Medicaid Long-Term Services and Supports

1
Medicaid Long-Term Services and Supports

• Eric Saber, Health Policy Analyst
• Long Term Care and Community Support Services
• Maryland Department of Health and Mental Hygiene
• December 19, 2011

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Agenda

• National Context for Rebalancing Efforts
• Affordable Care Act
• Money Follows the Person Extension
• Balancing Incentive Payments Program (BIPP)
• Community First Choice (CFC)
• Status Updates

3
Nationally, rebalancing efforts have reduced the
proportion of LTSS spending on nursing facilities
from 73.4 to 66.6 between 2004 and 2009.
Source National and State Long-Term Services and
Supports Spending for Adults Ages 65 and over and
Persons with Physical Disabilities. 2011.
Analysis of Thompson Reuters data by The Hilltop
Institute.
4
Maryland is behind these national trends and in
2009, ranked among the poorest in home and
community-based services (HCBS) financing. . .
Percentage of Medicaid Long-Term Services and
Supports Spending for HCBS Older Adults and
Persons with Physical Disabilities 2009
Maryland 14.9
Source National and State Long-Term Services and
Supports Spending for Adults Ages 65 and over and
Persons with Physical Disabilities. 2011.
Analysis of Thompson Reuters data by The Hilltop
Institute.
5
. . . indeed, Maryland was nearly alone among the
states in going backwards between 2004 and 2009.
Change in the Percentage of Medicaid Long-Term
Services and Supports Spending for HCBS Older
Adults and Persons with Physical Disabilities
2004-2009
Maryland -5.0
States
Source National and State Long-Term Services and
Supports Spending for Adults Ages 65 and over and
Persons with Physical Disabilities. 2011.
Analysis of Thompson Reuters data by The Hilltop
Institute.
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While Maryland Medicaids payment rates to
nursing facilities are higher than average. . .
Maryland 193.21
National Average 154.13
States
Source Harrington, et al. (2008). State Data
Book on Long Term Care, 2007. US Dept of Housing
and Urban Development.
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. . . payments to nursing facilities havent kept
up with medical inflation (and things are much
worse for home- and community-based service
providers).
Average Annual Increase 5.9
Average Annual Increase 4.6
Average Annual Increase 1.4
Sources Maryland Medicaid Long Term Care Rate
Changes. (2011). Department of Health and Mental
Hygiene and U.S. Bureau of Labor Statistics,
Occupational Archives. 1999-2010 and www.cms.gov.
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Affordable Care Act

• Supports most integrated setting, person-centered
  planning, and individual control.
• Includes increased focus on quality and
  accountability.
• Offers new or improved home and community-based
  services (HCBS) State Plan options.
• Offers enhanced Federal funding to help states
  modify delivery systems.
• Key Provisions
• Money Follows the Person Extension
• Balancing Incentive Payment Program
• Community First Choice 1915(k)

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MFP Overview

• Federal demonstration created by the Deficit
  Reduction Act of 2005, offered through the
  Centers for Medicare and Medicaid Services (CMS)
  and designed to
• Assist states in rebalancing long-term care
  systems
• Increase the use of Home- and Community-Based
  Services (HCBS)
• Remove barriers to receiving services in the
  community
• Maryland is one of 30 jurisdictions currently
  participating in the demonstration
• Affordable Care Act extended the demonstration
  and offered grants to additional states
• Transitions through December 31, 2016
• Spending through 2019

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MFP Overview

• To access MFP funds, states must transition
  individuals receiving Medicaid services from
  qualified institutions to qualified
  residences
• MFP Eligibility
• 90 days in institution
• 1 day of Medicaid eligibility in the institution
• The State receives enhanced federal matching
  funds for services provided to demonstration
  participants for 365 days
• Enhanced matching funds result in savings to
  the State
• States are required to spend savings on approved
  rebalancing initiatives
• Savings can not
• Pay for services
• Off-set ongoing state costs

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Federal Requirements

• Qualified Institutions
• Nursing Facilities (NFs)
• State Residential Centers (SRCs)
• Institutions for Mental Disease (IMDs)
• Chronic Hospitals
• Exploring expansion to include Psychiatric
  Residential Treatment Facilities (PRTFs)
• Qualified Residences
• A home owned or leased by the individual or the
  individual's family member
• An apartment with an individual lease, with
  lockable access and egress, and which includes
  living, sleeping, bathing, and cooking areas over
  which the individual or the individual's family
  has domain and control
• A residence, in a community-based residential
  setting, in which no more than 4 unrelated
  individuals reside.

