Board of Directors Meeting Agenda December 5, 2017

10:00 a.m. – 1:00 p.m. LAI Office – 11001 Aurora Ave. Urbandale, IA 50322

Mission: Expanding the world of possibilities for aging through advocacy, education, and collaboration.

I. Call Meeting to Order, Introductions – Bert Vigen (10:00 a.m.)

II. Antitrust, Conflicts, Confidentiality – Bert Vigen

III. Board Minutes September 12, 2017* – Bert Vigen

IV. Consent Agenda* – Bert Vigen (10:10 a.m.) A. October 23, 2017 Finance Committee Minutes B. LeadingAge Report C. Strategic Workplan Update D. 2018 LAI Calendar of Events

V. Chair’s Report – Bert Vigen (10:12 a.m.)

A. Board Orientation B. Conflict of Interest Disclosure Form

VI. President/CEO Report – Shannon Strickler (10:15 a.m.) A. Strategic Dashboard November 2017 B. 2018 General Assembly Lobbying C. Board Member Resignation, Public Policy Committee Chair & Awards Committee Chair D. IRS Audit E. Emergency Preparedness MOUs F. Emerge Leadership Academy

VII. Health Insurance Task Force* - Brynna Dooley, LMC (10:25 a.m.)

VIII. Treasurer’s Report – Pat Stilwill (10:45 a.m.) A. October 2017 Financials* B. Capitalization Policy* C. Investment Policy Amendment* D. 2018 Budget Recommendation*

IX. Public Policy Report – Shannon Strickler (10:55 a.m.)

A. Retroactive Eligibility & Medicaid MCO Update

B. IDPH & IDA Director Meetings C. LTSS & Dementia Task Force Meeting D. Federal Tax Reform Update E. CMS Region VII Meeting-December 14-15 F. RoP Enforcement Moratorium & 5-Star Changes G. 2018 Legislative Agenda*

X. Iowa Aging Services Network Update – Gretchen Brown (11:15 a.m.)

XI. Generative Discussion: Association Vision & Mission – BluOpal Consulting (11:20 a.m.)

XII. Other Business/Evaluation of Meeting (12:25 p.m.)

XIII. Adjourn – Bert Vigen (12:30 p.m.)

*Denotes Action Item

Lunch immediately following

2018 Meeting Dates

• Tuesday, February 20 from 9:30 a.m.-11:30 a.m. at the State Historical Building. This will be followed by the Legislative luncheon and hill visits.

• Tuesday, May 1 from 4:00 p.m.-6:30 p.m. at the Meadows Conference Center in Altoona with a board dinner immediately following onsite. This is the evening preceding the Spring Conference, May 2-3.

• Monday, August 27 from 4:00 p.m.-6:30 p.m. at the DoubleTree hotel in Cedar Rapids with a board dinner immediately following onsite. This is the evening preceding the Fall Conference, August 28 & 29.

• Tuesday, December 4 from 10:00 a.m.-1:00 p.m. at the LAI office in Urbandale.

Prior Board Meeting Packets

ANTITRUST COMPLIANCE POLICY STATEMENT

THE ANTITRUST LAWS

Introduction

LeadingAge Iowa intends to comply with all federal, state and local laws. Whenever a

member believes that LeadingAge Iowa or its staff may be in violation of a law, it should bring

such concern to the President of LeadingAge Iowa. In the event the matter concerns the

President of LeadingAge Iowa, the concern should be expressed to any officer of the

LeadingAge Iowa board.

Among the laws with which LeadingAge Iowa must comply are the antitrust laws.

The basic federal antitrust law is the Sherman Act. The Sherman Act outlaws agreements or

conspiracies which restrain competition in interstate. It also prohibits acts of monopolization

conducted individually or as part of a group. Iowa law has provisions which are similar to the

Sherman Act which also prohibit agreements to restrain competition or to monopolize any

business. There are significant criminal and civil penalties for violation of the Sherman Act. In

addition to the Sherman Act, the Clayton Act also imposes criminal and civil penalties for

violation of the prohibition of unfair methods of competition and deceptive acts or practices.

Included among the prohibited acts are certain types of price discrimination, tie in arrangements

or exclusive dealing arrangements. There are certain types of actions which raise issues under

the antitrust laws. When such issues arise, the policy is to refer them to the President of

LeadingAge Iowa for review for review and referral to counsel, if appropriate.

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Relevant Prohibited Acts

Matters which implicate the antitrust laws include any discussion of prices charged by members

of LeadingAge, agreements to divide markets or customers or boycotts or refusal to deal with

prospective customers or suppliers. For example, a member of LeadingAge cannot agree with

another member that the members will not provide services in the competing member’s

geographical service area.

Similarly, agreements among competitors to set compensation levels for staff also

implicate the antitrust laws. It is important to note that illegal arrangements can be formed

without a contract as courts have viewed handshakes, winks, nods, and even failures to respond

to a statement as evidence of illegal arrangements. Antitrust laws do not prohibit trade

associations from conducting surveys of compensation as long as certain specific guidelines for

such surveys are followed, which is why LeadingAge Iowa conducts a wage and benefit survey

as a membership benefit to capture relevant wage data within the legal limits of antitrust laws.

Other prohibited conduct may include certain exclusive dealing arrangements in which a

member, as a condition of a purchase of a service, would prohibit the service provider from

providing similar services to a competing member. Any conduct which a member believes may

implicate the antitrust laws should be brought to the attention of the President of LeadingAge

Iowa for review and referral to counsel, if appropriate.

Analysis and Enforcement of Antitrust Laws

Section 1 of the Sherman Act makes illegal any contract, combination or conspiracy

which unreasonably restrains trade. Section 1 is directed to agreements among competitors

whose effect or purpose is to limit or inhibit competition. There are certain categories of

activities which the law will find unreasonable under Section 1 by the mere proof of their

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existence. These are the “per se” violations of Section 1. “Per se” violations include agreements

among competitors to fix prices, allocate territories, allocate services, or boycott third parties.

Section 2 of the Sherman Act prohibits monopolization, attempts to monopolize or

combinations to monopolize any line of commerce. Oftentimes, the same facts which constitute

a violation of the restraint of trade provisions of Section 1 are sufficient to constitute a violation

of the monopoly provisions of Section 2 of the Sherman Act.

The federal antitrust laws may be enforced by the Antitrust Division of the Department of

Justice or the Federal Trade Commission. In addition, private lawsuits by individuals or by state

attorneys general on behalf of their citizens may be brought to recover civil damages as well as

attorney fees and costs.

Legislative Efforts

Efforts by LeadingAge Iowa and its members to advocate before legislative or

administrative bodies are generally considered immune from action under the antitrust laws.

Members of LeadingAge can work together to seek laws which the members believe would

benefit the members and their residents. The right to seek favorable action from the legislative

bodies or administrative agencies is generally protected under the First Amendment Right to

Petition.

The purpose of this conflict of interest policy is to protect LeadingAge Iowa (the “Corporation”) interest when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer or director of the Corporation. This policy is intended to supplement but not replace any applicable state laws governing conflicts of interest applicable to nonprofit and charitable corporations.

LEADINGAGE IOWA CONFLICT OF INTEREST POLICY

Article I Purpose

Article II Definitions

1. Interested Person

Any director, principal officer, or member of a committee with board-delegated powers who has a direct or indirect financial interest, as defined below is an interested person.

2. Financial Interest

A person has a financial interest if the person has, directly or indirectly, through business, investment or family (which are spouse, children and step children, and other relatives living with such person):

a. an ownership or investment interest in any entity with which the Corporation has a transaction or arrangement; or

b. a compensation arrangement with the Corporation or with any entity or individual with which the Corporation has a transaction or arrangement; or

c. a potential ownership or investment interest in, or compensation arrangement with, any entity or individual with which the Corporation is negotiating a transaction or arrangement.

Article III Procedures

Compensation includes direct and indirect remuneration as well as gifts or favors that are substantial in nature. Gifts and favors include any gratuitous service, loan, discount, money or article of value, but does not include loans from financial institutional on customary terms, articles of nominal value ordinarily used for sales promotion, ordinary "business lunches" or reasonable entertainment consistent with local social or business customs.

A financial interest is not necessarily a conflict of interest. Under Article III, Section 2, a person who has a financial interest may have a conflict of interest only if the board or appropriate board or committee decides that a conflict of interest exists.

1. Duty to Disclose

In connection with any actual or possible conflicts of interest, an interested person must disclose the existence and nature of his or her financial interest and must be given the opportunity to disclose all material facts to the directors and members of committees with board-delegated powers considering the proposed transaction or arrangement.

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2. Determining Whether a Conflict of Interest Exists

After disclosure of the financial interest and all material facts, and after any discussion with the interested person, he or she shall leave the board or committee meeting while the final determination of a conflict of interest is discussed and voted upon. The remaining board or committee members shall decide if a conflict of interest exists.

3. Procedures for Addressing the Conflict of Interest

a. An interested person may make a factual presentation at the board or committee meeting, but after such presentation, he or she shall leave the meeting during the discussion of, and the vote on, the transaction or arrangement that results in the conflict of interest. An interested person shall not actively participate in the discussion of, or vote on, the transaction or arrangement that results in the conflict of interest, either formally at a board or committee meeting or informally through contact with individual board or committee members. In addition, the interested person should not be counted in determining whether a quorum is present for the board or committee meeting at which the transaction or arrangement that results in the conflict of interest is to be voted upon.

b. The chair of the board or committee shall, if appropriate, appoint a disinterested person or committee to investigate alternatives to the proposed transaction or arrangement.

c. After exercising due diligence, the board or committee shall determine whether the Corporation can obtain a more advantageous transaction or arrangement with reasonable efforts from a person or entity that would not give rise to a conflict of interest.

d. If a more advantageous transaction or arrangement is not reasonably attainable under circumstances that would not give rise to a conflict of interest, the board or committee shall determine by a majority vote (or other voting requirement, as provided in the Corporation’s Bylaws) of the disinterested directors whether the transaction or arrangement is in the Corporation’s best interest and for its own benefit and whether the transaction is fair and reasonable to the Corporation and shall make its decision as to whether to enter into the transaction or arrangement in conformity with such determination.

4. Violations of the Conflicts of Interest Policy

a. If the board or committee has reasonable cause to believe that a member has failed to disclose actual or possible conflicts of interest, it shall inform the member of the basis for such belief and afford the member an opportunity to explain the alleged failure to disclose.

b. If, after hearing the response of the member and making such further investigation as may be warranted in the circumstances, the board or committee determines that the member has in fact failed to disclose an actual or possible conflict of interest, it shall take appropriate disciplinary and corrective actions.

Article IV Records of Proceedings

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The minutes of the board and all committees with board-delegated powers shall contain:

a. the names of the persons who disclosed or otherwise were found to have a financial interest in connection with an actual or possible conflict of interest, the nature of the financial interest, any action taken to determine whether a conflict of interest was present, and the board’s or committee’s decision as to whether a conflict of interest in fact existed, and

b. the names of the persons who were present for discussions and votes relating to the transaction or arrangement, the names of the persons who recused themselves from such discussion and votes, the content of the discussion, including any alternatives to the proposed transaction or arrangement, and a record of any votes taken in connection therewith.

Article V Compensation Committees

1. A voting member of the board of directors who receives compensation, directly or indirectly, from

the Corporation for services is precluded from voting on matters pertaining to that member’s compensation.

2. A voting member of any committee whose jurisdiction includes compensation matters and who receives compensation, directly or indirectly, from the Corporation for services is precluded form voting on matters pertaining to that member’s compensation.

