A CRS Review of 10 States: Home and Community-Based Services — States Seek to Change the Face of Long-Term Care: Maine

A CRS Review of 10 States: Home and Community-Based Services — States Seek to Change the Face of Long-Term Care: Maine

Order Code RL32166
CRS Report for Congress
Received through the CRS Web
A CRS Review of 10 States: Home and
Community-Based Services — States Seek to
Change the Face of Long-Term Care: Maine
September 30, 2003
Jane Tilly
Consultant
The Urban Institute
Carol O’Shaughnessy
Specialist in Social Legislation
Domestic Social Policy Division
Rob Weissert
Research Assistant
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

A CRS Review of 10 States: Home and Community-
Based Services — States Seek to Change the
Face of Long-Term Care: Maine
Summary
Demographic challenges posed by the growing elderly population and demands
for greater public commitment to home and community-based care for persons with
disabilities have drawn the attention of federal and state policymakers. Spending on
long-term care by both the public and private sectors is significant. In 2001,
spending for long-term care services for persons of all ages represented 12.2% of all
personal health care spending (almost $152 billion of $1.24 trillion). Federal and
state governments accounted for almost two-thirds of all spending. By far, the
primary payer for long-term care is the federal-state Medicaid program, which paid
for almost half of all long-term care spending in 2001.
Many states have devoted significant efforts to respond to the desire for home
and community-based care by persons with disabilities and their families.
Nevertheless, financing of nursing home care, chiefly by Medicaid, still dominates
most states’ spending for long-term care today. To assist Congress understand issues
that states face in providing long-term care services, CRS undertook a study of 10
states in 2002. This report presents background and analysis about long-term care
in Maine.
Maine is one of the smallest states in the country with 1.3 million people in
2000; it is also one of the oldest states, with 14.4% of its population aged 65 and
older. By 2025, over one-fifth of its population will be 65 and older.
Medicaid spending for long-term care in Maine in FY2001 was $411 million —
almost one-third of all Medicaid spending. In part due to the aging population and
because of a 1993 budgetary crisis involving rapidly escalating Medicaid nursing
home costs, Maine has pursued an aggressive policy to decrease dependence on
nursing homes. Between 1995 and 2001, the percentage of public long-term care
funding devoted to these facilities decreased from 84% to 61%. Moreover, the state
has decreased reliance on large state-operated residential facilities for persons with
mental retardation in favor of smaller community-based facilities. Maine’s efforts
to reduce reliance on institutional care has been in part due to expanded use of
Medicaid’s home and community-based waiver program as well as multiple state-
funded programs.
CRS interviews with state officials and a review of state reports highlighted
Maine’s reliance on a “Medicaid maximization” policy under which the state makes
every effort to draw down federal Medicaid dollars by incorporating in its state plan
almost all the home and community-based services options allowed by federal law.
One of the challenges the state faces during tight fiscal constraints is to hold on to the
gains it has made in providing home and community services to people with
disabilities.
The 10-state study was funded in part by grants from the Jewish Healthcare
Foundation and the U.S. Department of Health and Human Services, Health
Resources and Services Administration, Office of Rural Health Policy. This report
will not be updated.

Preface
Demographic challenges posed by the growing elderly population and demands
for greater public commitment to home and community-based care for persons with
disabilities have drawn the attention of federal and state policymakers for some time.
Spending on long-term care by both the public and private sectors is significant. In
2001, spending for long-term care services for persons of all ages represented 12.2%
of all personal health care spending (almost $152 billion of $1.24 trillion). Federal
and state governments accounted for almost two-thirds of all spending. By far, the
primary payor for long-term care is the federal-state Medicaid program, which paid
for almost half of all U.S. long-term care spending in 2001.
Federal and state Medicaid spending for long-term care in FY2001 was about
$75 billion, representing over one-third of all Medicaid spending. Over 70% of
Medicaid long-term care spending was for institutions — nursing homes and
intermediate care facilities for the mentally retarded (ICFs/MR). Many believe that
the current federal financing system paid through Medicaid is structurally biased in
favor of institutional care. State governments face significant challenges in
refocusing care systems, given the structure of current federal financing. Many states
have devoted significant efforts to change their long-term care systems to expand
home and community-based services for persons with disabilities and their families.
Nevertheless, financing of nursing home care — primarily through the Medicaid
program — still dominates most states’ spending on long-term care today.
While some advocates maintain that the federal government should play a larger
role in providing support for home and community-based care, Congress has not yet
decided whether or how to change current federal policy. One possibility is that
Congress may continue an incremental approach to long-term care, without major
federal policy involvement, leaving to state governments the responsibility for
developing strategies that support home and community-based care within existing
federal funding constraints and program rules.
To help Congress review various policy alternatives and to assist policymakers
understand issues that states face in development of long-term care services, the
Congressional Research Service (CRS) undertook a study of ten states in 2002. The
research was undertaken to look at state policies on long-term care as well as trends
in both institutional and home and community-based care for persons with
disabilities (the elderly, persons with mental retardation, and other adults with
disabilities). The research included a review of state documents and data on long-
term care, as well as national data sources on spending. Interviews were held with
state officials responsible for long-term care, a wide range of stakeholders and, in
some cases, members or staff of state legislatures.
The 10 states included in the study are: Arizona, Florida, Illinois, Indiana,
Louisiana, Maine, Oklahoma, Oregon, Pennsylvania, and Texas. States were chosen
according to a number of variables, including geographic distribution, demographic
trends, and approaches to financing, administration and delivery of long-term care
services.
This report presents background and analysis about long-term care in Maine.

Contents
Introduction: Federal Legislative Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Summary Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Demographic Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Administration of Long-Term Care Programs . . . . . . . . . . . . . . . . . . . . . . . . 4
Trends in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Trends in Home and Community-Based Care . . . . . . . . . . . . . . . . . . . . . . . . 5
Long-Term Care Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Issues in Financing and Delivery of Long-Term Care . . . . . . . . . . . . . . . . . . 6
Demographic Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Need for Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Administration of Long-Term Care Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Responsibility for Assessment, Eligibility, and Case Management . . . . . . . 10
Functional Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Financial Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Care Coordination and Consumer-Directed Services . . . . . . . . . . . . . 11
Maine’s Long-Term Care Services for the Elderly and Persons with
Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Trends in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Trends in Home and Community-Based Care . . . . . . . . . . . . . . . . . . . . . . . 14
Medicaid State Plan Services and 1915 (c) Waivers . . . . . . . . . . . . . . . . . . 15
Mandatory and Optional State Plan Services . . . . . . . . . . . . . . . . . . . . 15
Medicaid Section 1915(c) Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
State Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Maine’s Long-Term Care Services for Persons with Mental Retardation
and Developmental Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Trends in Institutional Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Trends in Home and Community-Based Care . . . . . . . . . . . . . . . . . . . . . . . 19
Financing of Long-Term Care in Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Medicaid Spending in Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Medicaid Long-Term Care Spending in Maine . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Medicaid and State Spending on Services for Persons with Mental
Retardation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Issues in Long-Term Care in Maine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Budgetary Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Labor Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Consumer Direction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Assisted Living Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Waiting List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Appendix 1. Major Home and Community-Based Long-Term Care
Programs for the Elderly and Persons with Disabilities in Maine . . . . . . . 29
Appendix 2. Population in Large State Facilities . . . . . . . . . . . . . . . . . . . . . . . . 35
Appendix 3. About the Census Population Projections . . . . . . . . . . . . . . . . . . . . 36
List of Figures
Figure 1. Projected Percentage Population Increases in Maine Over
2000 by Population for Selected Years, 2000-2025 . . . . . . . . . . . . . . . . . . . . 7
Figure 2. Institutional and Home and Community-Based Services as
a Percent of Medicaid Long-Term Care Spending in Maine, 1990-2001 . . 21
Figure 3. Medicaid Long-Term Care Spending in Maine by Category,
FY1990 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Figure 4. Medicaid Long-Term Care Spending in Maine by Category,
FY2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Figure 5. Medicaid Home and Community-Based Services Waiver
Spending by Target Population in Maine, FY2001 . . . . . . . . . . . . . . . . . . . 25

List of Tables
Table 1. Maine Population Age 65 and Older, 1990 and 2000 . . . . . . . . . . . . . . . 7
Table 2. Elderly Population as a Percent of Total Population, Maine
and the United States, 2025 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Table 3. Estimated Number of Persons with Two or More Limitations in
Activities of Daily Living (ADLs), by Poverty Status, in Maine . . . . . . . . . . 9
Table 4. Where People Receive Publicly Funded Long-Term Care Services . . . 13
Table 5. Where Public Long-Term Care Funding Goes . . . . . . . . . . . . . . . . . . . 13
Table 6. Nursing Home Characteristics in Maine and the United States . . . . . . 14
Table 7. Persons with Mental Retardation and Developmental Disabilities
Served in Residential Settings, by Size of Setting, 1991, 1995 and 2002 . . 19
Table 8. Share of State Spending by Category, Maine and the
United States, 1990-2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Table 9. State Spending for Medicaid as a Percent of Total State Spending,
Maine and the United States, 1990-2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Table 10. Medicaid Long-Term Care Spending in Maine, FY1990-FY2001 . . . 22
Table 11. Medicaid Spending in Maine, Total Spending and Long-Term
Care Spending, by Category, FY1990-FY2001 . . . . . . . . . . . . . . . . . . . . . . 23
Table 12. Federal and State Spending for Institutional and Community
Services for Persons with Mental Retardation/Developmental
Disabilities in Maine, 1990 and 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Table A-2. Population in Large State Facilities for Persons with Mental
Retardation/Developmental Disabilities and Closure Date, Maine . . . . . . 35
Acknowledgments
The Congressional Research Service (CRS) wishes to acknowledge the generous
time and contributions of the many state officials and stakeholders who provided
information on long-term care services in Maine. Without their generous time and
invaluable experience and insight, this report would not be possible. We would
particularly like to thank officials from the Department of Human Services, the
Department of Behavioral and Developmental Services, and the Department of
Labor. We would also like to thank the advocates and providers who offered
valuable perspectives on the long-term care system in Maine.
The authors also gratefully acknowledge the excellent assistance of Flora Adams
and Charlotte Foote in the production of this report.

