Big Sky WaiverCommunity First Choice

Personal Assistance ServicesHJ 50

Barbara Smith, AdministratorSenior and Long Term Care Division444-4147 – barbarasmith@mt.gov

DPHHS - SLTCAdministrator

Adult Protective Services

Investigation

Support to Law Enforcement

Training

Aging Services Bureau

Older Americans Act

Alzheimer’s Grant

Life Span Respite

Community Services Bureau

(Medicaid)

Big Sky Waiver

Community First Choice

Personal Care Services

Home Health

Hospice

Level of Care

DCW - HCHCW

Nursing Facility Services

(Medicaid)

Reimbursement

Reporting

Prior approval leave & Add-on

Special Projects –Medicaid Reform

Fiscal bureau

GlossaryAcronym/Term Description

1915(b) Federal Waiver Authority 1915(c) Federal Waive AuthorityADL Activities of Daily Living

Age Group

< 21 - considered a child - medicaid21 - 64 Disabled - medicaid65 & up - elderly - medicaid60+ - Elderly in Aging Services

AL Assisted LivingAPS Adult Protective ServicesAR Adult Residential ARM Administrative Rules of MTBSB Big Sky Bonanza BSB Workgroup Consumer/Advocate WG for BSB onlyBSW Big Sky Waiver - >65 or physically disabledCFC Community First ChoiceCFC Council Consumer/Advocate Council (required by Feds)CFR Code of Federal RegulationsCMS Center for Medicare & Medicaid Services (the Feds)CSB Community Services BureauDCW Direct Care WagesDD Developmental Disability

Deeming When one party's income is disregarded for eligibility purposes

EVV Electronic Visit Verification

GAC-TBIGovernor's Advisory Council - Traumatic Brain Injury

HCBS Home & Community Based ServicesHCHCW Health Care for Health Care Workers

Health MaintenanceNursing Tasks delegated under law for SD PAS/CFC

I & A Information & Assistance & Referral ServicesILC Independent Living Center (aka CIL)LOC Level of Care Determination for NH, BSW and CFCLTCO Long-Term Care OmbudsmanMFP Money Follows the PersonOAA Older Americans Act of 1965PAS Personal Assistance ServicePM Performance MeasuresSelf-Direct Member managed services w/fiscal agentSLOT Budget for BSW represented in slots not personsSPA State Plan AgreementSPA add-ons Provides authoirty for DCW, HCHCW

State Plan Services Services that do not require a waiver from CMS, all available to those who physically qualify/need services

Supplant Replacing GF w/federal moniesUpcharging Using a code incorrectly to earn more revenue

Funding SourcesMedicaid Appropriations 2021B

FY 2020 2021 2021 BBig Sky WaiverGeneral Fund 11,161,770 11,161,770 22,323,540 State Special 3,705,209 3,936,851 7,642,060 Federal Funds 26,482,505 28,010,298 54,492,803

Total 41,349,484 43,108,919 84,458,403

Community First ChoiceGeneral Fund 8,567,925 10,790,528 19,358,453 State Special 1,513,650 1,788,272 3,301,922 Federal Funds 18,745,624 22,982,299 41,727,923

Total 28,827,199 35,561,099 64,388,298

Personal Assistance ServicesGeneral Fund 932,071 928,107 1,860,178 State Special 106,777 306,777 413,553 Federal Funds 1,952,604 1,744,794 3,697,398

Total 2,991,452 2,979,678 5,971,130

Grand TotalGeneral Fund 20,661,766 22,880,405 43,542,171 State Special 5,325,636 6,031,900 11,357,535 Federal Funds 47,180,733 52,737,391 99,918,124

Total 73,168,135 81,649,696 154,817,831

State SpecialTobacco Health & Medicaid InitTobacco Interest

Personal Assistance Services

• Long Standing In-Home Services Program

• State Plan Entitlement• Functional need supported with

diagnosis• Provides assistance with ADLs, Limited

IADLs, Medical Escort and related mileage

• Service is eligible for DCW and HCHCW initiatives

650608

430367

602

0

100

200

300

400

500

600

700

FY 15 FY 16 FY 17 FY 18 FY 19

PAS Recipients - Unduplicated

Community First Choice – CFC – 1915(K)

• New option to states in FY 13• State Plan Service• 6% higher FFP• Different from PAS

• Functional Need• Requires LOC• Same ADLs, IADLs and

• Offers Community Integration Service

• Extended homemaker services

3,000

3,050

3,100

3,150

3,200

3,250

3,300

3,350

3,400

FY15 FY 16 FY 17 FY18 FY 19 YTD

CFC Recipients - Unduplicated

36,785,775 38,293,50040,527,762

38,329,189

32,653,509

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

35,000,000

40,000,000

45,000,000

FY15 FY 16 FY 17 FY18 FY 19 YTD

CFC - Total Expenditures

ComparisonPAS 80 hrs/ 2 wk CFC 80hrs /2 wks BSW BSW Comment/Service

MA Eligible x x xDiagnosis/Functional Need x x xMeet Level of Care 0 x x DeemingServices to Prevent Institutionalization x x x RequiredHigh Risk Admission Process x x 0 Emergency AL Slots180 & Annual Reviews x x x More often as needed

