State Perspectives on Emerging Medicaid Longterm

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• State Perspectives on Emerging Medicaid Long-term
  
• Care Policies and Practices

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In a perfect world
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Survey

• Surveyed developed by the Chronic Care TAG and
  Eligibility TAG
• Reviewing two things impact on the DRA on LTC
  and major activities in states on LTC
• July 2007
• 43 states and 2 territories completed the survey

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DRA Changes

• Eligibility
• Long-Term Care Partnership Programs
• Family Opportunity Act
• Money Follows the Person Demonstration
• HCBS-State Option
• Personal Care Services Cash and Counseling

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Demographics

• Medicaid accounts for 40 percent of all Long-Term
  Care services
• Total Medicaid LTC services in FY06 were nearly
  100 billion
• Medicaid Nursing Home expenditures in FY06 were
  47.7 billion
• Spending on community-based LTC services rose to
  39 percent while 61 percent was on institutional
  care

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Trend Aging Population
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HCBS Services and Medicaid

• Individuals under 65 are more likely then those
  over 65 to use HCBS
• Expenditures for community-based LTC continue to
  expand more rapidly than institutional
  expenditures

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Finding 1

• Eligibility for Long-Term Care services under the
  Deficit Reduction Act was tightened and states
  have responded.

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Changes states made

• Changing the look-back period
• Changes in annuities
• Income-first rules
• Home-equity limits
• Changing the start date of the penalty period
• Changing the requirement on partial months of
  ineligibility

• Changes to accumulate multiple transfers in one
  month
• Changes regarding purchase of promissory notes,
  loans, mortgages
• Changing requirements regarding the purchase of
  life estates
• Changing the hardship waivers

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Finding 2

• Most states have not used the Family Opportunity
  Act to extend Medicaid coverage to children with
  disabilities in families with higher incomes

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Family Opportunity Act

• 3 states plan to make this option available
• 4 states still considering it

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Finding 3

• States are using their Money Follows the Person
  Grant dollars in several ways
• Goal is to create a incentive for states to
  rebalance their long-term care services programs
• 31 states, 1.4 billion in funding

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Finding 4

• To date, most states are not opting to switch to
  the HCBS State Plan Amendment option

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HCBS Waiver v. Plan

• Waiver
• Includes level of care requirements
• Must be cost-neutral
• Can waiver income limits and eligibility criteria

• State Plan
• No level of care requirement
• Does not have to be cost-neutral
• Cannot expand eligibility, income can only go to
  150 FPL

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Services States Plan to Provide

• Adult day health
• Attendant care
• Companion care
• Emergency Alert system
• Habilitation
• Home-delivered meals
• Home health services/home health aide

• Home health services/RN and LPN
• Home modification
• Respite
• Assertive community treatment
• Partial Hospitalization
• Psychosocial Rehab

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States Reasons for not moving to SPA

• Lack of federal guidance
• Lack of ability to alter services among
  populations
• Increased state costs
• Financial eligibility too restrictive
• Financial constraints

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Finding 5

• States are initiating efforts to transition
  individuals out of institutions

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State Innovations

• One-stop resource centers and websites
• Pre-admissions screening tools
• Relocation case management services
• Approving spouses as paid caregivers

• Paying for transitional needs under a home
  again program
• Reviewing all nursing home admissions at 45 days
• Providing an establishment fundfurnishings,
  lights, water

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Finding 6

• States are using managed care for individuals
  with disabilities
• 14 states now have a managed care program for
  individuals with disabilities

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Finding 7

• Fewer than 10 states plan to submit a SPA for
  Personal Care Services (Cash and Counseling)
  programs
• Survey conducted prior to the release of the SMD
  providing states with additional guidance

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Benefits of Self-Directed Services

• Allows participants flexibility and authority in
  hiring, training, and selection of providers
• Provides the participants with choices

• Promotes independence
• Allows ultimate flexibility in securing
  non-medical services

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Finding 8

• Special Needs Plans are in place in at least 21
  states, but states have concerns about the
  coordination between Medicare and Medicaid.

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Special Needs Plans State Concerns

• Wide variation among plans
• Lack of experience dealing with developmentally
  delayed clients/mental health clients
• Lack of services in rural areas
• Poor coordination among Medicare and Medicaid

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Finding 9

• Long-Term Care reform in the states continues to
  encourage home- and community-based living

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Long-Term Care Reform

• Long-Term Care media awareness campaigns
• Nursing Home Reform

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Finding 10

• States are using Care Coordination to improve and
  integrate care

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Care Coordination

• 20 statesa dozen more reported putting in place
• Helps to develop plans of care and ensure
  individuals receive services
• Coordinate access to care, social and community
  supports
• Nurses and medical social workers

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Finding 11

• More states are using Disease Management to help
  manage chronic conditions

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Disease Management

• Diabetes, obesity, congestive heart failure, and
  asthma
• Help patients to adhere to medication regimens,
  receive regular monitoring, and develop healthy
  lifestyle choices

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Finding 12

• Many states are using the new option on Long-Term
  Care Partnership Projects

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Finding 13

• Benchmark benefit packages are not widely used
  for Long-Term Care services

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Benchmark Benefit Packages

• Kentuckys Comprehensive Choices Optimum Choices
• Idahos Medicaid Reform
• Virginias Healthy Returns Disease Management
  Program
• Washingtons Disease Management and Care
  Coordination plan

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For more information

• Martha Roherty
• NASMD
• 810 First Street, N.E.
• Suite 500
• Washington, DC 20002
• 202-682-0100
• www.nasmd.org
• mroherty_at_aphsa.org