A CRS Review of 10 States:
Home and Community-Based Services —
States Seek to Change the Face of
Long-Term Care: Maine
Introduction: Federal Legislative Perspective
States choosing to
modify their programs for
The Social Security Amendments of 1965, which
l o n g - t e r m c a r e f a c e
created the Medicaid program, required states to
provide skilled nursing facility services under their
signifi cant challenges.
state Medicaid plans, and gave nursing home care the
Financing of nursing home
same level of priority as hospital and physician
care has dominated long-term
services.
care spending for decades.
The federal financing
“Section 1902 (a) A State plan for medical assistance
must provide for inclusion of some institutional and
structure that created
some noninstitutional care and services, and, effective
incentives t o s u pport
July 1, 1967, provide (A) for inclusion of at least ...
institutional care reaches
(1) inpatient hospital services ...; (2) outpatient
back to 1965. A number of
hospital services; (3) other laboratory and X-ray
converging factors have
services; (4) skilled nursing home services (other than
services in an institution for tuberculosis or mental
supported reliance on nursing
diseases) for individuals 21 years of age or older; (5)
home spending. Prior to
physicians’ services . . . .;” P.L. 89-97, July 30, 1965.
enactment of Medicaid,
homes for the aged and other
public institutions were
financed by a combination of direct payments made by individuals with their Social
Security Old Age Assistance (OAA) benefits, and vendor payments made by states
with federal matching payments on behalf of individuals. The Kerr-Mills Medical
Assistance to the Aged (MAA) program, enacted in 1960, a predecessor to Medicaid,
allowed states to provide medical services, including skilled nursing home services,
to persons who were not eligible for OAA cash payments, thereby expanding the
eligible population.1
In 1965, when Kerr-Mills was transformed into the federal-state Medicaid
program, Congress created an entitlement to skilled nursing facility care under the
expanded program. The Social Security Amendments of 1965 required that states
provide skilled nursing facility services and gave nursing home care the same level
of priority as hospital and physician services. Amendments in 1967 allowed states
to provide care in “intermediate care facilities” (ICFs) for persons who did not need
1 CRS Report 83-181, Nursing Home Legislation: Issues and Policies, by Maureen Baltay.
Archived and available upon request from the Congressional Research Service (CRS).

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skilled nursing home care, but needed more than room and board. In 1987, Congress
eliminated the distinction between skilled nursing facilities and intermediate care
facilities (effective in 1990). As a result of these various amendments, people
eligible under the state’s Medicaid plan are entitled to nursing home facility care; that
is, if a person meets the state’s income and asset requirements, as well as the state’s
functional eligibility requirements for entry into a nursing home, he or she is entitled
to the benefit.
These early legislative developments were the basis for the beginnings of the
modern day nursing home industry. Significant growth in the number of nursing
homes occurred during the 1960s — from 1960 to 1970, the number of homes more
than doubled, from 9,582 to almost 23,000, and the number of beds more than
tripled, from 331,000 to
more than one million.2
(Today there are about
Since its inception, Medicaid has been the predominant
17,000 nursing homes with
payor for nursing home care. In 1970, over $1 billion
was spent on nursing home care through Medicaid and
1.8 million beds.3)
Medicare. Federal and state Medicaid payments
accounted for almost all of this spending — 87%.
During the latter part
Medicaid spending for nursing home care grew by 50% in
of the 1960s and the 1970s,
the three-year period beginning in 1967.
nursing home care attracted
In FY2001, Medicaid spent $53.1 billion on institutional
a g r e a t d e a l o f
care (for nursing homes and care in intermediate care
congressional oversight as a
facilities for the mentally retarded).
result of concern about
i n c r e a s i n g f e d e r a l
expenditures, and a pattern
of instances of fraud and abuse that was becoming evident. Between 1969 and 1976,
the Subcommittee on Long-Term Care of the Senate Special Committee on Aging,
held 30 hearings on problems in the nursing home industry.4
Home care services received some congressional attention in the authorizing
statute — home health care services were one of the optional services that states
could provide under the 1965 law. Three years later in 1968, Congress amended the
law to require states to provide home health care services to persons entitled to
skilled nursing facility care as part of their state Medicaid plans (effective in 1970).
During the 1970s, the Department of Health, Education and Welfare (now Health and
Human Services, DHHS) devoted attention to “alternatives to nursing home care”
through a variety of federal research and demonstration efforts. These efforts were
2 U.S. Congress, Senate Special Committee on Aging, Developments in Aging, 1970,
Report 92-46, Feb. 16, 1970, Washington, cited from the American Nursing Home
Association Fact Book, 1969-1970.
3 American Health Care Association, Facts and Trends 2001, The Nursing Facility
Sourcebook, 2001, Washington. The number of nursing homes is for 1999-2000 and number
of beds is for 1998. (Hereafter cited as American Health Care Association, The Nursing
Facility Sourcebook.)
4 U.S. Congress, Senate Special Committee on Aging, Nursing Home Care in the United
States: Failure of Public Policy, Washington, 1974, and supporting papers published in
succeeding years.

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undertaken not only to find ways to offset the high costs of nursing facility care, but
also to respond to the desires of persons with disabilities to remain in their homes and
in community settings, rather than in institutions. However, it was not until 1981 that
Congress took significant legislative action to expand home and community-based
services through Medicaid when it authorized the Medicaid Section 1915(c) home
and community-based waiver program.
Under that authority (known then as the Section 2176 waiver program), the
Secretary of DHHS may waive certain Medicaid state plan requirements to allow
states to cover a wide range of home and community-based services to persons who
otherwise meet the state’s eligibility requirements for institutional care. The waiver
provision was designed to alter the fact that the Medicaid program had emphasized
institutional care rather than care in home and community-based settings. Services
under the Section 1915(c) waiver include: case management, personal care,
homemaker, home health aide, adult day care, habilitation, environmental
modifications, among many others.5 These services are covered as an option of
states, and under the law, persons are not entitled to these services as they are to
nursing facility care. Moreover, states are allowed to set cost caps and limits on the
numbers and types of persons to be served under their waiver programs.
Notwithstanding wide use of the Section 1915(c) waiver authority by states over
the last two decades, total spending for Medicaid home and community-based
services waivers is significantly less than institutional care — about $14.4 billion in
2001, compared to $53.1 billion for nursing facility care services and care for persons
with mental retardation in intermediate care facilities (ICFs/MR). Despite this
disparity in spending, in many states the Section 1915(c) waiver program is the
primary source of financial support for a wide range of home and community-based
services, and funding has been increasing steadily. Federal and state Medicaid
support for the waiver programs increased by over 807% from FY1990 to FY2001
(in constant 2001 dollars).
The home and community-based waiver program has been a significant source
of support to care for persons with mental retardation and developmental disabilities
as states have closed large state institutions for these persons over the last two
decades. Nationally, in FY2001, almost 75% of Section 1915(c) waiver funding was
devoted to providing services to these individuals.
States administer their long-term care programs against this backdrop of federal
legislative initiatives — first, the entitlement to nursing home care, and requirement
to provide home health services to persons entitled to nursing home care, and,
5 States may waive the following Medicaid requirements: (1) statewideness — states may
cover services in only a portion of the state, rather than in all geographic jurisdictions; (2)
comparability of services — states may cover state-selected groups of persons, rather than
all persons otherwise eligible. In addition, states may use more liberal income requirements
for persons needing home and community-based waiver services than would otherwise apply
to persons living in the community. For further information, see CRS Report RL31163,
Long-Term Care: A Profile of Medicaid 1915(c) Home and Community-based Services
Waivers, by Carol O’Shaughnessy and Rachel Kelly.

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second, the option to provide a wide range of home and community-based services
through waiver of federal law, within state-defined eligibility requirements, service
availability, and limits on numbers of persons served.
Summary Overview6
Overview
! Maine has pursued an aggressive policy to decrease dependence on
nursing homes as a result of a 1993 budgetary crisis involving
rapidly escalating Medicaid nursing home costs. Its policies to
tighten nursing home eligibility and expand community options have
decreased reliance on nursing homes dramatically.
! Maine has also decreased its reliance on institutions for persons with
developmental disabilities. The state closed its large state-operated
facility in 1995, and has greatly reduced its use of private
intermediate care facilities for the mentally retarded (ICFs/MR).
Care of this population has shifted to the home and smaller group
residential settings.
Demographic Trends
! Maine is one of the smallest states in the country with 1.27 million
people in 2000; its population increased by 50,000 people during the
1990s. It also is one of the oldest states, with 14.4% of its
population aged 65 and older. In 2025, 21.4% of Maine’s
population will be age 65 years or older, compared to 18.5% for the
nation.
! Persons aged 85 and over with two or more limitations in activities
of daily living are estimated to increase 15.3% by 2010 to reach
2,047; the number of persons aged 18 to 64 with the same level of
disability will increase by 6% reaching 2,990.
Administration of Long-Term Care Programs
! Responsibility for administration and management of long-term care
services for persons with disabilities is spread across several state
agencies, with the Department of Human Services (DHS) retaining
responsibility for most programs. Various sub-state agencies and
some private contractors have responsibility for different aspects of
long-term care administration and services.
6 Information based on Maine data and documents, national data, and interviews with state
officials. This report does not discuss programs for persons with mental illness. It also
generally excludes discussion of programs for infants and children with disabilities, other
than those serving persons with mental retardation and developmental disabilities.