ADL Support x x p if exceeds limits of PAS and CFCSkill Acquistion 0 x 90 day limits x Habilitation

IADL x x 0Medical Escort x x 0Community Integration 0 x x Social or supervision - soft capCorrespondence Assistance 0 x x Social or supervision - soft capYard Maintenance/Hazard Removal 0 x o home modification for safetyEmergency Response System 0 x x CFC predominantlyShopping x grocery/meds x x Social or supervisionHousehold support x x x homemaker

Family Support Policy x x x Identifies Respite needDCW can be spouse 0 0 xDCW can be parent of a minor child 0 0 xAge related services for children x x x

Self Directed Services OnlyHealth Maintenance x x x could be Pvt Duty Nsg

0100200300400500600700

0-30 Days(1 Month):

31-90 Days(3

Months):

91-180Days (6

Months):

181-365Days (1Year):

366-730Days (2Years):

731-1826Days (5Years):

1827+Days:

BSW Current Length of StayAge of oldest male member 96Age of oldest female member 102Age of youngest male member 4Age of youngest female member 5Arithmetic nean of all members 51.53Arithmetic mean of male members 45.89Arithmetic mean of female members 55.1

Age of CFC and PAS Members

Big Sky Waiver • The Medicaid Home- and Community-Based

Services (HCBS) waiver program was authorized under Section 1915(c) of the Social Security Act. Through this program, states can help provide different services that allow those who need care to receive services in their homes or communities.

• A state can waive certain Medicaid program requirements, allowing the state to provide care for people who might not otherwise be eligible under Medicaid. Through certain waivers, states can target services to people who need long term care supports.

• Waivers can be used along with federal, state, and local programs, such as Medicaid state plans and Administration on Aging grants.

• Waivers are approved through an application process and serves as the federal/state agreement.

• A wait list is allowed to address natural turnover and expansion. (42 CFR § 441.305 )

• Services that are not available through state plan include:

• Assisted Living• Home Modifications• Private Duty Nursing for Adults

• Target audience• Elderly – over 65• Physically Disabled

• Spousal Impoverishment

• State plan (CFC, Home Health) and OAA programs (home delivered meals, socialization). State plan services prior to BSW. Coordination is key.

Big Sky Waiver

• Enforced wait list policy• Meet Medicaid Eligibility• Require Service only available

under the waiver to avoid institutionalization and/or support community integration

• Willing to accept services

• 42 CFR § 441.305 Replacement of beneficiaries in approved waiver programs

Count Percentage

Moved out of service area 5 2%

Appropriateness for BSW 6 2%

Did not meet Level of Care 2 1%

Disability determination denied 8 3%

Deceased 21 7%

Unable to Contact 45 14%

Needs met with CFC 13 4%

Member/Family Choice Withdrawl 82 26%

Higher LOC Requied 41 13%

Provider unavailability 20 6%

Medicaid Ineligibility 76 24%

319

0

50

100

150

200

250

Total Male Female Disabled Elderly Child

213

82

131

93

199

1

211

79

132

89

120

2

203

73

130

87

112

4

209

77

132

88

114

7

WAIT LIST TOTALS

8/2/2019 8/9/2019 9/5/2019 9/12/2019

0

50

100

150

200

250

Total AR Basic CC3-GroupHome

CC3-SupportedLiving

CC5 Uknown

213

108101

1 1 1 1

211

107100

1 1 1 1

203

95104

1 2 1 0

209

94

111

1 1 1 0

HCBS Services

8/2/2019 8/9/2019 9/5/2019 9/12/2019

0

50

100

150

200

250

Tota

l

Part

ners

in H

ome

Care

Spec

trum

Billi

ngs

Spec

trum

Boze

man

Spec

trum

Butt

e

Spec

trum

Gre

atFa

lls

Spec

trum

Hav

re

Spec

trum

Hel

ena

Spec

trum

Kalis

pell

Spec

trum

Mile

sCi

ty

Spec

trum

Sidn

ey

233

5137

1625

33

8

41

163 3

231

5141

19 2129

7

42

173 1

218

45 40

14 15

31

6

44

20

2 1

226

42 39

14 16

32

9

46

25

2 1

CM TEAM

8/2/2019 8/9/2019 9/5/2019 9/12/2019

Slot: An allotted place in an arrangement or plan

• In BSW the allotted place is the budget and waiver agreement.• Slot is an allocation method not a person• Slot type moves with admit and discharge of individuals