Article VI Annual Statements

Each director, principal officer, and member of a committee with board-delegated powers shall annually sign a statement which affirms that such person: a. has received a copy of the conflict of interest policy, b. has read and understands the policy, c. has agreed to comply with the policy,

d. understands that the Corporation is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes, and

e. does not have any financial interests or fiduciary responsibilities, other than the interests or

fiduciary responsibilities disclosed.

Article VII Periodic Reviews

To ensure that the Corporation operates in a manner consistent with its charitable purposes and that it does not engage in activities that could jeopardize its status as an organization exempt from federal income tax, periodic reviews shall be conducted.

Article VIII Use of Outside Experts

In conducting the periodic reviews provided for in Article VII, the Corporation may, but need not, use outside experts. If outside experts are used, their use shall not relieve the board of its responsibility for ensuring that periodic reviews are conducted.

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LeadingAge Iowa Board of Officers and Trustees Meeting Minutes

September 12, 2017 DoubleTree Hotel by Hilton Cedar Rapids

Call to Order: 4:03 p.m. Adjourn: 6:05 p.m.

Present: Bert Vigen, Chair Mindi Baker Jim Clindaniel Kathy Horan Teresa Krueger (phone) Heather Rehmer

Hallie Salmen Cheri Schendel-Hennager Pat Stilwill Millisa Tierney Julie Thorson Janet Warren (phone)

Excused: Lisa Gates Scott Halbach Jeffrey Schmidt Mark Teigland

Staff and Guests: Matt Blake Liz Davidson Amy Huisman Shannon Strickler

Agenda Discussion Action Call Meeting to Order Board Chair Bert Vigen called the meeting to order. The meeting was called to

order at 4:03 p.m. Antitrust/Conflicts Chair Bert Vigen referenced the antitrust and conflict of

interest policies in the packet as a reminder and asked whether anyone had any conflicts to disclose. None were raised.

Minutes Minutes from the May 2, 2017 board meeting were approved with no corrections.

Motion made to approve minutes by Millisa Tierney, seconded by Kathy Horan. Motion approved.

Consent Agenda The consent agenda was called before the board including the Finance Committee minutes from August 7, 2017, the July 2017 financial report, and the LeadingAge report. No one from the board requested any of the items be removed.

Motion made to approve the items in the consent agenda by Millisa Tierney, seconded by Pat Stilwill. Motion approved.

AUP Report Treasurer Pat Stilwill provided an overview of the AUP report which found no issues. He also shared that Derek Johnson with McGowen walked through the report during the Financial Committee meeting. There were no questions.

Motion made to accept the report by Hallie Salmen, seconded by Mindi Baker. Motion approved.

Chair’s Report Bert Vigen highlighted the agenda for the national LeadingAge Leadership forum in July as well as the results of the Board Self-Assessment. Finally, Mr. Vigen reviewed a proposed process for the board to reassess and define the association’s vision statement and

Motion made to approve the BluOpal proposal utilizing the balance of the consulting funds from the 2017 budget by Cheri Schendel-Hennager,

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mission utilizing a proposal from BluOpal Consulting. He also explained the rationale for the timing of the visioning process.

seconded by Millisa Tierney. Motion approved.

President/CEO Report Shannon Strickler reviewed the September 2017 LAI performance dashboard based on July 2017 financials and July YTD data. She reported that revenue continues to exceed expectations due to the increased number of programs during 2017 that were not anticipated in the 2017 budget planning process, which occurred prior to the assessment of needs related to the final RoPs. Ms. Strickler also shared that membership recruitment and engagement continue to be focus areas of the association. She also reported that the strategic work plan update is included with progress occurring as outlined. Operationally, the focus has been on maintaining the same pace and expectations of service in a demanding year when short-staffed. Dawn will be returning from maternity leave when Matt departs for national guard training. The association will engage a contract lobbyist to assist with duties during the early part of session when Matt is gone. Shannon also shared that she is excited for the opportunity to participate in the national LeadingAge Leadership Academy starting this fall. Ms. Strickler reported that the association will be hosting a health insurance task force to test the concept of “stronger together” when applied to insurance. The association will invite two potential partners into the first meeting on November 7 to explore options available and then determine which direction the task force would like to explore further. As the association continues to review member savings partnerships, the association has worked with Martin Bros. to reshape the food purchasing program to include a rebate and thus be more competitive. It does mean a smaller percentage back to the association (.25 percent less) but will deliver more funds to the members and hopefully grow the program overall. An outline of the revised program was included in the board packet. Ms. Strickler reported that attendance at the fall conference is slightly below projections but the exhibitor hall is sold out. All board members were asked to

Jim Clindaniel made a motion to approve the new rebate structure for the procurement program with Martin Bros., seconded by Pat Stilwill. Motion approved.

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minimally visit the exhibitors assigned to them and as many as possible. Their support is vital to the conference success. Finally, Ms. Strickler commented that the 2017 Emerge Leadership Academy graduation takes place at the conference, and the association is really pleased with the feedback from fellows on the new format. Board members service as mentors or as sponsors of fellows all contributed on how well the 2017 program has gone. Registration is open for 2018 now.

Reports Iowa Aging Services Network Yasemin Washington shared that LeadingAge has hired a new Vice President of workforce and created a workforce advisory group. LeadingAge’s efforts will focus on promoting the value entering the field, scaling state initiatives, policy initiatives, and key partnerships. Public Policy Matt Blake shared the press releases and related press coverage since the previous board meeting related to the American Health Care Act and LeadingAge's paper on LTSS Financing. He also shared the work related to the workforce infographic that will be incorporated into a future press release, advocacy and for use with members. Mr. Blake also discussed some of the work underway related to workforce with Senator Ernst's office on the 8-Hours rule as well as an update on DIA's rulemaking process related to online CAN training. Additionally, Mr. Blake shared that he is compiling research and materials for a workforce section on the LAI website. Finally, Mr. Blake shared that LAI is planning a future of aging services summit in May to raise awareness and begin talking about issues that Iowa is facing. Phase 2 of the RoPs & New Survey Process Liz Davidson discussed the tools available for members for Phase 2 of the RoPs and provided a brief overview of the new survey process. She talked about the potential challenges that LAI believes members may have with implementation and how the association is working to provide support.

Strategic Discussion Membership Value & Growth

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Ms. Strickler highlighted some findings of high drivers of membership based upon the LeadingAge national survey and the status of the leadership transition at IHCA. She also included the current Prospective Membership Recruitment list. After an overview, the board engaged in conversation related to what they value most in membership and ideas for recruitment strategies. The key areas that board members valued were tools & templates and education. Ideas for recruitment included giving away a sneak peek at tools available, highlighting outcomes of membership, offering discounts to get them to educational events, highlighting unique values like IASN and the Leadership Academy. Testimonial videos would be impactful as well. Then, follow up with incentives. Board members shared that they would be happy to help when called upon.

Other Business None was raised.

Adjourn Being there no other business raised, the meeting was adjourned.

The meeting was adjourned at 6:05 p.m.

LeadingAge Iowa Finance Committee Minutes

October 23, 2017 VIA Conference Call

Call to Order: 2:03 p.m. Adjourn: 2:40 p.m.

Present: Pat Stilwill, Chair Rod Copple Matt Garcia Susan Feldman Robin Mixdorf Steve Roe Debbie Russell

Excused: Mindi Baker Lisa Gates Kathy Horan Brian Phillips Janet Warren Hallie Salmen

Staff/Business Partners: Shannon Strickler Matt Meline, Morgan Stanley

Agenda Discussion Action Call Meeting to Order Treasurer Pat Stilwill called the meeting to order. Meeting called to order at

2:03 p.m. Approval of Minutes No corrections needed to the minutes. Robin Mixdorf moved

approval of the August 7, 2017 minutes. Motion seconded by Matt Garcia. Motion approved.

Financial Report Pat Stilwill presented the September 2017 financial statement. Mr. Stilwill asked if committee members had any questions and there were none.

A motion was made by Rod Copple and seconded by Matt Garcia to accept the financial report. Motion approved.

Investment Report Matt Meline reviewed the materials included in the packet including an overview of the LAI portfolio. Mr. Meline shared that they have lightened up the high yield fixed market to better reflect the quality position wanted in equities. The portfolio is ahead of the 3 and 5-year benchmarks but not for the year due to the 'quality' philosophy which does not grow as quickly when entire market grows due to conservative nature.

Investment Policy Change

Matt Meline presented his recommendation for an investment policy change as outlined in a memorandum and supplemental documentation included in the packet.

Robin Mixdorf made a motion, seconded by Rod Copple, to recommend that

Agenda Discussion Action Mr. Meline recommends the addition of market neutral funds to the portfolio as an alternative to bonds in order to get some returns from the market without taking undue risk. After questions and discussion of the material provided, the committee recommended that the board adopt an investment policy change to include a new category for market neutral funds not to exceed 10 percent of the total balance.

the LAI board amend the investment policy to add a new category of allocation of market neutral funds, not to exceed 10 percent of the total balance. Motion approved

2018 LAI Budget Shannon Strickler provided an overview of the 2018 draft LAI budget as outlined in the budget memorandum in the meeting packet. Committe members asked questions regarding dues, professional development, and accounting. They also requested that the association move nurse consulting out of other revenue to its own line in the budget and financial statements and also requested that Shannon Strickler inquire with accounting about an updated capitalization policy.

Matt Garcia made a motion to recommend the budget to the board seconded by Rod Copple. Motion approved.

Other Business Shannon Strickler notified the committee that the association had been selected for an IRS audit for the 2015 tax year. Ms. Strickler shared that the full board had been notified and that the association's CPA had been engaged to represent the association through the audit. The IRS agent will be onsite on December 7-8.

Adjourn With no other business, the committee adjourned at 2:40 p.m.

Adjourned at 2:40 p.m.

Public Policy Tax legislation: On November 16th, the House of Representatives passed its version of H.R. 1, the Tax Cuts and Jobs Act. No changes were made to the following provisions that concern us:

• Elimination of the individual tax deduction for medical expenses; • Elimination of tax exempt private activity bonds, which is disadvantageous to both affordable

housing and life plan communities; • Elimination of the 4% low-income housing tax credit; and • Elimination of the tax deduction for state and local taxes, except for up to $10,000 in local

property taxes. We have since focused our attention focus to the Senate legislation provisions as follows:

• The Senate bill completely eliminates the tax deduction for state and local taxes; • Unlike the House bill, the Senate bill preserves the medical expense deduction; • Unlike the House bill, the Senate bill allows for continued issuance of tax-exempt private activity

bonds and preserves the 4% low-income housing tax credit; • Unlike the House bill, the Senate bill contains a complete repeal of the Affordable Care Act’s

individual mandate; and • Like the House bill, the Senate bill ends authority for issuance of tax-exempt advance refunding

bonds. Status: The Senate bill has been approved by the Finance Committee and is ready for a floor vote. Since Congress is in recess this week, we anticipate the Senate tax vote will come the week after Thanksgiving. If the legislation passes the Senate, members of the House and Senate will then need to draft a final version of the bill for both houses to pass. President Trump has said he wants the bill on his desk before Christmas. Our Concerns: The potential impact of both versions of the tax legislation on Medicaid are of great concern to us. At the federal level, nonpartisan scoring indicates that the tax legislation will add $1.5 trillion to the already-large federal budget deficit over the next ten years. It is foreseeable that a deficit increase so huge may lead to calls for substantial reductions in “entitlement” programs like Medicare and Medicaid. At the state and local level, the elimination of the deduction for state and local taxes puts pressure on communities and states to lower their taxes. Tax cuts of this kind would result in less state revenue. Most, if not all, states have constitutional balanced budget requirements and Medicaid is generally one of the largest items in a state’s budget. Therefore, it is quite possible that Medicaid cuts at the state as well as the federal level may result from this tax legislation. Until there is a better way of financing long-term services and supports, we need to be concerned about threats to the Medicaid program. We continue our advocacy urging Congress not to pass tax legislation that would be harmful to long-term services and supports providers and those they serve.