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! Maine uses several management tools to try to control use of nursing
homes and to manage its home and community-based services
including: 1) pre-admission screening for all nursing home
applicants, 2) contracted assessment and case management agencies
for adults receiving home care agency services, and 3) a separate
agency for participants in consumer-directed, personal assistance
programs.
Trends in Institutional Care
! Between 1995 and 2001, according to state data, the percentage of
public long-term care beneficiaries served in nursing homes declined
from 50% to 33%. During the same time period, the percentage of
public long-term care funding devoted to these facilities decreased
from 84% to 61%.
! Very few persons with mental retardation and developmental
disabilities who live in residential settings live in large institutions;
in 2002, 10% of persons in residential settings lived in settings
serving seven or more persons. Persons living in small residential
settings (with six or fewer persons) has increased from 62% of all
persons living in group residential settings in 1991 to over 90% in
2002. This is due in part to expanded use of Maine’s Section
1915(c) home and community-based waiver program which was
designed to move people from large institutions into smaller
settings.
Trends in Home and Community-Based Care
! In FY2001, Maine provided about 5,000 older persons and persons
with disabilities with the following Medicaid state plan services:
private duty nursing, home health, personal care, and adult day care.
In addition, the state relies on two Medicaid Section 1915(c) home
and community based waivers to serve the adult population with
disabilities — the Elder and Adult Waiver and the Consumer-
Directed Waiver. Together they served about 2,000 participants in
FY2001. The state also has a large Medicaid and state-funded
residential care program which served about 4,300 persons in
FY2001. The largest state funded program is Home-Based Care,
which served about 4,000 people in FY2001.
! Maine uses one optional Medicaid state plan service — day
habilitation; one Medicaid Section 1915(c) home and community-
based services waiver, which includes day habilitation; and some
state-funded programs to serve persons with developmental
disabilities. The state’s Section 1915(c) waiver serves people who
would otherwise be in an institution. It provides residential training
in licensed homes, personal support, day habilitation, supported
employment, respite, environmental modification, crisis
intervention, and other services. About 2,200 people received
services in FY2002.

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Long-Term Care Spending
! Long-term care comprises a significant portion of Medicaid
spending in Maine — about 30% of all Medicaid spending was
devoted to long-term care in FY2001 ($411 million out of $1.3
billion). Nursing home spending represented 15% of all Medicaid
spending.
! As a share of Medicaid long-term care spending, nursing home
spending decreased from 65.5% to 49% from FY1990-FY2001.
During the same time period, Medicaid spending for institutions for
persons with mental retardation decreased from 23.2% to 10.9%.
! In FY2001, Maine spent $152.8 million on Medicaid Section
1915(c) home and community-based services waiver programs, a
536% increase (in constant 2001 dollars) from FY1990.
Issues in Financing and Delivery of Long-Term Care
! One of the challenges Maine faces during its 2003 budgetary crisis
is to hold on to the gains it has made in providing home and
community services to people with disabilities, while dealing with
its fiscal constraints.
! The labor shortage is a critical problem affecting all areas of health
care, including long-term care for older persons and care for persons
with developmental disabilities, particularly in Southern Maine. The
labor shortage also makes it difficult to recruit state and privately-
employed case managers.
! Much of the state is rural and it is a challenge for people to travel to
services or for workers to get to the homes of people with
disabilities. Transportation services is a largely unmet need in these
areas.
Demographic Trends
Maine is one of the smallest states in the country with 1.27 million people in
2000; the population increased by about 50,000 people in the past decade. It also is
one of the oldest states, with 14.4% of its population aged 65 and older — more than
183,000 people in 2000. The state’s older population is growing quite rapidly; it rose
12.3% during the 1990s. Those most in need of long-term care — the population age
85 and older — grew by 27.9% during the same time period (Table 1). Almost one-
third of non-institutionalized persons age 65 and older live alone.

CRS-7
Table 1. Maine Population Age 65 and Older, 1990 and 2000
1990
2000
2000
1990-
population
Percent of
2000
rank in
total
Percent of
percent
U.S.
Age
Number
population
Number
population
change
(based on
percent)
65+
163,373
13.3%
183,402
14.4%
12.3%
7
65-74
91,600
7.5%
96,196
7.5%
5.0%
4
75-84
53,547
4.4%
63,890
5.0%
19.3%
9
85+
18,226
1.5%
23,316
1.8%
27.9%
45
Under 65
1,064,555
86.7%
1,091,521
85.6%
2.5%
45
Total
1,227,928
1,274,923
3.85
40
Source: U.S. Census Bureau, Profile of General Demographics for Maine: 1990. 2000 at
[http://www.census.gov/census2000/states/me.html]. Numbers may not sum to 100 due to rounding.
Maine, along with the rest of the country, will experience large increases in its
older population over the next 25 years. By 2025, its elderly population will have
increased by 77.3% (see Figure 1). In 2025, 21.4% of Maine’s population will be
aged 65 years or older, compared to 18.5% for the nation (Table 2). Maine will have
to address the long-term care needs of 300,000 elderly in that year, 30,000 of whom
will be aged 85 or older.
Figure 1. Projected Percentage Population Increases in Maine Over
2000 by Population for Selected Years,
2000-2025
120%
100%
80%
60%
40%
20%
0%
2005
2010
2015
2020
2025
-20%
65-74
75-84
85+
65+
Total
Under 65
Source: CRS calculations based on data from the U.S. Census Bureau, Projections at
[http://www.census.gov/populations/st_yrby5.html]; analyzed data from State Populations Projections:
Every Fifth Year.

CRS-8
Table 2. Elderly Population as a Percent of Total Population,
Maine and the United States, 2025
Percent of total
Percent of total
population, United
Age
population, Maine
States
65+
21.4%
18.5%
65-74
12.8%
10.5%
75-84
6.6%
5.8%
85+
2.0%
2.2%
Under 65 population
78.6%
81.5%
Source: CRS calculations based on data from the U.S. Census Bureau. Projections at
[http://www.gov/population/www/projections/st_urby5.html]; analyzed data from State Populations
Projections: Every Fifth Year. See Appendix 3 for information about projection assumptions.
Need for Long-Term Care
Table 3 presents estimates of the number of persons aged 18 and over in Maine
who have limitations in two or more activities of daily living (ADLs) and thus may
need long-term care. These estimates were derived from data generated by The
Lewin Group and combine national level data on persons with disabilities with state-
level data from the U.S. Census Bureau on age, income, and broad measures of
disability. Persons aged 85 and over with two or more limitations in ADLs are
estimated to increase 15.3% by 2010 to reach 2,047. The number of persons aged 18
to 64 with the same level of disability will increase by 6% reaching almost 3,000.
Growth in the number of adults of all ages with disabilities will place pressure on
public and private long-term care resources.

CRS-9
Table 3. Estimated Number of Persons with
Two or More Limitations in Activities of Daily Living (ADLs),
by Poverty Status, in Maine
2002
2005
2010
Percent
of
poverty
Persons with 2+ ADL limitations by age and income
18-64
65+
85+
18-64
65+
85+
18-64
65+
85+
Up to
100%
597
742
128
613
752
134
634
796
148
Up to
150%
954
1,984
738
979
2,027
771
1,014
2,159
852
Up to
200%
1,234
2,770
1,070
1,276
2,830
1,119
1,321
3,032
1,235
All
income
2,822
5,239
1,775
2,894
5,343
1,854
2,990
5,707
2,047
Source: CRS analysis based on projections generated by The Lewin Group through the HCBS State-
by-State Population Tool available on-line at [http://www.lewin.com/cltc]. Lisa M.B. Alecxih, and
Ryan Foreman, The Lewin Group Center on Long Term Care HCBS Population Tool, 2002.
Administration of Long-Term Care Program
Responsibility for administration and management of long-term care services
for persons with disabilities is spread across several state agencies, with the
Department of Human Services (DHS) retaining responsibility for most programs.
Various sub-state agencies and some private contractors have responsibility for
different aspects of long-term care administration and services.
The Department of Human Services is the single state agency for Medicaid; and
three of its bureaus administer most of the state’s long-term care programs. The
Bureau of Medical Services (BMS) is the fiscal agent for Medicaid; it processes
claims, enrolls participating providers, and manages Medicaid’s optional personal
care service. The Bureau of Elder and Adult Services (BEAS) manages two of the
state’s four Medicaid Section 1915(c) home and community-based services waivers
along with Medicaid home health and private duty nursing, nursing home eligibility
determination and some of the residential options. The Bureau of Family
Independence (BFI) determines financial eligibility for all Medicaid applicants.
The Department of Behavioral and Developmental Services (DBDS) houses the
Bureau of Adult Mental Retardation Services, which manages one waiver, day
habilitation, and a number of state-funded services for persons with developmental
disabilities. The waiver is managed in partnership with the DHS.