• AL• Basic• High cost

• End of fiscal year – should be more members served than slots available

BSW Historical ExpendituresBig Sky Waiver Historic Expenditures

FY 2015 2016 2017 2018 2019 YTD*Elderly

Members 1,346 1,336 1,406 1,387 1,410 Expenditures $18,938,630 $19,681,275 $21,313,721 $21,695,340 $21,549,244Average $14,070 $14,731 $15,159 $15,642 $15,283

Disabled

Members 1,196 1,198 1,249 1,223 1,161 Expenditures $20,444,155 $20,211,717 $22,146,235 $20,288,117 $19,274,929Average $17,094 $16,871 $17,731 $16,589 $16,602

TOTAL 2,542 2,534 2,655 2,610 2,571 $39,382,785 $39,892,992 $43,459,956 $41,983,457 $40,824,173

$15,493 $15,743 $16,369 $16,086 $15,879

% Change Total Exp. -0.3% 4.6% -1.7% -1.5%

*10 months until year is closed

$17,000,000

$18,000,000

$19,000,000

$20,000,000

$21,000,000

$22,000,000

$23,000,000

2015 2016 2017 2018 2019 YTD*

Historic Expenditures

Elderly Disabled Linear (Elderly) Linear (Disabled)

Per Member Cost of Selected Services

Big Sky Waiver - FY 18 & FY 19Per Member cost of select services

Undup Member FY 2018 Cost Per Member

Undup Member FY 2019Cost Per Member

ASSIST LIVING, WAIVER PER DIEM 991 $15,558,390 $15,700 1001 $16,129,409 $16,113NURSING CARE, IN THE HOME 6 $622,407 $103,734 4 $475,337 $118,834RN SERVICES UP TO 15 MINUTES 229 $270,358 $1,181 196 $268,641 $1,371CASE MANAGEMENT, PER MONTH 2502 $7,598,432 $3,037 2487 $7,500,744 $3,016PERSONAL CARE SER PER 15 MIN 1265 $6,991,535 $5,527 1261 $6,541,343 $5,187

Complexities of BSW fiscal management

Member’s Plan of Care Cost

Area Budget

BSW Appropriationfor services

Consider Plan of Care Vs Actual Costs

POC Budget UTILZATION DIFFERENCE

Case Management $4,015 $4,015 $0 Respite Care $2,500 $1,250 ($1,250)Equipment $3,590 $550 ($3,040)Social Hours $4,250 $1,250 ($3,000)

Totals $14,355 $7,065 ($7,290)

Projections• Average cost per slot• Straight line - total expenditures• CMT – Utilization Reports• Paid Claims• Incurment Abatement

Points of Interest• SLTC Manages Admissions

• SLTC manages the exchange of eligibility (MA-55s), emergency AL slots and High cost slots• CMTs are required to visit, track wait list members and present the highest scored case for

admission• BSW policy is changed with basis

• Policy is built on federal law, state law, state rules. Each policy is tied back to the appropriate cites.

• Negotiated Rule Making Process will be used to update waiting list rules per HB 529• SLTC changed long standing policy

• Perception• Activities that violated or stretched policy were corrected• All actions based on current rules, polices, CFR, waiver document

• Risk – paying for services without match

Points of Interest• Case Management Teams are enrolled providers

• Sort Of. Case Management teams are under contract with the state awarded through a competitive bid solicitation.

• Contract includes response to RFP• Broader responsibilities to the state and members• Paid to provide conflict free case management services that are within the

scope of federal waiver authority, state laws. ARMs and policies

• Individuals on the waiting list do have services• A majority of members on the wait list receive other services such as cfc, life

span respite, congregate meals, family support

Points of Interest

• SLTC placed 17-7-140, MCA reductions back into services

Subclass Name Account 17-7-140 Reductions Restorations Change

Senior & LTC Division Pers. Svcs 187,500 150,000 37,500

Operations 102,290 0 102,290

MED WVR Benefits 1,743,460 1,912,213 168,753

MED Nursing Home Benefits 412,766 412,766

MED CFC Benefits 927,731 1,311,534 383,803

3,373,747 3,373,747 0

Direct Care Wage

• DCW program is not easy to implement

• Track separately• Base – but not line itemed• HB 638 – no longer C&D

• Provider perception that HB 638 (17) funding is temporary

• Is it time to set a wage floor ?

References• 1915 section of Social Security Act• BSW Approved Waiver• Instructions to find rules in book format• Kaiser Family Foundation Articles

• “Key Questions About Medicaid Home and Community Based Services Waiver Waiting Lists”

• “Medicaid Home and Community Based Services Enrollment and Spending”• “Key State Policy Choices About Medicaid Home and Community Based Services”

• Websites• www.Medicaid.gov/Medicaid/hcbs/authorities/1915-c/index• www.dphhs.mt.gov/sltc/csb/provider