LeadingAge Update

November 21, 2017

Medicare Therapy Caps: A press release from the House Ways and Means Committee on November 15th indicated that committee members have reached a bipartisan agreement on extending various Medicare provisions due to expire at the end of this calendar year. This agreement, which has not been written as legislation thus far, would make the therapy caps exceptions process permanent and would extend the rural home health add-on for another five years. However, because of the committee’s deep concern about the federal budget deficit, this measure must be budget-neutral and must, therefore, contain offsetting spending cuts. Reimbursement reductions for skilled nursing facilities and home health care providers are on the list. Federal spending: Federal programs have been operating under a continuing resolution due to expire on December 8th. So far, we haven’t seen a proposal for a spending bill to fund federal agencies past that date. The congressional leadership is discussing a two-year budget deal with the Trump Administration. The main issue right now is apparently how much to boost defense spending versus spending on non-defense programs. House leaders are holding off on agreeing to a deal until the Senate votes on tax reform. Our primary stake here is 2018 funding for senior housing and Older Americans Act home- and community-based services programs. In General, Where Do Aging Services Stand on Capitol Hill? As the end of the year approaches, we have achieved some successes on our three main advocacy issues for 2017 - funding for senior housing, the preservation of Medicaid and regulatory relief. Though Fiscal year 2018 began on October 1st, Congress has not passed a budget or appropriations bills for the new year. A continuing resolution, enacted in September, suspended the federal debt ceiling and kept federal programs in operation through December 8th. The targeted congressional adjournment date of December 14th could slip if necessary. Medicaid - The Affordable Care Act repeal and replacement legislation, H.R. 1628, has dominated the congressional agenda this year. The many iterations of this legislation all contained deep cuts to Medicaid in the form of block grants and per capita capped allotments to the states. These provisions would have reduced federal Medicaid spending by hundreds of billions of dollars over the next ten years and beyond. We did extensive direct lobbying and grassroots advocacy against this legislation all year. Activities included a Capitol Hill rally, member Hill visits during PEAK, a full-page ad in an influential Capitol Hill publication, a report analyzing the impact of Medicaid cuts, numerous letters to Congress and meetings with legislators and their staff and strong grassroots activity by LeadingAge members and their residents. This broad-based advocacy succeeded in persuading a majority of senators not to support legislation containing huge Medicaid cuts. Senior Housing Funding for 2018 - Rejecting the Administration’s call for funding cuts, both the House and Senate Appropriations Committees approved HUD 2018 spending legislation that would fund Section 202 at $573 million, $70.6 million more than FY17. This amount would fully cover contract renewals and amendments. These provisions were incorporated into the omnibus 2018 spending bill, H.R. 3354, which the House passed on September 14th. The 2018 appropriations legislation has not yet come to the Senate floor.

Low-Income Housing Tax Credits (LIHTC) - We support legislation (H.R. 1661/S. 548) to expand and improve the LIHTC program. These measures would expand the LIHTC program by 50% and make many improvements to the program, especially in the determination of tenants’ income eligibility. Nursing Home Oversight and Requirements of Participation (ROPs) - Even before President Trump took office and the 115th Congress began, we used every possible opportunity to advocate for delay of Phase II and reconsideration of the new requirements of participation. While Phase II is going into effect as of November 28th, our advocacy resulted in a delay in the imposition of civil monetary penalties for any deficiencies cited on the new requirements for the first year. We have posted tools and conducted multiple webinars on the new requirements to assist our members in preparing. Medicare Observation Days legislation - We are supporting H.R. 1421 and S. 568, the Improving Access to Medicare Coverage Act. The legislation would resolve the observation days issue by requiring all time Medicare beneficiaries spend in a hospital to count toward the three-day stay requirement for coverage of any subsequent post-acute care. We urge legislators to co-sponsor these bills. Medicare therapy caps - The therapy caps exceptions process expires at the end of this calendar year. There are ongoing negotiations among House and Senate staff to revise the caps and exceptions process, but legislation has not been introduced at this point. We support H.R. 807 and S. 253, to repeal the therapy caps, which will likely serve as the “base” bill for final consideration.

Home Health Access Legislation Re-Introduced - Senators Susan Collins (R-ME), the Chair of the Senate Aging Committee, and Ben Cardin (D-MD) have re-introduced the Home Health Care Planning Improvement Act of 2017 (S.445). The bill seeks to improve the access Medicare beneficiaries have to home health care by allowing physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives to order home health services. These are increasingly important roles in the delivery of health care, particularly in rural and underserved areas. Rep. Chris Collins (R-NY) introduced the House companion bill (H.R. 1825). Under current law, only physicians are allowed to certify or initiate home health care for Medicare patients, even though they may not be as familiar with the patient’s case as the non-physician provider.

The Home Health Care Planning Improvement Act removes the needless delays in getting Medicare patients the home health care they need simply because a physician is not available to sign the form required by law. Rural Home Health Bill Introduced - Senator Susan Collins (R-ME) has introduced S. 353, Preserve Access to Medicare Rural Home Health Services Act, a bill that would make the 3% add-on for home health services delivered to residents of rural areas permanent. A targeted rural add-on is an important payment to provide rural home health agencies the resources they need to provide quality care. Technology – We support the following measures to advance the application of technology in the long-term services and supports field:

• S. 870 – CHRONIC Care Act: Bipartisan legislation which is ready for floor votes in Senate. Among its provisions to improve Medicare coverage of services people living with chronic health conditions need, the CHRONIC Care Act would authorize payment for telehealth for accountable care organizations and includes “home” in the definition of “originating site.”

• S.1016 - CONNECT for Health Act of 2017: A bipartisan bill to allow Medicare reimbursement for telehealth in a variety of settings and for a variety of conditions, including accountable care organizations and bundled health payments.

• S.787 - Telehealth Innovation and Improvement Act of 2017: Bipartisan legislation allowing CMS to test the use of telehealth and other technologies in improving care for Medicare beneficiaries with certain defined conditions in conjunction with existing evaluations of accountable care organizations, bundled payment models and coordinated care models.

Other News Disaster Relief – LeadingAge Appeal To mitigate the impact of destruction that Hurricanes Harvey, Irma and Maria caused, as well as the devastating California fires, LeadingAge established a Disaster Relief Fund. The LeadingAge community rallied to support their peers and has raised $ $557,064.47 from 1,038 donors as of November 15, 2017. We are incredibly grateful for this outpouring of generosity from our LeadingAge family. 100% of all donations will go directly to members and their staff to cover a range of needs including basics supplies such as food and water. Although our members in the states of Texas and Florida have begun to reach normalcy, we have several members in Puerto Rico and California that are in need of assistance. We are working with the management of these communities to help serve resident and staff needs. 2030 Scenario Planning for Aging Services In an uncertain political and regulatory environment with multiple forces impacting aging services, it is imperative that we help our provider members take the initiative to plan for possible futures. While none of us have a crystal ball, we have a sense of the forces that will impact us and, as a result, we can imagine possible scenarios for the future. We have engaged the Institute for Alternative Futures to help us with 2030 Scenario Planning for Aging Services. We will be working together over the next six months and, at the end of this process, we hope to have a set of free, proactive tools. These will be designed to be used by members to guide their boards through generative discussions around these scenarios with an eye to planning for the future. Stay tuned for more information to come! Center for Workforce Solutions LeadingAge’s Center for Workforce Solutions is thrilled to announce a brand-new podcast, LeadingAge Workforce Innovators. During each episode, we interview extraordinary LeadingAge members who share their promising practices. We also strive to explain how those solutions might be replicable for your organization’s workforce. The 1st episode is now available for free, along with several other mini-interviews. Subscribe to LeadingAge Workforce Innovators now wherever you get your podcasts (e.g., Apple, Google, etc.). CAST Updates Medication Management Selection Tools LeadingAge and CAST announced an updated Medication Management Selection Tool and a new case study, released new data on EHR sophistication among LZ-150 participants and shared the news that nursing homes can now benefit from Rural Health Care Program subsidies, thanks to LeadingAge and CAST member advocacy. Perspectives on electronic health record (EHR) and IT spending, CAST member news and patients’ openness to telehealth round out CAST’s recent message.

Goals, Strategies, and Tactics to Achieve GoalsTask Owner Contributors Due Date Status Notes

~ Deliver education on managed care and payment changes at Spring and Fall Conferences Amy Shannon; Matt

Spring/Fall Annually

Complete Spring 2017; completed fall 2017

~ Create board-focused presentation on environmental, quality and payment changes Shannon Matt, Liz Annually

Completed environmental scan update Sept 2017

~ Offer the Emerge Leadership Program Annually Amy Shannon January 2017 class complete; marketing for 2018

~ Ensure that Workforce is a emphasis at the Fall Conferences Amy Shannon

Fall 2017, Fall 2018, Fall 2019 complete fall 2017

~ Collaborate with the community colleges to develop training for competency-based staffing. Liz Amy; Matt 2018

~Develop training for effective staff training programs Liz Amy 2019

~ Develop training on emergency preparedness Amy Liz Jun-17 Held 6/28/17~ Develop training on infecton control program Amy Liz Jun-17 Held 6/28/17~ Develop training on new survey process Liz Amy Oct-17 Plannded for 10/20/17

~QAPI Program Liz Amy

March 2017; Nov. 2017

Complete for March 2017; Complete for Nov 2017

~ Care Planning at Nurse Leadership Amy Liz Nov-17 Complete Nov 2017~ Facility Based Assessment Liz Amy Aug-17 Held 8/30/2017~ Develop compliance & ethics training Liz Amy Held 7/25/2017

Tactic: Support clinical best practices, regulatory compliance, and continuous quality improvement

LeadingAge Iowa Strategic Plan Action Plan 2017-2019

Goal: Provide learning opportunities to equip members for the futureTactic: Assist members in developing their future

Tactic: Support a Qualified & Competent Workforce

Goals, Strategies, and Tactics to Achieve GoalsTask Owner Contributors Due Date Status Notes

LeadingAge Iowa Strategic Plan Action Plan 2017-2019

~Develop sessions related to the Impact Act Liz AmyOffered at Spring Conference 2017

~ Develop training for Section N & P changes of the MDS Amy Liz Oct-17 Webinar held Sept 2017

~ HCBS Rules Setting Matt Amy Spring 2018 Effective date delayed

~Develop 1-day networking program for adult day Amy Shannon 2018Plans underway for April 2018

~Launch Iowa Aging Services Network Shannon Mar-17 45 sites joined initially

~ Support Iowa Aging Services Network through engagement on committees and boards Shannon Liz, Matt ongoing

First committee meetings in April; data collection training started in July; first contract signed October 2017

~ Create workforce best practices and HR support section on website Matt Dawn Nov-17

Research complete, programming & launch remain

~Market MDS scrubber and quality improvement tool to members (Quality APEX) Shannon Dawn

Starting June 2017

Launch delayed until November 1; materials on website, brochures included in dues renewal packet

~ Market & increase nurse consulting services to members Liz Dawn, Sherry Ongoing

Consulting services trending way ahead at mid-year point

Goal: Grow members through meaningful resources & support

Tactic: Provide business intelligence, quality, and operating support and tools to help members thrive.