CRS-10
The Department of Labor (DoL) gained responsibility for administering the
state’s consumer-directed programs in 2002, including the Medicaid personal care
optional service for those who want to direct their own services, the consumer-
directed Medicaid Section 1915(c) home and community-based services waiver, and
the state-funded consumer-directed program.
The DHS Division of Licensing and Certification licenses nursing homes and
ICFs/MR. Until 2001, the Division also licensed assisted living facilities (ALFs).
This responsibility went to BEAS because the state wanted to maintain the social
model for ALFs in contrast to the medical model that the Department used when it
regulated those facilities.
Responsibility for Assessment, Eligibility, and Case
Management
Maine uses several management tools to try to control use of nursing homes and
to manage its home and community-based services including: 1) pre-admission
screening for nursing home applicants using a standardized assessment tool, 2)
contracted assessment and case management agencies for adults receiving agency-
provided home care services, and 3) a contracted agency that assists participants in
consumer-directed programs.
Functional Eligibility. A private agency — Goold Data Management —
conducts the assessments of functional eligibility and authorizes service plans that
establish the amount and type of services for all persons receiving Medicaid home
and community-based services. After this assessment, people are advised of what
their long-term care options are and many are able to remain in the community or
enter group residential settings rather than enter a nursing home. Fifty-four nurses
statewide conducted 16,359 assessments in State Fiscal Year (SFY) 2001 at a cost
of $153 per assessment.7 State officials and stakeholders commented that people
who receive Medicaid home health services from certified home health agencies must
have two assessments, the state’s uniform assessment as well as the Outcome and
Assessment Information Set (OASIS) tool that is federally required when people
receive Medicare or Medicaid-funded home health services. Some stakeholders
advocate replacing the state’s tool with OASIS, but state officials resist this idea
because they believe their tool meets their management needs better than OASIS
would.
Financial Eligibility. The Bureau of Family Independence handles the
financial eligibility determination for Medicaid services through its 15 local offices.
Some interviewees said that financial eligibility standards for long-term care
programs differ and are so complex that applicants cannot understand them; BEAS
staff say they help people work through the eligibility rules so that they obtain the
benefits for which they qualify. However, some stakeholders complained that the
determination process can take several months, which delays receipt of services.
State officials say that financial eligibility determination generally takes place within
7 Bureau of Elder and Adult Services, Maine’s Home and Community-Based Care System,
at [www.state.me.as.dhs/ltc/2000], accessed on Feb. 6, 2002.

CRS-11
45 days of submission of the forms; complex financial situations can take longer to
process.
Care Coordination and Consumer-Directed Services. In 1996, Elder
Independence of Maine (EIM), which is a division of the Western Maine Area
Agency on Aging, began providing care coordination services (i.e., arranging and
monitoring services) to persons across the state who receive Medicaid and state-
funded home and community-based services. EIM receives a monthly per capita
payment of $117 to arrange services, coordinate and monitor care, calculate
consumer copayments, contract with service providers, pay claims, audit providers,
and participate in quality improvement activities. EIM contracted with 200 providers
and served 6,825 consumers in SFY2001 in four programs.
Maine has established a consumer-directed program where persons with
disabilities plan their care, including services and providers of their choice. The state
contracts out management of its consumer-directed programs to Alpha One, Maine’s
Center for Independent Living (CIL). Alpha One conducts assessments for people
seeking to direct their own services and coordinates the state’s three consumer-
directed programs. The CIL provides consumer skills training, monitoring, and
payroll processing for consumers. In SFY2001, Alpha One served 357 consumers
eligible under the state’s Medicaid consumer-directed program and received
payments of $132 per consumer per month; it also served 297 consumers eligible
under the state’s Section 1915(c) waiver program and received payments of $335 per
consumer per month.8
The Department of Behavioral and Developmental Services performs case
management for its clients with developmental disabilities through its three regional
offices. Case managers are state employees who, in addition to assessing eligibility
and developing service plans, also visit people in nursing homes to determine if they
can live in the community in small group homes, for example. About 4,500 people
receive case management services from the Department. After a person is
determined eligible and has a service plan, the provider agency takes over most day-
to-day case management functions, in addition to providing services.
8 Personal communication with staff of the Maine Department of Labor, June 6, 2003.

CRS-12
Maine’s Long-Term Care Services
for the Elderly and Persons with Disabilities
Trends in Institutional Care
Maine has pursued an aggressive policy to decrease dependence on nursing
homes in its long-term care system. The state started on this course because of a
1993 budgetary crisis. Since nursing home costs had increased by 50% over a 3-year
period,9 the state implemented stringent functional eligibility criteria for Medicaid
nursing home care in 1994. Prior to implementation of these criteria, people had
been able to obtain Medicaid nursing home coverage if they needed assistance with
one activity of daily living (ADL) or one instrumental activity of daily living
(IADL).10 According to some stakeholders, the new criteria resulted in some people
being released to or remaining in the community without sufficient home and
community service alternatives. According to interviewees, the Alzheimer’s
Association succeeded in amending the functional criteria for nursing home
eligibility to define nursing need to include management of cognition and behavior.
The standard now requires an applicant to need a form of therapy 5 days a week,
assistance with three specific ADLs, nursing services three times a week, or have a
cognitive or behavior problem.
In 1994, the Maine legislature adopted a policy of universal pre-admission
screening of all nursing home applicants so facilities cannot admit anyone unless they
first have an assessment. The state found that there were not enough residential
alternatives to nursing homes, and that waiting lists for home and community
services had developed. To ameliorate this situation, in 1996, the state devoted more
funding to home and community services. As a result, Medicaid nursing home
admissions decreased and use of home and community services increased. (Tables
4 and 5). Between 1995 and 2001, the percentage of publicly-funded, aged and
disabled long-term care beneficiaries served in nursing homes declined from 50% to
33%. During the same time period the percentage of public long-term care funding
devoted to these facilities decreased from 84% to 61%.
9 Bureau of Elder and Adult Services, Long-Term Care Reform in Maine.
10 The need for long-term care assistance is measured by assessing a person’s need for
assistance with activities of daily living (ADLs) and/or instrumental activities of daily living
(IADLs). ADLs are activities necessary to carry out basic human functions, and include the
following: bathing, dressing, eating, getting around inside the home, toileting, and
transferring from a bed to a chair. IADLs are tasks necessary for independent community
living, and include the following: shopping, light housework, laundry, taking medication,
telephoning, money management, and meal preparation.

CRS-13
Table 4. Where People Receive Publicly Funded
Long-Term Care Services
1995
2001
Total served in all settings
19,803
25,455
Home care
39%
49%
Assisted living
11%
18%
Nursing homes
50%
33%
Source: Calculations based on the Bureau of Elder and Adult Services, Dec. 27, 2001, as revised on
Feb. 7, 2002.
Table 5. Where Public Long-Term Care Funding Goes
1995
2001
Funds spent in all settings
$284,715,157
$328,581,664
Home care
10%
20%
Assisted living
6%
19%
Nursing homes
84%
61%
Source: Calculations based on the Bureau of Elder and Adult Services, Dec. 27, 2001, as revised on
Feb. 7, 2002.
In 2000, Maine had 126 nursing facilities with 8,236 beds, with an occupancy
rate of 88.7% (Table 6). The number of beds per 1,000 older persons (44.9) is lower
than the national average (52.7). The state’s ratio for persons aged 85 and older is
353.2 beds per 1,000, a figure much lower than the national rate of 434.8. The
relatively high occupancy rates combined with the low ratio of nursing home beds
to older persons, implies that the state does not have much excess capacity in its
nursing home industry. According to data supplied by officials from the Maine
Bureau of Medical Services, Medicaid helps fund the costs of 72% of all nursing
home residents.

CRS-14
Table 6. Nursing Home Characteristics
in Maine and the United States
Characteristics
Maine
United States
Number of facilities
126
17,023
Number of residents
7,309
1,490,155
Number of beds
8,236
1,843,522
Number of Medicaid beds
6,497
841,458
Number of beds per 1,000
pop. aged 65 and older
44.9
52.7
Number of beds per 1,000
pop. aged 75 and older
94.4
111.1
Number of beds per 1,000
pop. aged 85 and older
353.2
434.8
Occupancy rate
88.7%
80.8%
Source: CRS calculations based on data from the American Health Care Association (ACHA), Facts
and Trends: The Nursing Facility Sourcebook, 2001. All figures represent 1999-2000 data.
Some stakeholders claim that about half of nursing facilities are technically
insolvent due to low payment rates and a handful have closed in recent years. State
officials counter that Maine has one of the highest nursing home payment rates in the
country. Officials mentioned that elimination of the Boren amendment, which
required that state Medicaid nursing home payment rates be “reasonable and
adequate to meet the costs which must be incurred by efficiently and economically
operated facilities” (Section 1902(a)(13) of the Social Security Act), enabled the state
to control payments to nursing homes and avoid paying unnecessary costs.
Nursing home quality is said to be generally good. According to interviewees,
since many homes are located in rural areas where people know one another well, the
resulting sense of community promotes delivery of good quality care. In some rural
communities, the facilities are a major employer in the area.
Trends in Home and Community-Based Care
Maine takes advantage of Medicaid’s mandatory and optional state plan services
as well as Section 1915(c) waivers to provide home and community-based care to
adults with disabilities. In FY2001, the state provided about 5,000 participants with
the following Medicaid state plan services: private duty nursing, home health,
personal care, and adult day care. Costs of these services in FY2001 were $19.4
million. In addition, the state relies on two waivers to serve the adult population with
disabilities in home and community-based settings — the Elder and Adult Waiver
and the Consumer-directed waiver. Together they served almost 2,000 participants
at a cost of $27 million in FY2001. The state also has a large residential care
program funded by Medicaid and state funds, which served about 4,300 persons in
FY2001.

CRS-15
The state also sponsors a number of programs that do not receive federal
funding, most of which serve just a few hundred people. By far the largest program
is Home-Based Care, which served about 4,000 people at a cost of $15 million in
FY2001. This program and the state’s other home and community-based programs
for adults have separate consumer-directed components that mirror the main
programs.
Medicaid State Plan Services and 1915 (c) Waivers
Maine’s Medicaid mandatory and optional long-term services have varying
functional eligibility standards, but all have the same financial eligibility standards.
Under the state’s Medicaid program, a person’s countable income cannot exceed
100% of the federal poverty level. Countable assets cannot exceed $2,000,11
although the state can disregard an additional $8,000 in financial assets when
calculating financial eligibility.
Section 1915(c) waiver services require that a person meet the state’s functional
eligibility criteria for nursing facility coverage. The income eligibility standard for
these waivers is 222% of the federal poverty level and countable assets cannot exceed
$2,000, or $10,000 including an $8,000 additional asset disregard.
Mandatory and Optional State Plan Services. The mandatory state plan
home health service requires beneficiaries of any age to have a need for skilled care
and to be homebound; physicians must order the service. Available services are
nursing, therapies, aides, and psychiatric monitoring. There is no cap on the amount
of care available to an individual. About 2,000 adults received these services in
FY2001 at a cost of $5.3 million.
Private duty nursing and personal care, both optional services under the Maine
state Medicaid plan, require beneficiaries of any age to need assistance in at least two
of seven activities of daily living (ADLs) or need direction with four ADLs. Both
services offer nursing, home health aide, and personal care assistance. Costs are
limited to $3,884 a month in FY2001 for people needing a nursing home level of
care, but the cost cap for beneficiaries who are dependent on a ventilator is $20,100
a month. The programs served about 2,500 adults in FY2001; the cost of the two
programs was $9.3 million in that year.
Consumer-Directed Personal Care is an optional service for persons age 18 and
over who need assistance with two of seven ADLs but who are cognitively capable
of directing their own services. The service limit is 35 hours a week of daytime care
and 14 hours of night-time care. In FY2001, Alpha One served 357 consumers at a
cost of $4.1 million.
11 In addition, Medicaid statute requires that certain items are excluded from assets: an
individual’s home; up to $2,000 of household goods and personal effects; life insurance
policies with a face value of $1,500 or less; an automobile with value up to $14,500; and
burial funds up to $1,500, among other things.

