that started in the 1950s to support older assessments, enrollee needs assessments, and adults and people with disabilities who needed assis- IHSS provider enrollment and administrative tance with personal care to remain in the community. support. The program originally provided grants to the care A Brief History of In-Home Supportive Services Since the inception of California's IHSS program, the state has developed various eligibility and service pathways, as summarized in the table below. YEAR PROGRAM NAME COVERED POPULATIONS 1974 IHSS Residual Program (IHSS-R) - the People who are not eligible for federally funded original IHSS program Medi-Cal but require IHSS care services 1993 Personal Care Services Program (PCSP) Medi-Cal–eligible aged, blind, or disabled populations that require personal care assistance but do not need the level of care that is provided in a nursing home 2009 IHSS Plus Option (IPO) Program* People eligible for Medi-Cal who require personal care assistance, do not need a nursing home level of care, and receive care assistance from a spouse or parent who is paid as an IHSS provider 2011 Community First Choice Option (CFCO) People eligible for Medi-Cal who require a nursing home level of care *Prior to becoming a Medi-Cal State Plan option, this program was previously called the IHSS Plus Waiver. Sources: "In Home Supportive Services (IHSS) Program," California Department of Social Services (CDSS), accessed February 28, 2023; and Program History [from 2023-24 Governor's Budget] (PDF), CDSS, accessed April 3, 2023. In-Home Supportive Services (IHSS) 101: Opportunities and Challenges Under CalAIM 3 recipients to contract directly with providers of their $ Nonmedical personal care services, such as bath- choosing, with the right to both hire and fire their care ing and grooming attendants. While IHSS has evolved over the years, $ Accompaniment to medical appointments its distinct grassroots, consumer-directed history has shaped its evolution, and these strong self-direction $ Protective supervision specifically for people with principles remain core to the program design. In impairment in memory, orientation, or judgment addition, the program's administrative history still $ Paramedical services7 influences it today: While recipients must be eligible for Medi-Cal to qualify for the benefit, IHSS is admin- $ Heavy cleaning, yard hazard abatement, and istered through CDSS and counties. teaching/demonstration (authorized under spe- cial circumstances and generally one-time or Today, to be eligible to apply for IHSS, one must phys- time-limited benefits) ically reside in California and5: $ Bedetermined by the county to be eligible for IHSS Funding and Costs Medi-Cal. As shown in Figure 1, IHSS accounts for $19.2 billion (including $5.9 billion in state dollars) in California's $ Live at home or a residence of their own choosing, 2022–23 state budget - that's 8% of the state's total which can include shelters, recreational vehicles health and human services spending and the second- (RVs), or other temporary living situations (e.g., largest component of the health and human services on someone's couch). Acute care hospitals, long- budget.8 IHSS has what is known as a county main- term care facilities, and licensed community care tenance-of-effort agreement whereby the county is facilities, such as Residential Care Facilities for required to cover a set amount of total nonfederal the Elderly, are not considered "own home," and IHSS costs, and the state is responsible for the remain- therefore IHSS is not provided to people living in der of nonfederal funds.9 This puts the state at risk for these settings. increasing costs of the IHSS program over time, while $ Submit a completed Health Care Certification the county responsibility is capped at a defined cost; form, which provides basic contact information therefore, the increases in spending on IHSS over time and describes the cognitive and/or physical limi- have a larger impact on the state budget. tations of the applicant and recommended IHSS services for authorization. IHSS Care Recipients and Costs Are County IHSS eligibility workers or caseworkers evalu- Both Increasing ate IHSS care recipients' needs and authorize specific From FY 2014–15 to FY 2021–22, the average services based on those needs. The IHSS program monthly IHSS caseload increased 32%, from 443,734 includes the following services6: to 586,627, an average increase of 4% per year.10 Consistent with this