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Existing Waivers

• Maryland will serve MFP participants using five
  home- and community-based waiver programs
• The Traumatic Brain Injury (TBI) waiver
• Serves adults in chronic hospitals and
  State-owned nursing facilities
• The Community Pathways (CP) waiver
• Serves adults with developmental disabilities
• The New Directions (ND) waiver
• Self-directed waiver for adults with
  developmental disabilities
• The Living at Home (LAH) waiver
• serves people with physical disabilities between
  18 and 65
• The Older Adults Waiver (OAW)
• serves adults with disabilities over the age of
  50

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Rebalancing Initiatives

• Increase outreach to institutional residents
• Peer Outreach Contracts
• Program Education
• Application Assistance
• Improve the transition process
• Enhance Transitional Case Management
• Housing Assistance
• Enhance existing community-based services
• Peer Mentoring
• New Waiver Services
• Improve Systems
• Statewide ADRC sites

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Balancing Incentive Payments Program (BIPP)

• Offers an enhanced federal medical assistance
  percentage (FMAP) for all HCBS covered during the
  balancing incentive period through September
  30, 2015.
• Maryland qualifies for a 2 enhanced payment
  rate.
• All enhanced federal payments must be used to
  fund new and expanded Medicaid community-based
  LTSS.
• Within six months, states must initiate
  structural changes to their LTSS systems that
  include
• Creation of a Single Point of Entry system for
  LTSS
• Development of a Standardized Assessment
  Instrument
• Implementation of Conflict Free Case Management
• By the end of the BIPP period states must
• Increase HCBS to 50 of total Medicaid LTSS
  spending
• Implement required structural changes

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BIPP Updates Financial

• Received CMS assurance that Maryland is eligible
  to apply for a 2 enhanced match based on the
  Federal Fiscal Year (FFY) 2009 LTSS spending
  percentages included in BIPP Application
• Marylands calculated percentage in the BIPP
  Application was 36.8
• Services included in this percentage are waiver
  programs (including DD waivers), home health and
  personal care expenditures.

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Community First Choice (CFC)

• Optional State Plan benefit to offer Attendant
  Care and related supports to individuals,
  providing opportunities for self-direction.
• Includes 6 enhanced FMAP.
• CMS is still discussing policy decisions.
• Specifically, CMS is discussing whether all CFC
  participants must meet the States institutional
  level of care, or whether CFC also is available
  for people who require attendant care but are not
  at institutional level of care.
• Final Federal regulations may not be available
  until 2012.

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Community First Choice (CFC)

• We propose to offer all required and optional
  services allowed under CFC regulations.
  Specifically, CFC would offer
• Personal / Attendant Care
• Personal Emergency Response Systems (PERS)
• Voluntary training for participants
• Transition Services and
• Services that increase independence or substitute
  for human assistance.
• Services offered under CFC would no longer be
  covered as a waiver service, but rather covered
  as a State Plan service. Waiver participants are
  eligible to receive all State Plan services.
• The State will
• Refine this concept as federal guidance emerges,
  especially regarding the potential institutional
  level of care qualifying criteria
• Seek technical assistance from CMS on policy
  decisions
• Establish an Implementation Council and
• Analyze further policy decisions and
  implementation plan for CFC.

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Community First Choice (CFC)

• CFC is not creating a new eligibility standard.
• CFC is a consolidation of current State Plan
  eligible participants who receive personal care
  into one robust program offering additional
  services and self-direction.
• The program is expected to grow based on
  increased utilization due to
• Increased services to certain current
  participants,
• Participation of currently eligible participants
  not receiving services, and
• Improved reimbursement to most providers.

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Improvements possible under CFC

• In addition to services offered under CFC, with
  the enhanced match the State would be able to
  also provide the following
• Enhanced quality assurance.
• A provider registry.
• Trainings to providers.
• Coordinated rates across programs.
• An option to develop a back-up system.

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Status Updates

• Long Term Care Reform Workgroup is submitting a
  report to the legislature in December 2011.
• Long Term Care Reform Workgroup will transition
  to the Money Follows the Person Workgroup and the
  Community First Choice Implementation Council in
  January.
• MFP-BIPP stakeholder meeting on January 10, 2012
• Community First Choice Implementation Council
  will meet in January after council selection is
  complete.
• Core Standardized Assessment stakeholder meetings
  were held on December 12 and 15 for stakeholder
  input.