CRS-16
Adult day health services, another Medicaid optional service under the clinic
option, serves people who are age 18 or older and who attend day care a minimum
of four hours a week. Services available to the 173 participants (FY2001) include
health care monitoring, nursing, rehabilitation counseling, and health promotion. The
functional and financial eligibility standards for this service are the same as for
private duty nursing and personal care. Adult day health spending was $787,000 in
FY2001.
Medicaid Section 1915(c) Waivers. Maine has two Section 1915(c)
waivers for the adult population, one for services provided through home care
agencies services and the other for consumer-directed services. (The Section 1915(c)
waiver for persons with mental retardation is discussed below.) They are
administered independently of one another. The Elder and Adult with Disabilities
Waiver is for persons aged 18 and older who receive a range of services including
case management; nursing, aide, and personal care services; therapies; homemaker;
adult day care; mental health; and transportation services. The cap on services is
100% of the average nursing facility payment. Elder Independence of Maine
administers these waivers.
The Consumer-Directed Waiver also serves people who are eligible for nursing
facility care, but who are cognitively capable of directing their services. This waiver
provides case management, skills training, and personal care assistance. The cap on
services is 90% of the average nursing facility payment. As of June 2003, the state
was considering exploring an amendment to its Medicaid waiver that would increase
the cost cap. The waiver served 279 participants at a cost of $8.3 million in FY2001.
Alpha One manages this waiver.
One of the state’s largest Medicaid programs is the Residential Care Services
Program, which paid for the medical and remedial component of group residential
care for 4,325 participants in FY2001 at a cost of $45.1 million. State funds paid for
the room and board component for most participants accounting for $17 million in
the same year. The state expanded this program as it sought to increase alternatives
to nursing home care during its budget crisis in the mid-1990s.
Medicaid finances the care component of services in residential care homes
(adult family care homes and residential care homes), which have private or shared
rooms and baths; and assisted living facilities, which have private apartments.
Medicaid payments for residents of all residential facilities are adjusted for varying
categories (15 case-mix groups), using a standardized assessment of all residents.
Assisted living facility residents receive an average subsidy of $10,657 per year in
SFY2003. According to data supplied by the Bureau of Medical Services, Medicaid
helps fund the costs of 67% of ALF residents.
Residents who are eligible for Supplemental Security Income (SSI) use these
payments and their SSI state supplemental payments to fund their room and board
costs. Those who are not SSI eligible must pay 40% of their income and 3% of
liquid assets over $10,000 as a co-payment for residential care.
State Programs. There are a number of pathways that establish Medicaid
eligibility for home and community-based long-term care services. These include

CRS-17
coverage of persons whose income is 300% of the federal Supplemental Security
Income (SSI) payment level, as allowed under the Section 1915(c) waiver program
($1,656 a month for an individual in 2003). Despite the availability of this more
liberal standard, many people may need community care but cannot meet Medicaid’s
income limits or resource tests. Many of these persons cannot establish eligibility
until they spend-down almost all of their resources and income to meet that eligibility
level, and, by that time, may be in danger of entering an institution. One of the issues
many states have confronted is how to serve these people.
Maine has addressed this issue in part through its seven state-funded programs.
Many of these programs are designed to complement their Medicaid counterparts
with more generous financial eligibility standards than those of Medicaid.
By far the largest program is Home-based Care for adults aged 18 and over.
Eligibility for services is based on the presence of limitations in ADLs and IADLs
with at least one being an ADL or if they need direction with four ADLs. The
program has no upper limits on participants’ incomes or assets. However, the
program has a copayment of 4% of monthly income and 3% of assets exceeding
$15,000. The program offers a wide array of services including case management,
nursing, home health aide, therapies, personal care, and adult day care. These are the
same basic services provided under the Elder and Adult Waiver. There are four
levels of care with corresponding maximum caps. The cap on services for the highest
level is 85% of the nursing facility rate. Elder Independence of Maine runs the
program, which served 3,863 persons in FY2001 at a cost of $12.4 million.
In addition, the program has a separately-managed consumer-directed
component with the same basic eligibility standards as the agency-provided service
program; the service cap is set at 35 hours per week plus 14 hours per week of night
personal care services. The consumer-directed component, managed by Alpha One,
served 203 people in FY2001 at a cost of $3.1 million.
The state has five other state funded programs — adult day services, congregate
housing, assisted living, Alzheimer’s respite, and homemaker services — all of
which have similar functional and financial eligibility standards as the other two
state-funded programs. These five programs served a total of 2,672 participants at
a cost of $6 million in FY2001.

CRS-18
Maine’s Long-Term Care Services for Persons with
Mental Retardation and Developmental Disabilities
Overview
Services to persons with mental retardation and other developmental disabilities
in the United States changed dramatically over the last half of the 20th century as a
result of a number of converging factors. These include the advocacy efforts of
families and organized constituency groups, various changes to the Social Security
law that provided payments to individuals through Supplemental Security Income
(SSI) and Supplemental Security Disability Insurance (SSDI) and to service providers
through the Medicaid program, and significant litigation brought on behalf of persons
with mental retardation.12
Trends in Institutional Care
The early history of services to persons with mental retardation is characterized
by the development of large state institutions or training schools begun during the
latter part of the 19th century and continuing through the first part of the 20th century.
Between 1920 and 1967, institutions quadrupled in size and peaked at almost
200,000 individuals nationwide in 165 free-standing, state-operated mental
retardation institutional facilities.13 Today, some states are still faced with the legacy
of large state-operated institutions.
Maine has eliminated its sole large state-operated facility for persons with
mental retardation and developmental disabilities. It is also making strides to
downsize its other three smaller state-operated facilities (see Appendix Table 2 for
a list of the facilities).
Very few persons with mental retardation and developmental disabilities who
live in residential settings live in large institutions; in 2002, 10% of persons in
residential settings lived in settings serving 7 or more persons. Persons living in
small residential settings (with six or fewer persons) has increased from 62% of all
persons living in group residential settings in 1991 to over 90% in 2002 (Table 7).
This is due in part to expanded use of Maine’s Section 1915(c) home and
community-based waiver program which was designed to move people from large
institutions into smaller settings.
12 For a detailed history of the development of services for persons with developmental
disabilities, see David Braddock, Richard Hemp, Susan Parish, and James Westrich, The
State of the States in Developmental Disabilities, University of Illinois at Chicago.
American Association on Mental Retardation, Washington, DC, 1998. (Hereafter cited as
Braddock, et al., The State of the States in Developmental Disabilities.)
13 Ibid.

CRS-19
Table 7. Persons with Mental Retardation and Developmental
Disabilities Served in Residential Settings, by Size of Setting,
1991, 1995 and 2002
Persons served by residential setting
1991
1995
2002
2,018
1,577
3,073
Setting by size
(100%)
(100%)
(100%)
572
191
43
16+ Persons
(28.3%)
(12.1%)
(1.4%)
187
298
247
7-15 Persons
(9.3%)
(18.9%)
(8.0%)
1,259
1,088
2,783
<6 Persons
(62.4%)
(69%)
(90.6%)
Source: Prouty, Robert W., Gary Smith and K. Charlie Lakin, Residential Services for Persons with
Developmental Disabilities: Status and Trends Through 2002. Research and Training Center on
Community Living. University of Minnesota, June 2003. [Http://rtc.umn.edu/risp].
Trends in Home and Community-Based Care
As the number and size of larger facilities has decreased over the years, the state
has made significant use of Medicaid financing for community-based care. Maine
uses one optional service — day habilitation; one Section 1915(c) waiver, which
includes day habilitation; and some state-funded programs to support community-
based care. Day habilitation services are available to persons who meet the ICF/MR
eligibility criteria. The service originally was designed to serve people with
developmental disabilities who live in nursing homes and need special services due
to their conditions.
The state’s Home and Community Based Waiver Services for Persons with
Mental Retardation serves people who would otherwise be in an institution. It
provides residential training in a licensed home, including personal support, day
habilitation, supported employment, respite, environmental modification, crisis
intervention, and other services. About 2,200 people received services in FY2002.
Costs are limited to 100% of the aggregate average cost of ICF/MR facilities across
the state (approximately $110,000 in 2003).

