REIMBURSEMENT BENEFITS
§ 20.41. General reimbursement.
(a) Expenditure parameters. When an area agency on aging has annualized its Program and the ongoing caseload level has stabilized at, or around, the level projected in the approved Program plan, the following parameters on expenditures shall be observed:
(1) At least 55% of the allocated funding shall be budgeted and expended for the reimbursement of care-givers.
(2) No more than 20% of the amount budgeted and expended for the reimbursement of caregivers may be budgeted and expended for home modifications and assistive devices.
(b) Cost-shared benefits. Funding to reimburse primary caregivers for caregiving expenses as provided in this chapter is available on a cost-sharing basis as follows:
(1) Up to 100% of the maximum amounts provided in subsection (c), depending on expenditures and availability of funds, may be used to reimburse primary caregivers whose household income does not exceed 200% of the current poverty level.
(2) As household income increases in 20% brackets, the available reimbursement benefit decreases by 10%. Thus, a primary caregiver whose household income is between 280% and 300% of the poverty level may be reimbursed for up to 50% of the maximum benefit available, or up to $100 per month for ongoing expenses or $1,000 for home modifications or assistive devices as provided under subsection (c).
(3) The Department will maintain a cost-sharing table indicating the current dollar amounts of household income ranges at the different cost-sharing levels and household sizes. This table will be updated annually on the basis of revised Federal poverty guidelines published in the Federal Register. Interested parties may obtain a copy of the current cost-sharing table from the local area agency on aging or from the Division of Policy, Department of Aging, 231 State Street, Harrisburg, Pennsylvania 17101-1195.
(4) To determine the amount which may be reimbursable by the area agency on aging, the appropriate percentage of the maximum benefit available is applied to the amount the caregiver expended up to that maximum. When caregiver expenditures exceed the maximum amounts available, the percentage is applied only to the maximum amount. Thus, if a primary caregiver is eligible for 50% of the maximum benefit and incurs monthly caregiving expenditures of $400, the most the caregiver may be reimbursed is $100; that is, 50% of the $200 maximum benefit available.
(c) Maximum amounts.
(1) To reimburse for ongoing expenses of respite care services, other related services and consumable supplies needed to provide the necessary care, up to $200 per month may be made available depending upon actual expenditures, household income and the availability of funds.
(2) To reimburse for expenses incurred for home modifications and assistive devices purchased under this chapter, up to $2,000, depending upon actual expenditures, household income and the availability of funds, may be made available during the full time that a case is active.
(3) Caregivers are not entitled to the maximum amounts under paragraphs (1) and (2). Reimbursements are made on the basis of need, income, actual expenditures and the availability of funds. Although area agencies on aging retain the discretion to control caregiver reimbursements to prevent the depletion of available funds by projected utilization patterns, an area agency on aging does not have authority to set different maximum amounts in its planning and service area.
(d) Other general controls.
(1) An area agency on aging may control the utilization of reimbursement funding through the use of waiting lists for new families, delay in accepting families from waiting lists to permit attrition to decrease funding demands, delay in preapprovals of home modifications and assistive devices until additional funds are available. Primary caregivers shall be made aware at intake that reimbursements are not entitlements and are contingent upon the availability of funds under the Program appropriation.
(2) An area agency on aging may require a primary caregiver to provide additional documentation of the income information provided during assessment when there is clear justification to question the validity of the documentation provided previously.
(3) Some form of direct reimbursement of documented caregiving expenses shall be instituted. If explained in an approved Program plan, as provided under § 20.12 (relating to administrative functions and responsibilities of area agencies on aging), an area agency on aging may also use one or more other methods, such as a voucher system, to get the reimbursement benefits to primary caregivers.
(4) Funding available for the reimbursement of care-givers is not intended to displace other resources available to the caregiver family. Area agencies on aging may not knowingly use the resources of the Program to provide benefits available under other resources and shall take steps through benefits counseling to promote the utilization of other available resources to assure that displacement of other resources does not occur.
(5) To provide an adequate audit trail for reimbursements, the area agency on aging shall obtain from primary caregivers and retain in agency files documentation of caregiver expenditures for which reimbursements are made.
(6) Funding available for the reimbursement of caregiving expenses may not be used to cover caregiver payments for the services of relatives. Area agencies on aging shall make primary caregivers aware of this restriction at the time they are admitted into the Program by including it in the certification of accountability required under § 20.22 (relating to conditions of participation).
(7) Categories for reimbursed purchases shall remain distinct when maximum amounts are applied. Costs of ongoing expenses and consumable supplies are subject to the $200 per month maximum. Costs of home modifications and assistive device purchases are subject to the $2,000 maximum during the full time the case is active. Since the costs of leasing an assistive device are also an ongoing ‘‘out-of-pocket’’ expense, an area agency may have some discretion in determining which category is to be charged if the caregiver’s needs for other respite care are not jeopardized.
(8) Area agencies on aging are expected to promote the concept that the reimbursement for ongoing expenses is available to empower caregivers to make their own decisions and choices. While it is important to work with caregivers in planning appropriate responses to their needs, the emphasis should be on expanding the awareness of caregivers of the various options which may be open to them.
Cross References This section cited in 6 Pa. Code § 20.21 (relating to eligibility for Program benefits); 6 Pa. Code § 20.22 (relating to conditions of participation); and 6 Pa. Code § 20.23 (relating to income).
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