trend, California's proposed 2023– $ Domestic services 24 state budget reflects estimates that IHSS average monthly caseload will increase by 4.3% from FY 2022– $ Meal preparation and cleanup 23 to FY 2023–24: from 615,607 to 642,289.11 These $ Laundry program growth trends are accompanied by contin- ued increases in program costs. (See Figure 2.) $ Grocery shopping and other shopping/errands California Health Care Foundation www.chcf.org 4 Figure 1. California Health and Human Services Proposed Figure 2. In-Home Supportive Services Average Monthly 2022–23 Funding, All Funds (Dollars in Billions)* Caseload and Annual Budget, Fiscal Years 2014–15 Through 2021–22 $6.3 3% $22.6 Caseload $4.4 10% 0 200,000 400,000 600,000 2% $3.1 2014-15 1% 443,734 $19.2 $7.5 8% 2015-16 466,493 $135.5 $9.8 $13.9 60% 6% 2016-17 492,542 $12.7 $11.8 6% 2017-18 516,377 $11.5 $3.2 2018-19 1% 536,628 $6.7 $11.6 3% Total: $227.6 2019-20 555,324 Medi-Cal $13.3 2020-21 Public Health 566,994 State Hospitals $15.3 Developmental Services 2021-22 586,627 1991 and 2011 State-Local Realignment $17.2 In-Home Supportive Services 0 5 10 15 20 Supplemental Security Income/ Budget in Billions (TF) State Supplementary Payment (SSI/SSP) CalWORKs Note: TF is Total Funds (federal, state, county). Childcare Sources: Caseload Projections [from 2023-24 Governor's Budget] (PDF), California Department of Social Services (CDSS), accessed April 3, 2023; Other and In-Home Supportive Services (IHSS) Legislative Briefings (PDF), CDSS, December 2022. *Totals $227.6 billion for support, local assistance, and capital outlay. This figure includes reimbursements of $21 billion and excludes $2.5 million in Proposition 98 funding in the Department of Developmental Services and Department of Social Services budgets and county funds that do not flow through the state budget. $ Population growth. The California Department Source: Health and Human Services [Budget Summary, May Revision - 2022-23] (PDF), Department of Finance, accessed April 4, 2023. of Aging estimates that by 2030, 10.8 million Californians will be age 60 or older, making up one-quarter of the state's population.12 These historical enrollment and cost growth trends $ Medi-Cal enrollment growth. According to are expected to continue, due to population growth California's Legislative Analyst's Office, expanded (particularly among older adults), Medi-Cal enrollment Medi-Cal eligibility due to the elimination of the growth, wage growth for IHSS providers, and shifts in Medi-Cal Asset Limit will result in an estimated federal versus state funding. 6,000 additional people becoming eligible for In-Home Supportive Services (IHSS) 101: Opportunities and Challenges Under CalAIM www.chcf.org 5 IHSS and an increase of $67 million in state costs support Medi-Cal enrollees prior to enrolling for the program in 2022–23. In addition, the in IHSS and could increase supports for those expansion of full-scope Medi-Cal coverage to already enrolled in IHSS. income-eligible persons regardless of immigra- $ The implementation of the institutional long- tion status is expected to increase IHSS costs in term care benefit under the MCPs should create future years, reaching an estimated state cost of a financial incentive to refer and coordinate with $400 million by 2026–27.13 IHSS to avoid unnecessary and more costly stays $ Wage growth. The IHSS provider hourly wage in a skilled nursing facility (SNF). has grown by 6% annually since 2014 to reflect $ DualEligible Special Needs Plans (D-SNPs) are increases in state minimum wage requirements responsible for care coordination of all Medicare and locally negotiated agreements in 50 coun- and Medi-Cal benefits for their members and ties to pay more than the state minimum wage can expand access to LTSS through the Special to IHSS providers. Statewide, the average hourly Supplemental Benefits for the Chronically Ill rate for IHSS providers is $16.44.14 (SSBCI).16 $ Shifts in federal versus state funding. The tem- $ Providers,MCPs, and community-based orga- porary 6.2% federal funding increase provided in nizations can leverage dollars and services response to the COVID-19 public health emer- available through the HCBS Spending Plan to gency and the additional 10% federal match for support workforce development for IHSS and home and community-based services (HCBS) related LTSS services, improving access and care under the American Rescue Plan Act offset IHSS for Medi-Cal enrollees. spending by $940 million and $1 