CRS-20
Financing of Long-Term Care in Maine
In most states, Medicaid is the chief source of financing for long-term care. In
Maine, long-term care spending accounted for about 30% of total Medicaid spending
in FY2001. In addition, Maine has a number of state-financed programs that
complement Medicaid programs. Maine’s Medicaid spending on institutional care
declined during the 1990s while spending on home and community-based services
rose rather dramatically.
Medicaid Spending in Maine
Medicaid is a significant part of state budgets. After elementary, secondary and
higher education spending, Medicaid spending was the largest share of state budgets
in 2001. According to data compiled by the National Association of State Budget
Officers (NASBO), federal and state Medicaid spending represented almost 20% of
state budgets for the United States as a whole in 2001.
In Maine, Medicaid spending is the largest single category of federal and state
spending. Of the state’s $5.3 billion budget in 2001, federal and state Medicaid
spending represented one out of every four dollars. Federal and state spending for
Medicaid increased from almost 15% of total spending in 1990, and in 2001 at
24.9%, was about equal to spending for elementary, secondary, and higher education
combined (Table 8).
Table 8. Share of State Spending by Category,
Maine and the United States, 1990-2001
Maine
U.S. total
Expenditure category
1990
1995
2000
2001
2001
Total expenditures
(in millions)
$2,651
$3,825
$4,847
$5,269
$1,024,439
Medicaid
14.9%
23.0%
25.0%
24.9%
19.6%
Elementary and secondary education
26.4%
13.9%
19.8%
20.4%
22.2%
Higher education
6.7%
4.4%
4.2%
4.6%
11.3%
Public assistance
6.9%
5.9%
3.4%
2.7%
2.2%
Corrections
2.4%
1.8%
2.0%
1.9%
3.7%
Transportation
10.8%
8.7%
8.6%
8.7%
8.9%
All other expenses
31.9%
42.2%
36.9%
36.8%
32.1%
Source: CRS calculations based on National Association of State Budget Officers (NASBO) State
Expenditures Reports 1990-2001.

CRS-21
State spending for Medicaid services in Maine contributed from state funds only
(excluding federal funds)14 increased over 3 times from 1990 to 2001. As a percent
of spending for all categories of state spending, state Medicaid spending increased
from 6.4% in 1990 to 12% in 2001 (Table 9).
Table 9. State Spending for Medicaid as a Percent of Total State
Spending, Maine and the United States, 1990-2001
Maine
All states
State spending
1990
1995
2000
2001
2001
Total state spending
(in millions)a
$2,009
$2,753
$3,352
$3,729
$760,419
State Medicaid spending
(millions)b $130
$275
$416
$447
$85,141
State Medicaid spending as a
percent of total state spending
6.4%
10.0%
12.4%
12.0%
11.2%
Source: CRS calculations based on data from the National Association of State Budget Officers
(NASBO), State Expenditure Reports for 1991, 1997 and 2001. Data reported are for state fiscal
years.
a Total state spending for all categories, excluding federal funds.
b State spending for Medicaid, exclusive of federal funds.
Figure 2. Institutional and Home and Community-Based Services as
a Percent of Medicaid Long-Term Care Spending in Maine, 1990-2001
100%
90%
$214.0 milion
80%
$289.2 million
$246.2
70%
million
60%
50%
40%
$164.8
30%
million
$27.2 million
$66.2 million
20%
10%
0%
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Total Institutional Care
Total Home and Community Based Services
Source: CRS calculations based on Burwell, Medicaid Expenditures FY1991-FY2001, 1990 total
Medicaid spending, based on HCFA 64 data provided by the Urban Institute, Washington, DC.
14 Federal and state governments share the costs of Medicaid spending according to a
statutory formula based on a state’s relative per capita income (federal medical assistance
percentage, or FMAP). In FY2001, the federal share for Medicaid in Maine was 66.12%.

CRS-22
Medicaid Long-Term Care Spending in Maine
Long-term care spending
represented 30.5% of all
Medicaid long-term spending in Maine at a glance:
Medicaid spending in Maine in
FY2001, a significant decrease
In FY2001, about 30%of Medicaid dollars were spent
from 55.1% in 1990 (Table
on long-term care. This is a decline from FY1990
when long-term care represented over 55% of
10). This reduction is due to
Medicaid spending.
the state’s pre-admission
screening process for nursing
This decline is largely attributed to a decline in
home applicants; restrictions
spending for nursing home care. This spending
represented 15% of total Medicaid spending in
on functional eligibility
FY2001 — a decline from the 36% it represented in
criteria for Medicaid nursing
FY1990. Nursing home spending grew less than one
home coverage; and increased
percent over the period.
use of home and community-
based alternatives to nursing
As a percent of Medicaid long-term care spending,
nursing home care declined from 65.5% to 49%
home care that the state started
FY1990 to FY2001 During the same period, the
providing in the wake of a mid-
portion spent on ICFs/MR decreased from 23.2% to
1990s state budget crisis.
10.9%.
During the same period,
At the same time, spending on home and community-
spending for home and
based services increased by almost 400% from
community-based services as a
FY1990 to FY2001. Home and community-based
proportion of total long-term
services represented 40% of long-term care spending
care spending grew almost
in FY2001.
fourfold to reach 40.1% of
long-term care spending in
FY2001. Nevertheless, institutional care still dominates long-term care spending and
is a significant share of these expenditures at 60%.
Table 10. Medicaid Long-Term Care Spending in Maine,
FY1990-FY2001
Maine
FY1990 FY1995 FY2000 FY2001
Long-term spending as a %of Medicaid spending
55.1%
37.5%
32.0%
30.5%
Institutional care spending as % of long-term care
spending
88.7%
81.4%
60.2%
59.9%
Nursing home spending as a % of long-term care
spending
65.5%
66.7%
51.2%
49.0%
ICFs/MR* spending as a % of long-term care
spending
23.2%
14.7%
9.0%
10.9%
Total home and community-based services spending
as a % of long-term care spending
11.3%
18.6%
39.8%
40.1%
HCBS waivers spending as a % of long-term care
spending
7.8%
14.7%
36.2%
37.2%
Source: CRS calculations based on CMS/HCFA 64 data provide by The Medstat Group, Inc. For
2000 and 2001, Burwell Brian et al., Medicaid Long-Term Care Expenditures in FY2001, May 10,
2002. For 1995, Brian Burwell, Medicaid Long-Term Care Expenditures in FY2000, May 7, 2001.
For 1990, Brian Burwell, Medicaid Expenditures for FY1991. Systemetrics/McGraw-Hill Healthcare
Management Group, Jan. 10, 1992, 1990 total Medicaid spending based on HCFA 64 data provided

CRS-23
by Urban Institute, Washington, DC. (Hereafter cited as Burwell, Medicaid Expenditures FY1991-
FY2001.)
*Intermediate care facilities for the mentally retarded.
In FY2001, $246.2 million or 18.2% of all Medicaid spending was for care in
institutions but nursing home spending accounted for 81.8% of total institutional
spending (Table 11). In the same year, home and community-based services
accounted for 12.2% of all Medicaid spending.
Table 11. Medicaid Spending in Maine, Total Spending and
Long-Term Care Spending, by Category, FY1990-FY2001
(dollars in millions)
Percent change
FY1990
FY1995
FY2000
FY2001
FY1990-FY2001
(current
(current
(current
(current
(in constant 2001
Spending category
dollars)
dollars)
dollars)
dollars)
dollars)
Total Medicaid
$437.8
$948.9
$1,218.5
$1,349.7
142.4%
Total long-term care*
$241.1
$355.5
$390.2
$411.0
34.1%
Total institutional care
$214.0
$289.2
$234.9
$246.3
-9.5%
Nursing homes
$158.0
$237.1
$199.6
$201.4
0.3%
ICFs/MR**
$56.0
$52.1
$35.3
$44.8
-37.0%
Total home and community
$27.2
$66.2
$155.3
$164.8
376.9%
based services
Home health
$5.9
$12.2
$9.4
$6.6
-12.2%
Personal care
$2.3
$2.0
$4.8
$5.3
78.9%
HCBS waivers
$18.9
$52.1
$141.1
$152.8
535.9%
Source: CRS calculations based on Burwell, Medicaid Expenditures FY1991-FY2001. Total 1990
Medicaid spending, based on HCFA 64 data provided by the Urban Institute, Washington, DC.
Figures 3 and 4 depict dramatic changes in long-term care spending patterns
from FY1990 to FY2001. In FY1990, 23.2% of Medicaid long-term care spending
was devoted to care for persons with developmental disabilities in ICFs/MR; this
decreased to 10.9% in FY2001. The proportion of Medicaid long-term care spending
on nursing home services also declined during that time period from 65.5% to 49.0%.
Spending on home and community services increased from 11.3% to 40.1% of long-
term care expenditures, primarily due to the expansion of Section 1915(c) waivers,
which increased 536% from FY1990 to FY2001 (in constant 2001 dollars).

CRS-24
Figure 3. Medicaid Long-Term Care Spending in Maine by Category,
FY1990
Total Medicaid LTC Spending: $241.1 million
Home Health
ICFs/MR
2.5%
23.2%
Personal Care
HCBS
1.0%
11.3%
HCBS Waivers
7.8%
Nursing Home
65.5%
Source: CRS calculations based on Burwell, Medicaid Expenditures FY1991-FY2001.
Figure 4. Medicaid Long-Term Care Spending in Maine by Category,
FY2001
Total Medicaid LTC Spending: $411.0 million
ICFs/MR
10.9%
Home Health
1.6%
Personal Care
1.3%
HCBS
40.1%
Nursing Home
49.0%
HCBS Waivers
37.2%
Source: CRS calculations based on Burwell, Medicaid Expenditures FY1991-FY2001.
Increased funding for Section 1915(c) waiver services does not affect all
populations equally. In FY2001, about 15.6% of waiver spending in Maine was
devoted to services for the aged and younger persons with disabilities; spending for
persons with mental retardation and developmental disabilities accounted for 84.4%
of waiver spending in FY2001.