Goals, Strategies, and Tactics to Achieve GoalsTask Owner Contributors Due Date Status Notes

LeadingAge Iowa Strategic Plan Action Plan 2017-2019

~Gather research on environmental changes and trends related to consumers and workforce, etc. and distribute to members in pictograph enhanced document. Shannon Matt, Dawn 2/year

Workforce infographic complete; distribution strategy as part of press release during session and workforce website

~ Update radar screen for HCBS and NH providers on semi-annual basis. Shannon Matt 2/year Completed June 2017

~Enhance Medicaid cost tool with push reports Shannon 2017

Targeting fall after release of compilation in Sept.; NY had data & under development

~Develop networking call schedule for adult day Matt Shannon, Amy 2017Call schedule set for 2017; Held 7/18, 10/17,

~ Conduct membership visits with members at least once every 2 years Shannon Liz, Matt, Amy

Semi-Annual underway

~ Offer quarterly networking meetings Shannon Liz, Matt, Amy 4/year

March at Immanuel Pathways; July at Simpson Memorial Home

~ Develop opportunities for Emerge fellows and alumni to network Amy Dawn, Shannon 2/year

Downtown Night Out on 5/3/17

~Develop quarterly newsletter with most vital news Dawn Liz, Matt, Shannon 4/yearFirst edition distributed in June 2017

~ Redesign website to be more customer-friendly Dawn Liz, Matt, Shannon Dec-17

~Refresh membership recruitment strategy Shannon Team Sep-17 Board discussion in Sept

Tactic: Serve as a connector for members through excellent customer service & networking opportunities

Tactic: Ensure stable future for association through membership growth, retention and services

Goals, Strategies, and Tactics to Achieve GoalsTask Owner Contributors Due Date Status Notes

LeadingAge Iowa Strategic Plan Action Plan 2017-2019

~Implement membership recruitment strategy Shannon Team Ongoing

Implementing pieces of board recommendations including teaser

~Develop membership retention strategy Shannon Team Sep-17~Implement membership retention strategy Shannon Team Ongoing

~Enhance shared services program Shannon 2017

Underway with concept complete but working through details to launch

~Re-market shared services program Shannon Dawn 2017Material development underway

~Merge Adult Day Services Association into LAI Shannon Team 2017 Merger vote on 5/3/17

~Implement marketing strategy for adult day programs Shannon Dawn, Matt 2017

Benefits piece drafted; several contacts made in 2017

~ Advocate for regulatory relief on RoPs Shannon 2017

Met with Congressional delegation in March. LA met with CMS in April; letters sent to Congress as part of red tape relief August 2017

~ Advocate for a fair and balanced survey and certification system Shannon Liz, Matt 2017, 2018

Met with DIA in March; meeting with CMS RO in December 2017

~ Protect Medicaid reimbursement and ensure MCO oversight Matt ongoing

Secured $2.5M in rebase funding

Tactic: Advocate for a fair regulatory and reimbursement environment

Goal: Advance the nonprofit mission of members

Goals, Strategies, and Tactics to Achieve GoalsTask Owner Contributors Due Date Status Notes

LeadingAge Iowa Strategic Plan Action Plan 2017-2019

~ Advocate for LTSS payment reform Matt Shannon 2017-2019

Included within top recommendations at LTSS/dementia taskforce in Nov 2017

~ Pass legislation to permit CNA online training Matt

Passed April 2017; Working on Administrative Rules in July/August 2017

~ Host summit for thought leadership on future of aging services with emphasis on workforce/payment/other gaps in need of work Shannon Matt, Amy, Liz, Dawn 2018

Planning underway for May 2018

~ Increase awareness & develop urgency through social media PR and toolkit for members Matt Dawn, Shannon

2017 and ongoing

Research complete, launch strategy needs to be developed and implemented

~ Develop public policy proposals and partnerships related to workforce Matt ongoing

~Market the Iowa Aging Services Network Shannon ongoing~Collaborate with the MCOs related to VBP and settings payment policy Matt Shannon 2018~Assist members with MCO support Matt ongoing

~Educate on IGT program if approved Matt Amy 2018

As of Nov 2017, approval seems unlikely as Oklahoma was denied.

Tactic: Advance public policy strategies to supprt workforce development and solutions

Tactic: Help members successfully navigate regulatory and reimbursement changes

[2018] SAVE THE DATE

January11 Social Media in the Long Term Care Setting Webinar

17 Maintaining Occupancy and Census Through Digital Marketing Webinar

31 Infection Control/Antibiotic Stewardship F880, F881 Webinar

February7-8 Emerge Leadership Academy Summit 1

28 Food Safety F812 & F813 Webinar March28 Quality Workshop Location: Aurora Training Center, Urbandale

28 Accidents/Bed Rails F689 & F700 Webinar

April3-5 DON Bootcamp: Success for Today’s Environment Location: Copper Creek Events Center, Pleasant Hill

10-11 Emerge Leadership Academy Summit 2

12 Assisted Living Nurse Delegation Location: Aurora Training Center, Urbandale

12 & 26 Assisted Living Leadership Certification Locations: 4/12 Aurora Training Center, Urbandale 4/26 Bishop Drumm Care Center, Johnston

19 Adult Day Conference Location: Aurora Training Center, Urbandale

25 Quality of Life/Quality of Care F675, 684, 697, 698, 744 Webinar

May2-3 LAI Spring Conference & Solutions Expo Location: The Meadows Conference Center, Altoona

30 Pharmacy Services F755, F761 Webinar

June5-6 Emerge Leadership Academy Summit 3

27 Comprehensive Care Plans F656 Webinar

July17-18 Emerge Leadership Academy Summit 4

25 Unnecessary Drugs F757-758 Webinar

August28-29 LAI Fall Leadership Conference & Solutions Expo Location: DoubleTree By Hilton Hotel Cedar Rapids Convention Complex

29 Resident Records F842 Webinar

September26 Resident Assessments/Accuracy of Assessments F641 Webinar

27-29 National Adult Day Services Association Conference Location: Baltimore, MD

October3 Assisted Living Nurse Delegation Location: Aurora Training Center, Urbandale

3 & 24 Assisted Living Leadership Certification Locations: 10/3 Aurora Training Center, Urbandale 10/24 Bishop Drumm Care Center, Johnston

9-11 Dementia Train-the-Trainer Location: Aurora Training Center, Urbandale

16-19 Resident Assessment Coordinator - Certified RACT-CT Workshop Location: Aurora Training Center, Urbandale

28-31 LeadingAge Annual Meeting & Expo Location: Philadelphia, PA

31 Dignity and Respect of Individuality F550 Webinar

November8 Nurse Leadership Symposium & Social Worker Conference Location: TBD

28 Treatment/Services to Prevent/Heal Pressure Ulcers F686 Webinar December13 DON 101: The Basics Location: Aurora Training Center, Urbandale

19 Services Meet Professional Standards F658 Webinar

More 2018 content to be added.Go to www.LeadingAgeIowa.org/Calendar for more details.

CONFLICT OF INTEREST

ACKNOWLEDGEMENT/DISCLOSURE FORM

1. CONFLICTING ORGANIZATIONS I am a director, trustee, officer, representative of, or have a financial or beneficial interest in the following organizations that have or may have a conflict with the interests of the Corporation:

Organization and Title or Interest:

2. CONFLICTING ACTIVITIES/OBLIGATIONS

I am involved in no activity or transaction, nor am I a party to any contract involving interests that are or could be found to be adverse to the Corporation, except for the following:

3. CONFLICTING BUSINESS OPPORTUNITIES/COMMITMENTS I have not committed to, nor am I pursuing, any business opportunity that does or might adversely affect the Corporation, except for the following:

4. OTHER POTENTIAL CONFLICTS Any other concerns I may have regarding actual or potential conflicts of interest are listed below:

I have received and reviewed LeadingAge Iowa’s Conflict of Interest Policy, and to the best of my knowledge, I have accurately answered the above questions.

__________________________________________ _________________________

Signature Date

__________________________________________

Please print name

RevenueDues $321,427 $364,165 $345,134 -5%

Non-Dues $504,083 $514,945 $586,333 14%Investment $23,429 $4,583 $42,248 822% $0

Total $848,939 $883,693 $973,715 10%Expenses

Personnel $491,316 $524,290 $510,578 -3%Other $277,864 $346,666 $340,150 -2%Total $769,180 $870,956 $850,728 -2%

NET INCOME $79,759 $12,737 $122,987 866%

Total Assets $922,528 $972,769 $1,062,353 9%Total Liabilities $139,226 $187,564 $192,624 3%Net Assets $783,302 $785,205 $869,729 11%

Membership 2015 Gain 2015 Loss2015

Retention Rate

2016 Gain2016 Loss

2016 Retention

Rate2017 Gain 2017 Loss

2017 Retention

RateType

Provider 9 3 97% 9 3 97% 8 2 98%Adult Day 0 0 100% 2 0 100% 3 0 100%

Associate (Business) 11 15 75% 19 10 86% 15 8 91%Subscriber (For-Profit) 0 0 0 0 0 0 0 0 n/a

New Members: Reason for loss:

Member Engagement

2015 2016 2017 YTD

Professional DevelopmentLives Touched 1611 1171 1727

% of Members Participated 79% 79% 73%Nurse Consulting

Members Served 10 17 10Group Purchasing (10/31/17)

Dollars Generated $134,300 $139,191 $113,808% Members Participating 62% 60% 54%

Member Visits% of campuses visited 56% 51% 28%

Unresponsive (Rotary Senior Living); Financial (Franklin General Hospital)

Luther Park Community, Tripoli Nursing & Rehab, Sanford Sr Care Sheldon, Crossroads of Western IA, North Star Community Services-Newel Post, Fellowship Village, Whispering Heights, Mercy Living Center South, Sioux Center Health, Goodwill of the Great Plains, Bethany Home

2017 LeadingAge Iowa Dashboard

November 27, 2017

Balance Sheet (October 31, 2017)

2017 YTD2016 YTD2016-17 %

Change2015 YTD

Profit and Loss (October 31, 2017)

2017YTD Budget

2017YTD Actual

Variance2016

YTD Actual

36%

60%

4%

Dues

Non-Dues

Investment

Revenue Mix YTD

MEMORANDUM

Date: November 27, 2017

To: LAI Board of Directors

From: LAI Health Insurance Task Force

Subject: Health Insurance Shared Risk Program Recommendation

Board Action Requested: The Health Insurance Task Force met on November 7 and recommends that the board authorize LAI to continue working with the task force to pursue a Health Insurance Risk Pooling program, similar to the Iowa Hospital Association program, in partnership with LMC with a goal effective date of January 1, 2019. Background During the annual meeting of the IASN Network in May, a member raised whether the concept of “stronger together” could be applied to health insurance. Many members agreed that they would have interest in exploring potential options so a Task Force meeting was held on November 7. Eighteen people representing 13 different organizations attended the meeting. Two potential partners, LMC and Lee Agency, were invited into the meeting to present on the options that LAI had to support members through pooled risk. Both agencies had equal opportunity and time to present to the task force. Following the presentations, the task force considered whether the association should further pursue an shared risk pool option for members and who the association should partner with to develop such plan. The task force overwhelmingly recommended that the association move forward in pursuit of a shared risk pool for members with a goal of implementation for January 1, 2019. Before selecting a recommended partner, the committee identified the criteria most important in selecting a partner in this space including: speed of implementation, experience implementing a model, outcomes of savings and quality, access to care, stability and sustainability of the program, ease of implementation, and industry knowledge. After listing the criteria, the committee evaluated each partner. LMC had the advantage over Lee Agency in every category except industry knowledge. Members of the task force were split on who had the most senior living industry knowledge. As a result, the task force recommends that LAI partner with LMC on this program which will cover not only health insurance but also ancillary benefits as well.