billion, respec- tively15; when these federal funding sources end, $ MCPs, D-SNPs, and counties can strengthen the those costs will shift back to the state. coordination of IHSS with other Medi-Cal ben- efits and LTSS through implementation of the IHSS memorandum of understanding (MOU) Looking Forward: IHSS and the requirements, which will be updated in 2024. Shifting LTSS Landscape Directives for all parties to actively accomplish The changes to the LTSS delivery system under the care coordination activities outlined in the CalAIM offer both opportunities for and challenges MOU would help achieve this goal. to ensuring that IHSS is coordinated with other Medi- $ The DHCS Population Health Management Cal benefits, and that recipients can access needed Service is intended to integrate medical, behav- services in what continues to be a very complicated ioral health, and social service information delivery system. from multiple sources, including the IHSS pro- gram, MCPs, and D-SNPs, which should enable Opportunities improved data access and sharing and better $ MCPs can expand access to LTSS (including coordination for IHSS care recipients.17 some IHSS-like services such as personal care and homemaker services) through the imple- $ DHCS, CDSS, and counties could explore the mentation of new benefits and programs under potential for targeted expansion of contract- CalAIM, including Enhanced Care Management, mode IHSS, which is a model wherein a payer Community Supports, and the Population Health (typically a county) contracts with an agency to Management initiative. These programs could employ IHSS providers for those IHSS care recipi- ents who have difficulty self-directing their care. California Health Care Foundation www.chcf.org 6 continuum of care will require deliberate action Opportunities to Improve Coordination in the context of competing priorities and limited The Master Plan for Aging LTSS Subcommittee resources. identified opportunities to improve coordination between IHSS, health, and other LTSS providers by $ Coordination between counties, Medi-Cal LTSS implementing the following strategies: waiver programs, and MCPs continues to be very limited, and there are no direct funding mecha- $ Includeformal authorization for secure informa- nisms or mandatory or contractual requirements tion sharing with managed care providers of creating incentives for such coordination around health and LTSS services. IHSS. $ Require the state to collect data and report on beneficiary access to services, including refer- $ Limited data-sharing capabilities between LTSS rals and receipt of services, transitions, and care providers across the system may continue to coordination. cause confusion for Medi-Cal enrollees and their $ Improve coordination between the IHSS pro- caregivers, because when MCPs, D-SNPs, and gram and institutional settings to ensure there LTSS/IHSS providers are not effectively commu- are no gaps in services for those being dis- nicating, enrollees might be offered duplicate charged. LTSS benefits or may not be offered LTSS ben- $ Create a dedicated cross-department unit with efits for which they are eligible. While the the authority to align the administration of LTSS DHCS Population Health Management Service across departments, and to coordinate LTSS, is intended to address coordination and com- including IHSS, in a way that promotes seamless munication for these partners, it is not currently access to services, integration, and coordination operational, and the final scope of data exchange of care. related to IHSS is not currently clear to MCPs and Source: Master Plan for Aging Long Term Services and Supports Subcommittee Stakeholder Report (PDF), California Health and other stakeholders. Human Services Agency, May 26, 2020. $ The unique regulatory and financial structures of IHSS, such as the county maintenance-of-effort requirements, separate IHSS administratively Challenges and operationally from the rest of the Medi-Cal $ Workforce constraints are creating challenges LTSS system. across the health care sector, including personal $ Many IHSS providers and consumers object to care services. A 2020 California State Auditor report found that 32 of 58 counties indicated changing the IHSS program authority or opera- that they lacked enough caregivers to provide tional components over concerns that this may all authorized services to each IHSS participant. impact the ability to maintain IHSS as a social IHSS caregiver shortages were exacerbated