CRS-25
Figure 5. Medicaid Home and Community-Based Services Waiver
Spending by Target Population in Maine,
FY2001
Total Medicaid HC BS Waiver Spending: $152.8 million
Age d Waive r s
15.6%
M R/DD Waive r s
84.4%
Source: CRS calculations based on Medicaid HCBS Waiver Expenditures, FY1995 through FY2001
by Steve Eiken and Brian Burwell, The Medstat Group, Inc., May 13, 2002.
Medicaid and State Spending on Services for Persons with
Mental Retardation
Federal and state spending for persons with mental retardation and
developmental disabilities was $216.8 million in 2000 (Table 12). This represented
an increase of 812.2% (in constant 2000 dollars) since 1990. Of total 2000 spending,
34.8% was contributed by state resources. Section 1915(c) waiver funding increased
from $9.2 million in 1990 to $84.8 million in 2000.
As discussed earlier, Maine has devoted considerable effort to increasing
services in home and community-based settings to persons with developmental
disabilities. Table 11 shows that in 2000, 95.6% of total spending was for home and
community-based services — $207.4 million. Of total spending in 2000, 39.1% was
from waiver programs. This spending increased by 640.9% in constant 2000 dollars
since 1990. The state has used waivers to maximize federal Medicaid reimbursement
for home and community-based services, while it has dramatically decreased federal
spending for institutional services. Federal spending for institutional services
decreased by 71.2% in constant dollars from 1990 to 2000.

CRS-26
Table 12. Federal and State Spending for Institutional and
Community Services for Persons with Mental
Retardation/Developmental Disabilities in Maine,
1990 and 2000
Percent
1990
2000
Percent of
change (in
(current
(current
FY2000
constant 2000
dollars)
dollars)
total
dollars)
Total funds
$79.6
$216.8
100%
812.2%
Congregate/institutional services
$31.4
$9.4
4.4%
-75.8%
Federal funds
$17.5
$6.3
2.9%
-71.2%
State funds
$14.0
$3.2
1.5%
-81.6%
Home and community-based
services
$48.2
$207.4
95.6%
246.7%
Federal funds
$29.0
$135.2
62.3%
275.0%
ICF/MR funds
$12.7
$16.8
7.8%
7.0%
HCBS waiver
$9.2
$84.8
39.1%
640.9%
Title XX/SSBG funds
$0.9
$0.8
0.4%
-29.6%
Other
$6.2
$32.8
15.1%
323.4%
State funds
$19.1
$72.2
33.3%
203.8%
Source: CRS calculations based on data presented in The State of the States in Developmental
Disabilities (Fifth Edition), by David Braddock et al., (1998) Washington, DC, American Association
on Mental Retardation, p. 404 (for 1990 data). Unpublished data furnished by Richard Hemp,
University of Colorado (for 2000 data).
Issues in Long-Term Care in Maine
The following discussion highlights selected issues raised in state reports
collected for this report and in interviews with state officials and key stakeholders
conducted during the site visit to Maine in the summer of 2002.
Budgetary Concerns. In dealing with prior budgetary dilemmas the state has
followed a “Medicaid maximization” policy in providing home and community-
based care. That is, because the state has opted to take opportunities to provide a
number of optional home and community-based services that are allowed under the
federal law, it can therefore draw down federal Medicaid matching dollars to support
its program.
One of the challenges the state faces during its budgetary crisis is to hold on to
the gains it has made in providing home and community services to people with
disabilities. According to interviewees, this is particularly the case when the state’s

CRS-27
nursing home lobby competes with other groups for funding. Part of the state
government’s plan to close its budget gap would involve a 6% “nursing home bed
tax,” which would raise $7 million.15 The money would be used to draw down
federal Medicaid funds, which would then go to wages for long-term care workers,
including providers other than nursing homes.
Other budget actions would shift some state funded residential costs to Medicaid
and reduce spending on state-funded services, including homemaker, adult day
services, and Alzheimer’s respite care. The Governor’s budget proposal would
decrease nursing facilities’ cost of living adjustment from 3% to 2%.16 According
to state officials, as of March 2002, home and community-based services had not
been affected too negatively by budget cuts.
Labor Issues. The health labor shortage is a critical problem affecting all
areas of health care, including long-term care and care for persons with
developmental disabilities, particularly in Southern Maine. The labor shortage also
makes it difficult to recruit state and privately-employed case managers.
Interviewees cited several reasons for the labor shortage. Fourteen percent of
Maine’s population is aged 65 or over and many younger people are leaving the state
to find employment. Interviewees also cited low wages and lack of health insurance
as barriers to employment in the long-term care sector. The state has considered
becoming a self-insurer for agencies contracting with the state to provide an
opportunity for them to participate in a large group health insurance plan.
The results of the labor shortage include high staff turnover and reliance on
temporary agency staff. This can disrupt continuity of care in facilities and lead to
staff having insufficient training to handle some of the complex needs of nursing
home residents. There is also a shortage of experienced nursing home administrators
so many come to their jobs with very little training. State officials said that some
people in southern Maine may have to be placed on waiting lists for home and
community services because of the labor shortage.
Conducting criminal background checks on long-term care employees is another
controversial labor issue in Maine. Not all long-term care programs require criminal
background checks for long-term care workers and consumer-directed programs have
actively resisted this. The state’s certified nurse aide registry does not allow people
who have committed crimes in health care settings to be on the registry but criminals
with other types of convictions can be. Some officials recommended more attention
to registries of nurse aides. State officials noted that a U.S.-wide registry could
prevent criminals working in long-term care from going from state to state when they
lose their credentials.
Consumer Direction. A number of controversial issues raised during the site
visit related to various aspects of the consumer-directed programs. Control of these
15 Rankin Joe, “Governor Proposes Nursing Home Tax,” Kennebec Journal, June 29, 2002.
16 Michael O’ D. Moore, “Health Professionals Wary of King Cuts,” Bangor Daily News,
June 27, 2002.

CRS-28
programs was transferred from the Maine Department of Human Services (DHS) to
the Department of Labor (DoL) in 2001. The transfer occurred as a result of advocacy
efforts on the part of consumers. Many believed that Maine DoL would be the more
appropriate administering agency since it has experience with rehabilitation services
and independent living services for persons with severe disabilities, (DoL administers
programs authorized under the Rehabilitation Act of 1973, including vocational
rehabilitation and centers for independent living programs).
Another controversy surrounds paying family members to work for
beneficiaries. According to interviewees, this can become problematic when the
family members come to consider the payments part of their rights and income, and
when families provide inadequate or substandard services. There is also the feeling
among some that women who receive payment will become the next generation of
poor women because they do not have access to employment that provides fringe
benefits (like retirement and health insurance).
Assisted Living Facilities. Some stakeholders interviewed said that assisted
living facilities (ALFs) are becoming more popular than nursing homes. However,
sometimes people enter nursing homes because federal money isn’t available for
assisted living facilities. Also, assisted living facilities are supposed to provide
personal care as part of the payment they receive from Medicaid but some do not.
The ALF regulations give residents the right to age in place but providers say that this
is not reflected in the level of Medicaid reimbursement they receive.
Waiting List. As of the summer of 2002, the waiting list for residential care
for persons with developmental disabilities was 500. People who are in crisis
situations move off of the list to receive services first. The waiting list for supported
employment was between 300 and 400.

CRS-29
Appendix 1. Major Home and Community-Based Long-Term Care Programs
for the Elderly and Persons with Disabilities in Maine
No. of persons
Functional eligibility
Financial eligibility
enrolled/
slots
Annual cost
Income/
approved and
cap
Target
Determined
resource
Determined
expenditures
(aggregate/
Administrative
Financial
Program
group
Criteria
by
limits
by
Services
(SFY2001)
individual)
oversight
oversight
Home health
Adults age
Need for
Home health
100% of
Bureau of
Nursing,
2,238 persons
None
Bureau of Elder
Department
(adults only)
18+
skilled
agency does
poverty; assets
Family
therapies, home
and Adult
of Human
nursing or
assessment
of $2,000 or
Independence
health aide,
$5,329,567
Services
Services
(Medicaid
therapy,
less with
psychiatric
state plan
homebound,
additional
monitoring
service)
and physician
exclusions in
ordered
certain
circumstances
Private duty
Adults age
Limited
Assessing
100% of
Bureau of
Nursing, home
1,188 persons
$3,884 a
Bureau of Elder
Department
nursing
18+
assistance
Services
poverty; assets
Family
health aide, and
month or, if
and Adult
of Human
(adults only)
and one
Agency
of $2,000 or
Independence
personal care
$4,292,745
ventilator
Services
Services
person
less with
assistance
dependent,
physical
additional
$20,100 a
(Medicaid
support in
exclusions in
month
state plan
two of seven
certain
service)
ADLs or
circumstances
cueing in four
ADLs
Personal care
Adults age
Limited
Assessing
100% of
Bureau of
Nursing, home
1,388 persons
$3,884 a
Bureau of Elder
Department
services
18 and over
assistance
Services
poverty; assets
Family
health aide, and
month or, if
and Adult
of Human
(adults only)
and one
Agency
of $2,000 or
Independence
personal care
$4,986,955
ventilator
Services
Services
person
less with
assistance
dependent,
(Medicaid
physical
additional
$20,100 a
state plan
support in
exclusions in
month
service)
two of seven
certain
ADLS or
circumstances
cueing in four
ADLs