4836-1669-1029\1

MEMORANDUM

TO: Shannon Strickler

FROM: Edwin N. McIntosh and Benjamin Fee

DATE: November 17, 2017

RE: MOU

We have reviewed the form MOU from Wisconsin LeadingAge. We have included an updated version with some minor revisions for your consideration if Iowa LeadingAge decides to make the form available to its members. A few notes about the MOU:

• As discussed in more detail below, the CMS emergency preparedness rules and interpretive guidance do not address specifically what needs to be included in the written agreement, instead only generally requiring that a written agreement be in place with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. The form MOU meets this requirement.

• The Wisconsin MOU is understandably short on firm obligations, instead obligating the receiving facility to be reasonably available and to extend reasonable efforts during emergency situations.

• Also, please note that the form uses a structure in which facilities essentially opt-in to the system. By indicating that it is willing to participate, a facility would be listed as a participating facility in a spreadsheet that would then be attached to every MOU used by the other participating facilities. This model has the benefit of allowing a facility to access multiple other facilities, but not requiring that it enter into multiple MOUs. It does, however, require some ongoing coordination by LeadingAge Iowa (tracking the facilities that have opted-in or that subsequently opt-out and distributing an updated Appendix A as necessary). Alternatively, we could revise the MOU to only be between two specific facilities and you could distribute the template to your members.

• Billing and compensation also generally defers to the “usual and customary channels…” Presumably this means the receiving facility would bill for services the same way it does for its other patients/residents. Although, the requesting facility is required to reimburse the receiving facility for “reasonable additional expenses incurred by Provider during the use of its premises in keeping with a common cost for those added expenses.”

• Also, the MOU simply states that “the Provider may discharge a resident in accordance with its standard procedures.” That is likely fine from a contract

2 4836-1669-1029\1

language perspective, but from a practical perspective, facilities should be aware that once they accept a resident, the Iowa rules for discharge and transfer will apply, and depending on the emergency that caused the transfer, the original requesting facility may never reopen. Plus, even if the facility does reopen, that would not be grounds to discharge a transferred resident under the DIA rules.

Below is some additional background on the applicable rule.

The specific requirement related to coordination with other facilities is located at 42 c.f.r. 483.73(b)(7). The regulation does not provide any detail about what is required, only that facilities need to have arrangements with other LTC facilities and providers to receive residents in the event of limitations or cessation of operations to maintain the continuity of services to LTC patients. The full text is included below.

The interpretive guidance is similarly vague on what needs to be included in the arrangements, clarifying only that the arrangements should be in writing, such as an MOU or transfer agreement, in order to demonstrate compliance with the rule.

Interestingly, the email from Leading Age Wisconsin included that the facility needs to have such an agreement in place with at least one facility that is 50 miles away. This requirement appears to come from an old CMS emergency preparedness checklist. If you use the opt-in approach that is included in the current MOU, any facility that opts-in would meet this requirement.

Applicable Language from the Regulation

483.73. The LTC facility must comply with all applicable Federal, State and local emergency preparedness requirements. The LTC facility must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(b) Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. At a minimum, the policies and procedures must address the following:

(7) The development of arrangements with other LTC facilities and other providers to receive residents in the event of limitations or cessation of operations to maintain the continuity of services to LTC residents.

Language from Interpretive Guidance

Facilities are required to have policies and procedures which include prearranged transfer agreements, which may include written agreements or contracted arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

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Facilities should consider all needed arrangements for the transfer of patients during an evacuation. For example, if a CAH is required to evacuate, policies and procedures should address what facilities are nearby and outside the area of disaster which could accept the CAH’s patients. Additionally, the policies and procedures and facility agreements should include pre-arranged agreements for transportation between the facilities. The arrangements should be in writing, such as Memorandums of Understanding (MOUs) and Transfer Agreements, in order to demonstrate compliance.

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LeadingAge Iowa Facilitated Memorandum of Understanding for

Temporary Shelter with a Like Facility

This Memorandum of Understanding (MOU) is entered into by (enter the name of your skilled nursing facility or assisted living community – hereinafter referred to as “Requester”):_______________________________________________ and those skilled nursing facilities/assisted living communities (“facilities”) who have agreed to serve as a receiving facility (listed in Appendix A and hereinafter referred to as “Provider”) to set forth reasonable guidelines under which each organization will transfer or accept residents or patients ("residents") in the event of a partial or total facility evacuation due to an emergency situation. The Requestor and Provider acknowledge this Memorandum of Understanding represents a good faith effort to address emergency situations, and that those situations requiring facility evacuations likely will be directed by a county or regional emergency preparedness coordinator. Agreement

1. Requester is responsible for informing the appropriate governing state agency about the disaster and the status of affected residents including the name of Provider(s) who will be serving evacuated residents.

2. Provider agrees to be reasonably available to the Requester and to extend

reasonable efforts during emergency situations to implement this understanding 24 hours/day, 7 days per week.

3. In the event Requester must evacuate residents, they will notify Provider

that service is needed by calling the day-time or after-hours telephone numbers listed in Appendix A. Requester and Provider will each designate a contact person at the time a request is made for the purposes of coordinating transfers and communication.

4. Length of understanding. The Requestor and Provider to this understanding

pledge to make a good faith effort to meet the needs of the residents. Further,

a. Provider agrees to provide services under this understanding and to accept residents subject to its capacity and capabilities for a mutually agreed upon period of time established at the time a request is made.

b. If the period of time has been reached and additional time is

needed, the parties will renegotiate the understanding.

c. The services of the Provider will be necessary only until it has been

2

deemed safe for the residents to return to Requester’s facility or residents have been placed in an alternative setting.

d. Provider is responsible for the care of residents while they are on the Provider’s premises.

e. The Provider may discharge or transfer a resident in accordance with its

standard procedures and applicable state law. As a courtesy and in accordance with applicable rules governing confidentiality of information, the receiving facility will notify the transferring facility of any discharges if the transfer occurs before the end of the emergency period.

f. Requester agrees to readmit residents that were transferred when

necessary services have been restored.

5. Requester will make a good faith effort to contact the resident’s family or responsible party (“family”) prior to transfer. Information provided to the family will include the reason for transfer, location and contact information of the Provider and, if available, condition of the resident. Provider is responsible for contacting the family or responsible party once residents have been transferred.

6. Transportation

a. Requester is responsible for arranging for the transport of residents to the Provider.

b. The parties agree to work together to arrange for the transport of

residents back to Requester when it has been deemed safe for resident to return.

c. Requester or other parties, but not the Provider, are responsible for the

cost of any transportation associated with transfers to and from Provider.

7. Requester and Provider generally agree to the following scope of services:

a. Provider: Depending on the needs of the residents being transferred, Provider will make reasonable efforts to supply sufficient space and services within its capacity to accommodate the agreed upon number of residents including beds and linens, utilities (heat, air conditioning, electricity, water, sanitary facilities, etc.), food, routine nursing and medical supplies, oxygen, and other supplies and services as deemed necessary.

b. Requester: As feasible and based on the circumstances of the disaster,

3

Requester will provide resident medical records, medications, mobility devices, other personal devices (hearing aids, eyewear, weighted blanket, etc.), essential clothing, food, linens, routine nursing and medical supplies, and other items as necessary and practicable.

c. By mutual agreement and in accordance with applicable rules and

requirements, employees of the Requester may be utilized by the Provider when practicable.

8. Compensation for the care of transferred residents will be made through the usual and customary channels for those under the care of the Provider. Requester agrees to reimburse Provider for reasonable additional expenses incurred by Provider during the use of its premises in keeping with a common cost for those added expenses. The Requestor and Provider support the efforts of governmental emergency relief programs to provide reimbursement for these extraordinary expenses.

9. Provider agrees to maintain premises’ liability insurance. 10. Provider and Requester agree to indemnify and hold each other harmless for all

claims and damages for all negligent acts or omissions arising out of or as a result of the performance of this understanding.

Term and Termination The term of this understanding will commence on November 15, 2017 and will continue in full force and effect, unless Provider withdraws from this understanding. Provider may elect to terminate their participation in this understanding by providing thirty (30) days written notice to LeadingAge Iowa, 11001 Aurora Avenue, Urbandale, Iowa, 50322. Upon receiving notice of termination, LeadingAge Iowa will publish a revised Appendix A and distribute said appendix via email to the participating facilities. The revised appendix will take effect upon distribution to participating facilities.

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APPENDIX A

Helping Members with EP “Like” Facility MOUs

The Center for Medicare and Medicaid Services (CMS) Emergency

Preparedness Requirements for Medicare and Medicaid Participating

Providers and Suppliers requires that health care providers establish

multiple, pre-determined evacuation locations with “like” facilities that have

suitable space, utilities, security, and sanitary facilities for individuals

receiving care, with at least one facility being 50 miles away.

LeadingAge Wisconsin wants to help member skilled nursing facilities and

assisted living communities ("facilities") meet this requirement*. First,

through a survey we will identify members who are willing to enter into a

memorandum of understanding (MOU) with fellow providers as a “like”

facility evacuation center. Facilities that complete the survey will receive an

Excel spreadsheet listing providers that responded to the survey. Click on

the following link to complete the survey:

www.surveymonkey.com/r/EmerPrepSurvey.

Second, we have developed a MOU, based on the Wisconsin Department of

Health Services (DHS) sample, which organizations can print and include in

their Emergency Preparedness plan. The spreadsheet, sorted by county (to

meet the 50+ mile requirement) and provider type, would be attached as an

appendix to the MOU so that providers would not need to create separate

MOUs with multiple “like” facilities. Facilities completing the survey are

agreeing to serve as a receiving facility under the terms of the MOU. Click

here to review the MOU.

SNFs interested in participating in this project should complete

the survey by Friday, November 10, 2017.

Please direct questions about this project to Jim Williams, Director of

Member Enrichment (JWilliams@LeadingAgeWI.org) at 608-255-7060.

*Although the CMS Emergency Preparedness rule does not require assisted

living communities (ALCs) to have "like" facility pre-determined evacuation

locations, LeadingAge Wisconsin is including ALCs in this project for those

providers who wish to establish MOUs for temporary shelter.

Emerge Leadership AcademyGrowing leaders, empowering positive change

3010-18

2018

Program Description

The Emerge Leadership Academy is designed for new and aspiring Iowa Aging Service Leaders to take their abilities to their own next level. This highly interactive eight-month program blends classroom learning with dynamic experiences including networking, learners learning from learners, visiting some of the most exciting programs in the state and accountability for applied learning. Four two-day summits include community visits throughout Iowa that make a difference in a variety of ways for older adults. Experienced leaders will share their knowledge and participants share insights to build each cohort of leaders stronger to make a difference for older Iowans.

Fellows will see a variety of approaches to serving clients while focusing on developing their leadership style. Each summit includes site visits, content delivered in a variety of learning styles, collaborative conversations, exposure to external forces impacting the profession and cutting-edge leadership theories. During the time between summits, participants will keep in touch by sharing application and learning where it counts the most - in their everyday work. Assigned reading and discussion strengthens knowledge for individuals. This multi-layered approach is designed to integrate theory into practice for leaders.

Emerge Faculty will also communicate with leaders of the sponsoring organizations to ensure they are aware of the Academy activities and progress.