dur- model of care program with local authority and ing the COVID-19 public health emergency.18 consumers' ability to direct their own care. This concern about changes in the IHSS program has $ Even with the implementation of CalAIM, Medi- hindered previous attempts at increased inte- Cal's LTSS programs are administered by multiple gration with Medi-Cal managed care, and these departments, which can lead to siloed delivery. dynamics seem likely to continue. Additionally, several different waivers and MCP delivery systems are involved in the administra- tion of LTSS. Developing collaboration across the In-Home Supportive Services (IHSS) 101: Opportunities and Challenges Under CalAIM 7 Endnotes Conclusion 1. Athena Chapman and Elizabeth Evenson, Medi-Cal Managed IHSS is an integral part of the California LTSS delivery Care and Long-Term Services and Supports: Opportunities and system and essential to allowing many Californians to Considerations Under CalAIM, California Health Care Foundation age and live safely in their communities, which aligns (CHCF), March 16, 2023. with the broader goals of CalAIM. LTSS initiatives 2. Caseload Projections [from 2023-24 Governor's Budget] (PDF), California Department of Social Services (CDSS), accessed April under CalAIM, and broader Medi-Cal reforms, have 3, 2023. created several avenues for increased access to LTSS 3. "IHSS Program Data" [January 2023], CDSS, accessed April 4, and an opportunity for policymakers and stakeholders 2023. to consider how IHSS recipients can be best supported 4. Welfare and Institutions Code - WIC: Article 7. In-Home Supportive Services [12300 - 12318], California Legislative Information, across programs and benefits, and how the IHSS pro- accessed April 4, 2023; and In-Home Supportive Services (IHSS) gram, MLTSS, and other benefits under CalAIM can Program Services (PDF), CDSS, accessed April 4, 2023. be effectively coordinated to more holistically serve 5. "In-Home Supportive Services (IHSS) Program," CDSS, accessed people who need LTSS. April 16, 2023. 6. IHSS Program Services, CDSS. 7. IHSS workers may be allowed to provide paramedical services in About the Authors some cases, with appropriate training. Paramedical services are services ordered by a licensed health care professional, which Athena Chapman, MPP, is president and Elizabeth a person could provide for themselves but for their functional Evenson is senior policy director at Chapman limitations. See Paramedical Services (PDF), CDSS, accessed January 30, 2023. Consulting, which provides strategic planning, 8. Health and Human Services [Budget Summary, May Revision - meeting facilitation, organizational support, market 2022-23] (PDF), Department of Finance, accessed April 4, 2023. research, and regulatory and statutory analysis to 9. The 2023–24 Budget: In-Home Supportive Services, Legislative organizations in the health care field. Analyst's Office, March 2, 2023. 10. Caseload Projections, CDSS. 11. 2023-24 Governor's Budget Executive Summary (PDF), CDSS, About the Foundation accessed April 4, 2023. The California Health Care Foundation (CHCF) is an 12. California's Master Plan for Aging (PDF), California Department of Aging, January 2021. independent, nonprofit philanthropy that works to 13. The 2022-23 Budget: In-Home Supportive Services (PDF), improve the health care system so that all Californians Legislative Analyst's Office (LAO), February 2022. have the care they need. We focus especially on mak- 14. "IHSS Program Data," CDSS. ing sure the system works for Californians with low 15. The 2022-23 Budget: IHSS, LAO. incomes and for communities who have traditionally 16. Kathryn A. Coleman (director, Medicare Drug & Health Plan faced the greatest barriers to care. We partner with Contract Administration Group, CMS) to all organization types and stakeholders, Final Contract Year 2023 Part C Benefits Review leaders across the health care safety net to ensure they and Evaluation (PDF), April 20, 2022. have the data and resources to make care more just 17. Population Health Management (PHM) Service All Comer and to drive improvement in a complex system. CHCF Webinar (PDF), DHCS, May 23, 2022. informs policymakers and industry leaders, invests in 18. In-Home Supportive Services Program (PDF), Auditor of the State ideas and innovations, and connects with change- of California, February 2021. makers to create a more responsive, patient-centered health care system. California Health Care Foundation www.chcf.org 8