CRS-30
No. of persons
Functional eligibility
Financial eligibility
enrolled/
slots
Annual cost
Income/
approved and
cap
Target
Determined
resource
Determined
expenditures
(aggregate/
Administrative
Financial
Program
group
Criteria
by
limits
by
Services
(SFY2001)
individual)
oversight
oversight
Adult day
18 and
Limited
Day care
100% of
Bureau of
Monitoring of
173 persons
Must attend a
Bureau of Elder
Department
health
older
assistance
provider or
poverty; assets
Family
health care,
minimum of 4
and Adult
of Human
services
and one
Assessing
of $2,000 or
Independence
nursing
$787,015
hours weekly
Services
Services
person
Services
less with
rehabilitation
(Medicaid
physical
Agency
additional
counseling,
state plan
support in
exclusions in
exercise, health
service)
two of seven
certain
promotion
ADLs or
circumstances
cueing in four
ADLs
Consumer-
18 and
Limited
Alpha One or
100% of
Bureau of
Personal care
357 persons
Up to 35 hours
Alpha One
Department
directed
older
assistance
Assessing
poverty; assets
Family
assistance, skills
a week plus
of Labor
personal care
and one
Services
of $2,000 or
Independence
training
$4.1 million
less than 14
person
Agency
less with
night-time
(Medicaid
physical
additional
hours a week
state plan
support in
exclusions in
service)
two ADLs
certain
and
circumstances
cognitively
capable of
self direction
Consumer-
18 and
Nursing
Alpha One or
222% of
Bureau of
Case
279 persons
90% of
Alpha One
Department
directed
older
facility
Assessing
poverty; and
Family
management
average
of Labor
waiver
eligible and
Services
assets of
Independence
with skills
$8.3 million
nursing facility
cognitively
Agency
$2,000 or less
training and
payment
(Medicaid
capable of
with additional
consumer
1915(c)
self direction
exclusions in
directed
waiver)
certain
personal care
circumstances
assistants

CRS-31
No. of persons
Functional eligibility
Financial eligibility
enrolled/
slots
Annual cost
Income/
approved and
cap
Target
Determined
resource
Determined
expenditures
(aggregate/
Administrative
Financial
Program
group
Criteria
by
limits
by
Services
(SFY2001)
individual)
oversight
oversight
Elder and
Age 18 and
Nursing
Assessing
222% of
Bureau of
Case
1,589 persons
100% of
Bureau of Elder
Department
adult waiver
older
facility
Services
poverty and
Family
management,
average
and Adult
of Human
eligible
Agency
assets of
Independence
nursing home
$19,096,433
nursing facility
Services
Services
(Medicaid
$2,000 or less
health aide,
payment
1915(c)
with additional
certified nursing
waiver)
exclusions in
assistants,
certain
therapies,
circumstances
personal care
assistant,
homemaker,
adult day health
care, emergency
response
systems, mental
health,
transportation
respite
Residential
Age 18 and
Needs shelter
Residential
Income limit
Bureau of
Room and
4,325
Personal needs
Bureau of Elder
Department
care:
older
and support
care provider
varies with
Family
board, medical
$45.1 million
allowance of
and Adult
of Human
medical and
facility rate;
Independence
and remedial
up to $70 a
Services
Services
remedial
assets of
services
month
component
$2,000 or less
(Medicaid and
state funded)
Residential
Age 18 and
Needs shelter
Residential
Income limit
Bureau of
Room and
4,403
Personal needs
Bureau of Elder
Department
care: room
older
and support
care provider
varies with
Family
board, medical
$16,698,724
allowance of
and Adult
of Human
and board
facility rate;
Independence
and remedial
up to $70 a
Services
Services
assets of
services
month
(Medicaid and
$2,000 or less
state funded)

CRS-32
No. of persons
Functional eligibility
Financial eligibility
enrolled/
slots
Annual cost
Income/
approved and
cap
Target
Determined
resource
Determined
expenditures
(aggregate/
Administrative
Financial
Program
group
Criteria
by
limits
by
Services
(SFY2001)
individual)
oversight
oversight
Congregate
18 and
three IADLs,
Provider
$50,000 asset
Bureau of
Service
260
Based on
Bureau of Elder
Department
housing
older
two ADLs, or
limit
Family
coordination,
$592,156
needs of
and Adult
of Human
program
one ADL and
Independence
chore services,
resident
Services
Services
two IADLs
one meal a day
(state funded)
Assisted
18 and
three IADLs,
Provider
$50,000 asset
Bureau of
Service
199
Based on
Bureau of Elder
Department
living CHSP
older
two ADLs, or
limit
Family
coordination,
$1,812,206
needs of
and Adult
of Human
one ADL and
Independence
chore services,
resident
Services
Services
(state funded)
two IADLs
one meal a day
Adult foster
18 and
Needs shelter
Provider
$14 gross
Bureau of
Medicaid and
Not available
Resident pays
Bureau of Elder
Department
homes
older
and support
income and
Family
remedial
maximum of
and Adult
of Human
assets of
Independence
services, room
$544 a month.
Services
Services
(state funded)
$2,000 or less
and board
Personal needs
allowance of
up to $70 a
month
Adult family
18 and
Cueing in
Provider
$1,706 gross
Bureau of
Medicaid and
Not available
Based on
Bureau of Elder
Department
care homes
older
four ADLs;
income and
Family
remedial
needs of
and Adult
of Human
cognitive or
assets of
Independence
services, room
resident.
Services
Services
(Medicaid and
behavioral
$2,000 or less
and board
Personal needs
state funded)
problems
allowance of
with two or
up to $70 a
four ADLs
month

CRS-33
No. of persons
Functional eligibility
Financial eligibility
enrolled/
slots
Annual cost
Income/
approved and
cap
Target
Determined
resource
Determined
expenditures
(aggregate/
Administrative
Financial
Program
group
Criteria
by
limits
by
Services
(SFY2001)
individual)
oversight
oversight
Home-based
18 and
Total of three
Assessing
No upper
Bureau of
Case
3,863 persons
85% of
Elder
Department
care
older
limitations
Services
limit.
Family
management,
nursing facility
Independence of
of Human
with at least
Agency
Copayment of
Independence
nursing home
$12.4 million
rate ($3,301 in
Maine
Services
(state funded)
one ADL or
4% of monthly
health aide,
SFY2002)
cueing in four
income and
certified nursing
ADLs
3% of assets
assistants,
exceeding
therapies,
$15,000
personal care
assistant,
homemaker,
adult day health
care, emergency
response
systems, mental
health,
transportation
respite
Home-based
18 and
Total of three
Assessing
No upper
Bureau of
Personal care
203
100% of
Alpha One
Department
care:
older
limitations
Services
limit.
Family
assistance and
$3,118,374
nursing facility
of Labor
consumer-
with at least
Agency or
Copayment of
Independence
skills training
rate ($3,884 a
directed
one ADL and
Alpha One
4% of monthly
month in
cognitively
income and
SFY2002)
(state funded)
capable of
3% of assets
self direction
exceeding
$30,000
Adult day
18 and
One ADL or
Day care
$50,000 asset
Monitor health
119
Attend a
Alpha One
Department
services
older
cueing with
provider or
test.
care, nursing
$304,240
minimum of 4
of Labor
four ADLs
assessing
Copayment of
rehabilitation
hours a week
(state funded)
services
20% of cost of
counseling,
agency
services
exercise, health
promotion

CRS-34
No. of persons
Functional eligibility
Financial eligibility
enrolled/
slots
Annual cost
Income/
approved and
cap
Target
Determined
resource
Determined
expenditures
(aggregate/
Administrative
Financial
Program
group
Criteria
by
limits
by
Services
(SFY2001)
individual)
oversight
oversight
Alzheimer’s
18 and
Need- based
Bureau of
$50,000 asset
In-home or
430
$3,800 a year
Bureau of Elder
Department
respite (state
older
Elder and
test.
institutional
$754,609
and Adult
of Human
and Older
Adult
Copayment of
respite, adult
Services
Services
Americans
Services/Area
20% of cost of
day care respite
Act funded)
Agencies in
services
Aging
Homemaker
21 and
Need help
Homemaker
$50,000 asset
Homemaking,
1,664
Ten hours a
Home Resources
Department
older
with three
provider or
test.
chore, grocery
$2,553,199
month
of Maine or
of Human
IADLs and
assessing
Copayment of
shopping,
Aroostook Home
Services
(state funded)
one ADL
services
20% of
laundry,
Health Services
agency
services
incidental
personal care,
transportation
Home and
All ages
ICF/MR level
Department of
300% of the
Department of
Residential
2,200 slots
100% of the
Department of
Department
community
of care
Behavioral and
SSI level;
Human
training services
average
Behavioral and
of Human
based waiver
Developmental
$2,000 per
Services,
in a DHS
aggregate costs
Developmental
Services
services for
Services,
individual
Bureau of
licensed home
of ICF/MR
Services, Adult
persons with
Adult Mental
Family
Personal
facilities
Mental
mental
Retardation
Independence
support services
(approx.
Retardation
retardation
Services
Day habilitation
$110,000 per
Services
services
year in 2003)
(Medicaid
Supported
1915(c)
employment
waiver)
Respite care
Environmental
modification,
communication
assessment
Crisis
intervention
Consultative
services

CRS-35
Appendix 2. Population in Large State Facilities
Table A-2. Population in Large State Facilities for Persons
with Mental Retardation/Developmental Disabilities and
Closure Date, Maine
Large state MR/DD facilities or units
operating 1908-1998
Year facility opened
Year closed
Aroostook Residential Center (Presque Isle)
1972
Elizabeth Levinson Center (Bangor)
1971
Freeport Town Square
not available
Pineland Center (Pownal)
1908
1995
Source: Residential Services for Persons with Developmental Disabilities: Status and Trends Through
2001, Research and Training Center on Community Living, Institute on Community
Integration/UCEED, University of Minnesota, June 2002; and personal communication with personnel
of the Department of Behavioral and Developmental Services.

CRS-36
Appendix 3. About the Census
Population Projections
The projections use the cohort-component method. The cohort-component
method requires separate assumptions for each component of population change:
births, deaths, internal migration (internal migration refers to state-to-state migration,
domestic migration, or interstate migration), and international migration .... The
projection’s starting date is July 1, 1994. The national population total is consistent
with the middle series of the Census Bureau’s national population projections for the
years 1996 to 2025. Source: Paul R. Campbell, 1996, Population Projections for
States by Age, Sex, Race, and Hispanic Origin: 1995 to 2025, U.S. Bureau of the
Census, Population Division, PPL-47. For detailed explanation of the methodology,
see same at [http://www.census.gov/population/www/projections/ppl47.html].