2018 Emerge Leadership Academy

Faculty

Faculty leaders are from BluOpal Consulting, LLC. BluOpal guides organizations to achieve results by awakening the power in people. Feel free to check them out at www.bluopal.com/our-team. BluOpal leaders come from diverse backgrounds, yet have been making health care and senior care leaders better for more than 15 years. The program will also incorporate coaching for the fellows by Iowa alumni of the LeadingAge Leadership Academy.

Vision: Will be the trusted leader and resource for excellence in aging services.

Mission: Expanding the world of possibilities for aging through advocacy, education, and collaboration.

Values: Integrity ~ Leadership ~ Compassion.

Emerge Leadership Academy incorporates these essential building blocks into the program as all leaders need a “North Star” to guide and align the journey. Fellows actively utilize Mission, Vision & Values to approach their leadership and make a difference.

Summit 1 Leading Self

February 7-8

Focusing first on leading self, individuals explore their own point of view and their unique point of view in leadership. The program explores personal strengths, emotional intelligence and self-awareness to help participants gain insight into their leadership approaches.

Summit 2Leading Others

April 10-11

Leading other people, those we work with, as well as residents and clients distinguishes a leader’s character. This workshop focuses on people-dynamics, service excellence and how to move through conflict with cognizance and best outcomes in mind, from the other person’s point of view.

Summit 3Leading without Title

June 5-6

While leadership is often about influencing others, many situations require people step up without assigned roles and structure. This summit looks at systems awareness and reading environments to discover best approaches to affect change in effective ways.

Summit 4Leading Everywhere

July 17-18

Strong leaders show their passion and make a difference through their presence in many ways. This final meeting ties learning of all the summits together so participants grow in innovative thinking and lead the way. Individuals consider what strategic partnerships might be built to lead powerfully into the future of senior care.

Leadership Components

The Emerge Leadership Academy is open to LeadingAge Iowa members. The tuition is $2,500 per participant.

Register at www.LeadingAgeIowa.org/Emerge.

Tuition fees include:

• Four 2-day summits. Site visits showcasing visionary leadership and innovation both within and outside the

aging services field.

• Registration at the LAI Spring Conference on May 2-3, 2018, at the Meadows Conference Center in Altoona.

• Registration at the LAI Fall Leadership Conference on August 28-29, 2018, at the DoubleTree by Hilton Hotel

in Cedar Rapids Convention Complex. EMERGE graduates will present their project at this conference. A

networking event targeted for EMERGE current and past graduates is scheduled as well as the EMERGE

graduation ceremony.

• Refreshment breaks and lunches at each of the onsite programs, as well as dinner with coaches, faculty,

and class on the first night of each summit.

• Small group coaching sessions throughout Academy experience.

Cancellation and Refund PolicyThe registration deadline is January 5, 2018. No-shows will be billed. Substitutions welcome prior to the first summit. A full refund will be given to all cancellations received 10 or more business days prior to the first meeting date. A $125 administrative fee will be charged to all cancellations received six to nine business days prior to the first meeting date. No refunds will be given to cancellations received five or fewer business days prior to the first meeting date. Refunds will be calculated by the date received and the LeadingAge Iowa business days remaining prior to the first meeting date. LeadingAge Iowa reserves the right to cancel the program due to insufficient enrollment, in which case pre-registered participants will be notified and full refunds provided. All cancellations and substitution requests must be sent by email to Amy Huisman (ahuisman@leadingageiowa.org).

Applicant Commitment

• Attend and actively participate in each of the four summits – no exceptions and the LAI Spring

and Fall conferences.

• Complete assignments to enhance the understanding and application of the content areas.

• Actively participate in the online communication and monthly conference calls with your team and assigned coach.

• Complete a project that benefits your sponsoring organization and the field and feature a project poster at the fall conference tradeshow exhibit hall.

• Remain employed with a LeadingAge Iowa member for the duration of the program.

Sponsor Commitment

• Provide tuition in full and cover any other travel, meals, and lodging costs associated with the program for all four summit sessions.

• Allow adequate time for the completion of assignments that will enhance the understanding and application of the content area of each session.

• Allow time for the Fellow to attend all four course sessions, participate in conference calls with his or her coach, and actively participate in distance learning activities. It is necessary to make a firm commitment to allow the Fellow to attend all four sessions. Inquire about and consider implementation of Fellow’s learning project.

Questions

Please contact Amy Huisman with any questions

ahuisman@leadingageiowa.org

515-440-4630

Emerge Leadership Academy

Growing leaders, empowering positive change

Continuing Education

Nursing Home Administrators: This program is intended to meet the criteria established by the Iowa Board of Examiners for Nursing Home Administrators. If audited, you will be asked to provide your certificate of attendance and program material. Retain certificate for four years.

Social Workers: This program is intended to meet the criteria established by the Iowa Board of Social Work Examiners. If audited, you will be asked to provide your certificate of attendance and program material. Retain certificate for four years.

Iowa Board of Nursing Provider #67: Portions of Summits 2, 3, and 4 are intended to meet the criteria established by the Iowa Board of Nursing. Retain certificate for four years.

For other long term support and service provider professional not listed above: Most licensure boards, credentialing agencies and professional organizations have processes that allow individuals to earn a certain number of CEUs for non-preapproved programs and/or to accommodate self-submission for approval of continuing education hours after the event takes place with proper documentation from the program sponsors. Most also require information objectives, date/time of presentation, agendas, faculty bios and number of hours earned. If you require information for this purpose, please contact Amy Huisman in advance for assistance.

LeadingAge Iowa11001 Aurora AveUrbandale, IA 50322515-440-4630www.LeadingAgeIowa.org

MEMORANDUM

Date: November 27, 2017

To: LAI Board of Directors

From: LAI Health Insurance Task Force

Subject: Health Insurance Shared Risk Program Recommendation

Board Action Requested: The Health Insurance Task Force met on November 7 and recommends that the board authorize LAI to continue working with the task force to pursue a Health Insurance Risk Pooling program, similar to the Iowa Hospital Association program, in partnership with LMC with a goal effective date of January 1, 2019. Background During the annual meeting of the IASN Network in May, a member raised whether the concept of “stronger together” could be applied to health insurance. Many members agreed that they would have interest in exploring potential options so a Task Force meeting was held on November 7. Eighteen people representing 13 different organizations attended the meeting. Two potential partners, LMC and Lee Agency, were invited into the meeting to present on the options that LAI had to support members through pooled risk. Both agencies had equal opportunity and time to present to the task force. Following the presentations, the task force considered whether the association should further pursue an shared risk pool option for members and who the association should partner with to develop such plan. The task force overwhelmingly recommended that the association move forward in pursuit of a shared risk pool for members with a goal of implementation for January 1, 2019. Before selecting a recommended partner, the committee identified the criteria most important in selecting a partner in this space including: speed of implementation, experience implementing a model, outcomes of savings and quality, access to care, stability and sustainability of the program, ease of implementation, and industry knowledge. After listing the criteria, the committee evaluated each partner. LMC had the advantage over Lee Agency in every category except industry knowledge. Members of the task force were split on who had the most senior living industry knowledge. As a result, the task force recommends that LAI partner with LMC on this program which will cover not only health insurance but also ancillary benefits as well.

LeadingAge Iowa Benefits Program Proposed Timeline & Process

Thank you for choosing LMC as your partner to develop a unique benefits program.

We have extensive experience and success with programs that leverage strength in

numbers, and we look forward to working with LAI to build and customize your own

program.

To meet LAI’s goal to implement the program by January 2019, we would recommend

the project commence in January 2018. The major project milestones include:

I. Data Gathering

a. Census, claims experience, plan documents

II. Program Design/Carrier Selection

a. Fully Insured and Self-Funded

b. Join the Wellmark IHA Trust Program

c. Create LAI Program

i. Wellmark

ii. Health Partners

iii. United Healthcare

III. Finalize decisions and rates by July 31, 2018 for program roll-out

In order to efficiently collect and share data necessary for this project, LMC is

requesting to become your agent of record effective February 1, 2018. This will allow

us to compile the data needed to conduct detailed RFPs and offset fees associated

with this process, including actuarial analysis from Milliman. LMC will fully service your

current plans until a decision is made on the proposed program. There will be no

change in fees or premium during that time. At the conclusion of the project, if it is

determined this is not a feasible program, LMC will work with carriers for a smooth

transition back to the prior broker as requested.

We look forward to a successful and long-term partnership!

LeadingAge Iowa Statement of Activities

For the Ten Months Ending Tuesday, October 31, 2017

ACTUAL BUDGET VARIANCE ACTUAL BUDGET VARIANCE 2016 2016 ANNUALOctober October YTD YTD YTD BUDGET

Member Dues $31,270 $33,300 ($2,030) $312,698 $332,998 ($20,300) $290,869 $347,083 $399,597Associate Member Dues 3,032 3,117 (85) 32,436 31,167 1,269 30,558 38,300 37,400Sponsorships 4,583 4,375 208 45,833 43,750 2,083 41,667 50,000 52,500Professional Development 42,145 32,630 9,515 397,227 327,395 69,832 322,544 350,354 341,130Nurse Consulting Income 1,574 2,250 (676) 27,186 22,500 4,686 21,686 27,516 27,000Publications/Advertising 865 1,300 (435) 1,300 1,300 1,300Revenue Sharing-GPO 11,419 11,833 (414) 113,808 118,333 (4,525) 116,381 139,191 142,000Investment Income (1,502) 458 (1,960) 42,248 4,583 37,665 23,429 26,010 5,500Other Income 200 167 33 1,414 1,667 (253) 505 535 2,000

Total Revenue 92,721 88,130 4,591 973,715 883,693 90,022 848,939 980,289 1,008,427

Staff Salaries & Benefits 49,475 52,357 2,882 510,578 524,290 13,712 491,316 605,987 637,526Professional Development 10,587 15,981 5,394 175,532 177,590 2,058 130,806 143,819 184,436Member Resource Tools 8,000 8,000 8,000 9,800 10,000Legislative Day & Special Events 600 600 418 418 600Board & Committee 28 333 305 3,281 3,333 52 3,016 3,965 4,000Travel 743 1,853 1,110 11,915 14,486 2,571 12,418 15,142 18,000Legal & Accounting 2,592 2,596 4 31,877 31,858 (19) 30,206 36,300 37,050Consulting 14,000 15,000 1,000 2,500 12,500 15,000Occupancy 5,391 5,633 242 57,938 56,333 (1,605) 53,848 66,157 67,600Office Administration 1,358 1,292 (66) 11,781 12,917 1,136 11,672 14,957 15,500Computers 1,381 1,375 (6) 12,571 13,750 1,179 12,484 15,042 16,500Depreciation 610 615 5 5,873 6,147 274 5,938 7,206 7,376Other Expense 1,934 523 (1,411) 7,382 6,652 (730) 6,558 7,701 8,000

Total Expense 74,099 82,558 8,459 850,728 870,956 20,228 769,180 938,994 1,021,588Net Increase(Decrease) in Assets 18,622 5,572 13,050 122,987 12,737 110,250 79,759 41,295 (13,161)

REVENUE

EXPENSE

DUES PROF DEV OTHER INVESTMENT

Revenue

Actual YTD Budget YTD Prev Year YTD

STAFF PROF DEV PROF FEES OFFICE ADMIN OTHER

Expense

Actual YTD Budget YTD Prev Year YTD

LeadingAge Iowa Statement of Financial Position

October 31, 2017

2017 2016Assets

Cash $123,635 $107,654Short Term Investments 75,813 75,803Long Term Investments 814,494 769,674Accounts Receivable 25,253 (5,614)Prepaid Expense 14,538 15,506Computers & Equip Net of Depreciation 8,620 9,746

Total Assets 1,062,353 972,769

Liabilities & Net WorthAccounts Payable (622) (2,840)Accrued Payroll 44,685 37,124Deferred Income 148,562 153,280

Total Liabilities 192,624 187,564Net Worth 746,741 705,448Current Earnings 122,988 79,757

Total Net Worth and Liabilities 1,062,353 972,769

LeadingAge Iowa Statement of Cash Flows

For the Ten Months Ending Tuesday, October 31, 2017

2017 YTD 2016 YTD

Cash Flow from Operating ActivitiesCash Received from Customers $803,841 $805,033Cash Paid to Vendors (334,262) (275,673)Cash Paid to Staff (513,211) (494,373)

Net Cash Flow from Operating Activities (43,632) 34,988

Cash Flows from Investing ActivitiesInvestment Income Received 42,248 23,429Transfered from (to) investmentsFixed asset purchases (6,016) (2,414)

Net Cash Flows from Investing Activities 36,232 21,014

Net Increase (Decrease) in Cash (7,400) 56,002Cash at Beginning of Period 1,021,342 897,029Cash and Equivalents at End of Period 1,013,942 953,031

MEMORANDUM

Date: November 27, 2017

To: LAI Board of Directors

From: Shannon Strickler

Subject: Capitalization Policy

At the October 23, 2017 Finance Committee meeting, committee members felt that the existing capitalization policy of $500 was outdated and too small. They directed Shannon Strickler to reach out to the accounting partners for a recommendation on a capitalization policy that was modern and met the needs of the organizational size and type. The accounting partner, shared the following capitalization policy:

Capitalization Policy

· Only items with a cost over $1,000.00 are capitalized.

· The item’s useful life must be 3 years or more.

· A Presidential Officer’s signature is required.

· The item is to be used by the association, not items for resale.

Shannon Strickler recommends adoption of the above policy by the board. The majority of capital expenditures of the association relate to technology. The $1,000 threshold ensures that the purchase is substantial but also covers most computer and technology purchases to keep technology updated on a regular basis while keeping the budgetary impact constant across the years. The impact that technology purchases would have on the budget every three years may lend itself to delaying technology needs which is negative for overall business operations. Additionally, the policy is consistent with our accounting partner and thus easily applied in their operations.

Morgan Stanley Smith Barney LLC. Member SIPC.

Matt Meline, CFP®, CRPS® Financial Advisor 801 Grand Avenue, Suite 3800 Des Moines, Iowa 50309

tel 515-283-7060 fax 515-283-7085

10/24/2017 To: LeadingAge Iowa Board of Directors

From: Matt Meline, CFP® Financial Advisor Re: Recommended investment policy change – addition of market neutral allocation Board Action Recommendation: At the October 23, 2017 meeting, the LAI Finance Committee voted to recommend that the LAI board amend the investment policy to add a new category of allocation of market neutral funds, not to exceed 10 percent of the total balance. Background At the August meeting of the Finance committee, I mentioned the longer-term concerns with the fixed income market. We are coming off a long cyclical up market in bonds due to lowering interest rates. That cycle has begun to turn and will make investing in the fixed income markets challenging. Appreciating the diversification and lower volatility benefits of fixed income I am recommending a small reduction of 10% in the fixed income percentage inside the long-term investment account. My recommendation to replace that allocation is a market neutral fund. These types of funds have similar characteristics to bonds, but due to a broader investment mandate have the potential for higher returns. I’ve included a summary report of the specific fund I’m recommending. Because these funds use covered call or option strategies they would fall into the “Derivative Investments” category of the investment policy statement. The policy explains that “the Investment Manager(s) must seek permission from the Board of Directors to include derivative investments in the Fund’s portfolio.” Therefore, I’m seeking permission to create an allocation to a market neutral strategy with a minimum investment threshold of 0% and a maximum threshold of 10% added to our investment policy.

Morgan Stanley Smith Barney LLC. Member SIPC.

www.calamos.com

The Hunt for Return:Potential Solutions for Your Clients in Today’s Fixed Income Environment

The following remarks have been adapted from a webcast given on May 24, 2016.

In an environment characterized by low interest rates and an unattractive risk/reward profile for bonds, many

investors and their financial advisors are seeking out new ways to capitalize on market volatility and produce steady

returns. In this Q&A, the portfolio management team of the Calamos Market Neutral Income Fund, Eli Pars, CFA,

Jason Hill and David O’Donohue, discuss the team’s strategy.

How Do You Find Returns in a Low-Return Environment?

Eli Pars: Today’s zero-LIBOR world creates a lot of challenges for investors. One of these is how to get stable

returns without taking on a ton of risk. Historically, fixed income provided that in portfolios, but these days to get

that out of fixed income requires taking a lot of credit risk, duration risk, or both.

The equity market is no walk in the park today either. The current equity market seems to go through periods of

calm, and we’ve seen that over the last couple of months, as well as the first half of last year. Then we have bursts

of extreme volatility like we saw in August and September of 2015 and January and February of this year. None

of this results in a very calm night’s sleep for anyone, but we think we have some ideas that can help investors

manage through these times.

Calamos Market Neutral Income Fund (CMNIX) is a flagship Calamos fund that goes back to the early 1990s. It has

a long history of consistent performance with only three negative calendar years and only two negative rolling-

three year periods since its inception (Figure 1). In our view, the fund offers a great profile for investors and we

believe the strategies offer attractive opportunities going forward.

NOT FDIC INSURED | NO BANK GUARANTEE | MAY LOSE VALUE

ELI PARS, CFA

CO-CIO, HEAD OF ALTERNATIVE STRATEGIES & CO-HEAD OF CONVERTIBLE STRATEGIES, AND SENIOR CO-PORTFOLIO MANAGER

JASON HILL

CO-PORTFOLIO MANAGER

DAVID O’DONOHUE

CO-PORTFOLIO MANAGER

We polled advisors about

their return expectations for

a 60% S&P 500/ 40%

Barclays Aggregate Bond

portfolio next year. The

majority expect a 1%-5%

return for a 60/40 portfolio.

Duration is the measure of the sensitivity of the price (the value of principal) of a fixed-income investment to a change in interest rates.

FOR INVESTMENT PROFESSIONAL USE ONLY. NOT FOR USE WITH THE PUBLIC.

2 WWW.CALAMOS.COM

Broadly speaking, the best way to think about Market Neutral

Income is to think about the two complementary strategies

individually: covered call writing and convertible arbitrage, each

of them represent around 50% of the portfolio. The strategy

allocation can change over time depending on the environment.

To drill down a little bit further, in convertible arbitrage we’re

buying convertible bonds and shorting the underlying stock of

the issuer. This is unlevered convertible arbitrage, so this is a

long, traditional hedge fund strategy, one of the first strategies

done in hedge funds. It can be a consistent return generator

in any kind of market. Nothing works every single day or every

single month, but over time we think convertible arbitrage is

something we can make money in, independent of the market

environment.

CMNIX ROLLING 3-YEAR PERIOD RETURNS SINCE I SHARE INCEPTION THROUGH MARCH 31, 2016

FIGURE 1. CALAMOS MARKET NEUTRAL INCOME FUND HAS PROVIDED CONSISTENT RETURNS OVER TIME

Source: Morningstar. Data as of 6/2003, the first three year rolling period following the fund’s I share inception (5/10/2000).Performance data quoted represents past performance, which is no guarantee of future results. Current performance may be lower or higher than the performance quoted. The principal value of an investment will fluctuate so that your shares, when redeemed, may be worth more or less than their original cost. You can obtain performance data current to the most recent month end by visiting www.calamos.com.

FIGURE 2. COMPLEMENTARY ALTERNATIVE STRATEGIES

Source: Calamos Investments. There can be no assurance the funds will achieve their investment objectives.

Beta is a historic measure of a fund’s relative volatility, which is one of the measures of risk; a beta of 0.5 reflects 1/2 the market’s volatility as represented by the Fund’s primary benchmark, while a beta of 2.0 reflects twice the volatility.

3

The tricky part to it is that it tends to be a spread strategy over

LIBOR—and with LIBOR at zero, there’s just a limit to how much

you can make in any given year in convertible arbitrage. That’s

where covered call comes into play. It offers a slightly higher beta

with a little juicier strategy, but is still hedged. It’s important to

understand the way we manage the strategy, it looks more like a

long-leaning collar than just buying equities and writing calls.

The portfolio consists of about 250 to 275 stocks, all in the S&P

500. Our goal is to add alpha in our equity book, but foremost

we are trying to have a minimal tracking error to the S&P

because on top of that, we trade S&P 500 Index options. We sell

calls on the S&P and buy puts.

Generally, in our base trade or what we refer to as our “North

Star” trade, we’re writing 80% notional calls and buying 40% to

50% notional puts. It allows us to generate an equity-like return

and incremental income over and above the dividend stream

and also have a hedge. Overall, the fund maintains a fairly lower

overall beta to the S&P, but with a relatively steady return profile.

In December of 2014 we launched Calamos Hedged Equity

Income Fund which is a pure play on the covered call side of

Market Neutral Income. It’s not 100% completely pari-passu with

how we do covered call in Market Neutral Income, but 99% of

the time they look almost exactly the same and utilize the same

process, same team and same execution on a day-to-day basis.

How Can These Funds Act As a Tool to

Manage Volatility?

Eli Pars: We’re all looking for ways to minimize volatility in the

market. The nice thing about Market Neutral Income is it also

at times offers opportunities to capitalize on and benefit from

volatility.

As we’ve seen during past drawdowns (Figure 3), the fund has

provided downside protection versus the S&P 500 during periods

of high volatility. We manage exposure through the drawdown

so the pain is somewhat mitigated by the relatively lower beta of

the fund, but then we have historically performed well coming

out of that.

In recent months, much of the fund’s performance has been

really driven by the convertible arbitrage side, as some of the

returns from that strategy tend to be time-based and evolve over

time. We expect to see the benefit of this as the year goes on.

CVSIX VS. S&P 500 AGAINST QUARTER-END CLOSING LEVELS OF THE VIX, 15-YEARS (3/31/01-3/31/16)

FIGURE 3. CALAMOS MARKET NEUTRAL INCOME FUND HAS CAPITALIZED ON MARKET VOLATILITY

Source: Monthly Data, Morningstar Direct. Past performance is no guarantee of future results, and there is no assurance that the fund will achieve its investment objectives.Current performance may be lower or higher than the performance quoted. The principal value and return of an investment will fluctuate so that your shares, when redeemed, may be worth more or less than their original cost. Performance reflected at NAV does not include the Fund’s maximum front-end sales load of 4.75% had it been included, the Fund’s return would have been lower. You can obtain performance data current to the most recent quarter end by visiting www.calamos.com.

A collar is a protective options strategy created by purchasing a put option while concurrently writing a call option. A long-leaning collar entails selling more calls than buying puts.Alpha is the measurement of performance on a risk adjusted basis. A positive alpha shows that performance of a portfolio was higher than expected given the risk. A negative alpha shows that the performance was less than expected given the risk.

4 WWW.CALAMOS.COM

Assuming a Flat or Rising Interest Rate Environment,

How Do You Keep Bond-like Risk but Avoid Interest

Rate Risk?

Eli Pars: It’s a real challenge in today’s market. We think Market

Neutral Income offers a very solid solution for that. If you look

back at recent performance, really we’ve been in a zero interest

rate environment going back to 2009. Market Neutral Income

hasn’t had a lot of interest rate opportunity or a lot of interest

rate sensitivity. We’re not benefiting when rates are moving

up. We’re generating more of a steady return from our trading

strategies and from the income components tied to those.

When you look at how our performance has been over the last

seven years, I think that’s a reasonable expectation of what we do

in that kind of environment. Figure 4 shows we have a relatively

low correlation to bonds going back the history of the fund.

It’s a great way to get bond-like returns with a lot less risk. The

other interesting angle is if you think about what’s going on

in the interest rate market and how the convertible arbitrage

strategy works mechanically. Historically, a nice source of returns

in convertible arbitrage is the rebate you get on the short

positions you have hedging your long convertible positions. In

today’s world, that return is basically zero.

In fact, when rates were a little bit lower before the December

2015 Federal Reserve increase it was actually slightly negative.

But as rates go up, we move up with that in lockstep. In a market

where it seems like the most likely scenario, at least to us, is a bear

flattener where what’s going on globally keeps longer-term rates

relatively in line. But as the economy continues to improve, the Fed

raises rates—maybe it’s once or twice or maybe it’s zero this year.

I think most of us think it’s pretty likely that by the end of next

year we’ll have seen a couple of rate increases, maybe three

or four. And that’s a great environment for the income side of

Market Neutral Income where that short rate flows through. If

we don’t see a lot of move in the rest of the curve, we won’t see

a lot of other movement in the portfolio. This is an interesting

environment for us and we think it could ultimately drive slightly

higher returns in convertible arbitrage.

FIGURE 4. CALAMOS MARKET NEUTRAL INCOME FUND OFFERS ATTRACTIVE DIVERSIFICATION POTENTIAL

Data as of 3/31/16. Past performance is no guarantee of future results. Source: Morningstar, Calamos Advisors LLC and BNY Mellon Performance & Risk Analytics, LLC. Diversification does not guarantee investment returns and does not eliminate the risk of loss. Correlation refers to how asset classes perform in relation to one another. Correlation is based on a range of 1 to -1; 1 represents two assets being highly correlated with each other and -1 representing two assets being negatively correlated with each other.

We polled advisors about their expectations for the

fixed income portion of a portfolio next year, using the

Barclays Aggregate Bond Index as a proxy. The majority

expect a 1%-3% return for the fixed income portion.

LOWER CORRELATIONS SINCE INCEPTION (9/4/90)

Citigroup 30-Day T-Bill Index 0.14

Barclays U.S. Government/Credit Index 0.18

Barclays U.S. Aggregate Bond Index 0.20

S&P 500 Index 0.74

Credit Suisse High Yield Index 0.68

MSCI EAFE Index 0.67

FTSE NAREIT All Equity REITs Index 0.58

5

How Do You Execute the Convertible

Arbitrage Strategy?

David O’Donohue: Convertible arbitrage is truly a market

neutral strategy. We are buying convertible bonds and we’re

selling short shares of the stock they convert into. Because of

that short, we’re able to set up trades that can potentially profit

from both rising and falling equity markets.

How do we source our investment opportunities? As with most

strategies used, we start with idea generation (Figure 5). First

and foremost is bottom-up. We have a deep team of analysts

that work to analyze credits and equities. They cover all sectors

and hopefully every name in the convertible market. We look

for equities we think are cheap or expensive and also same with

credits. We also look for specific catalysts or events, something

that could drive volatility and something that could change

inputs and maybe lead to market inefficiencies.

Next, we use proprietary scans. We have a number of tools

we’ve built in-house and also some market-wide tools that we

use to scan for ideas. We could be looking for simply cheap

convertibles based on credit and volatility inputs, but also we

could look for specific trade types we need. If we’re too long

leaning we can look for puts that have downside protection, and

if we’re too short leaning we can add calls for upside protection.

We also use it to look for market inefficiencies we may see coming

and this is where the experience of the team really comes into

play. We’ve been through a lot of different markets and seen a lot

of different environments. We have a pretty good sense given the

market environment what types of trades will be really powerful

in that environment and also what types will be laggards. We’re

trying to look and stay one step ahead and source trades we think

will be big return sources in the next environment.

The new issue calendar also serves as a great idea generator.

While it has a tendency to be lumpy at times, it’s a great source

of liquidity for us and also a nice return source. Typically those

issues come at a discount to where they would price in the

market. We’re able to realize a little bit of that.

One of the nice things about convertibles and convertible

arbitrage is that there’s a lot of different ways to structure trades.

But the basis of most of them can generally fit into one of these

three categories (Figure 6). First, a trade can be fundamentally

driven. We’re looking to profit from mispricings we see relating

FIGURE 5. CONVERTIBLE ARBITRAGE INVESTMENT PROCESS: IDEA GENERATION

Source: Calamos Investments. There can be no assurance the funds will achieve their investment objectives.

6 WWW.CALAMOS.COM

to credit spreads or equity valuations. We’re going to look to

hedge this as much as possible. Given the nature of the fund

we’re really not looking to take outside credit and equity bets.

We’ll try to mitigate this through hedges, as well as through

position sizing.

The next type of trade is skew or basically asymmetric payoffs. If

you think about a deep out-of-the-money call or deep out-of-

the-money put, something where there is really minimal risk,

we can create scenarios where there’s much larger payoffs.

The more of these we can stack into a portfolio and set up the

distribution the better. For many of them we may have very

small losses or no losses at all, while a few of them will be much

bigger winners. The more of these we can find for funds like

ours the better.

The third trade is what we refer to as volatility trades. Here, we’re

trying to isolate cheap optionality and buy convertibles where we

think the volatility component is mispriced. It could be mispriced

versus listed options, our expectations or historic observations.

We can realize value on this mispricing if the market realizes that

as well and things trade up and appreciate in value, but more

often the way we realize value on this is through gamma trading.

We’re buying convertible bonds and we’re selling short shares.

How we determine how many shares to short against that, is

based on the sensitivity that bond has to the movement in stock

price which is referred to as delta. That delta and that sensitivity

change as the stock price moves. The net effect of this is, as

stocks rise we’re mechanically forced to sell more shares if we

want to remain on that neutral hedge, and as stock prices fall

we’re buying in shares.

FIGURE 6. TRADITIONAL CONVERTIBLE ARBITRAGE TRADES

Source: Calamos Investments.

EXAMPLE: OUT OF THE MONEY

A stock is trading at $100.

Call options with strike

prices above $100 would

be out of the money. Put

options with strike prices

below $100 would be out

of the money puts.

Delta is how much the convertible value rises or falls for a

given stock move.

Gamma is the change in delta as stock price moves. Market

volatility can provide opportunities to profit through what is

referred to as gamma trading.

7

Figure 7 shows that as the stock moves along, we’re buying and

selling shares based on whether it’s rising or falling, and each

time we’re pocketing that difference between that buy and

that sell. During environments such as the beginning of the year

when volatility is rising and stock prices are falling, we’re

covering stock and adjusting our hedges.

We’re also able to take advantage of some asset class dislocation

as some of the correlations break down and it allows us to

source more trades. But when you start to see markets normalize

we start to bear the fruits of that, and realize a lot of that value

we’ve created. We then start to see that flow through and

provide a tailwind behind us as we move forward. Also, it can be

pretty powerful if we’re in more range-bound markets that still

have big up days and big down days back and forth. We’re able

to buy and sell on those.

Volatility trades can be considered the “bread and butter” of the

strategy. It’s what we spend a lot of time on, on a daily basis. For

essentially every name in our book, we have preset buy and sell

levels for both price and quantity. We’re ready to trade on those

as the market moves, so we spend a lot of time “in the weeds”

really monitoring those levels and trying to move quickly. This

can be a great source of return in both highly volatile markets as

well as those with a little bit of back and forth.

Do You Use Investment Grade Bonds and How

Are You Selecting Them as Well as Dealing With

Nonrated Bonds?

David O’Donohue: Yes, we definitely drop below investment

grade and a lot of the market is actually not rated. In the high

yield market you have to be rated in order to sell bonds, but

that’s not the case in the convertible market. When companies

come to issue a convertible, especially if that’s the only debt

they have, they may just not go through the process of getting

it rated.

I think it’s important to note that not rated doesn’t necessarily

mean poorly rated. A lot of those companies have no other debt

in the capital structure, and when you look at a lot of them

they’re actually not bad credits. But regardless, we’re doing

all of our own credit work. We have an experienced team of

analysts that know all of the sectors and also all the names in the

convertible universe and how they compare to other names in

that sector.

XYZ CLOSING STOCK PRICE

FIGURE 7. GAMMA TRADING HYPOTHETICAL

Source: Calamos Investments. The above example is not meant to represent the performance of any given security. It is a hypothetical illustration of general investment themes.

www.calamos.com/gamma

8 WWW.CALAMOS.COM

We also spend a fair amount of time monitoring that on the risk

management side. We focus on jump-to-default, jump-to-zero

and sizing of positions to make sure that even if we’re wrong

and something goes awry, that we’ve sized the position right—

that any individual name or even any collection of similar names

is not going to be enough to meaningfully drag down the return

of the portfolio.

Does the Use of Convertibles Naturally Cause

the Fund to Be Somewhat Correlated to the

Equity Market?

Eli Pars: On the convertible side, it’s hard to get a zero correlation

with anything. And just like any other strategy, you tend to have

a little bit of a risk on, risk off component on a daily basis. But as

you stretch your time period out longer from a day, to a month,

to a quarter or longer, I think you’ll notice that the correlation

between convertible arbitrage and the equity market is pretty low.

A good equity market tends to feed the new issue calendar which

can make it a nice source of incremental profits for us, so there’s

different ways that it helps. But keep in mind on the typical

convertible arbitrage trade, we’re trying to construct in a delta

neutral manner so that our P&L (profit and loss) is roughly even

whether it moves by the same amount—whether the stock goes

up or down. In regard to gamma trading, we’re adjusting that,

selling as the stock runs up and buying as the stock goes down.

So on any given day, we’re trading a lot of names. Almost any

trading strategy has a little bit of correlation, but it’s pretty low.

How Do You Use Option Strategies to Navigate a

Volatile, Low-Return Equity Environment?

Jason Hill: Through the use of S&P 500 Index long and short

options, and an optimized equity portfolio of about 250 to

270 names that represents the S&P 500, our covered call

strategy potentially provides a unique mix of absolute downside

protection with equity upside participation, with less volatile

returns even in a higher volatility environment.

Unlike the convertible arbitrage trades that typically have a

market beta of around zero, the covered call strategy runs with

an average beta to the S&P of around 0.5, and a historical

range of about 0.4 to 0.6 on the high side. This is a good

example of why we believe these two strategies complement

each other so nicely within the fund. You have convertible

arbitrage, a high risk-adjusted return strategy with a beta near

zero, mixed with a covered call strategy that provides an equity

upside participation component.

This raises the absolute return level of the overall fund, which

we believe makes it especially attractive within a low-rate

environment. Most importantly, we’re getting this from the

covered call strategy that does so with lower volatility than most

equity strategies, along with downside protection.

What Are the Sources of Income and Return for the

Covered Call Strategy?

Jason Hill: Income and capital gains both serve as sources

of potential total return (Figure 9). There’s some overlap to a

degree, but the income piece is made up of option premiums

that we’re collecting and also equity dividends on the long

side. We are a net seller of option premiums, so we do have

positive carry in this strategy. Within the current market, our

goal in the portfolio is around 1% to 3% annualized from

option premiums. From our equity dividend, we’re very close to

the S&P 500 yield, which is around 2.25%.

We polled advisors for their expectations for the equity

portion of a portfolio next year using the S&P 500 Index

as a proxy. The majority expect a 6%-10% return for the

equity portion.

9

FIGURE 8. COVERED CALL WRITING INVESTMENT PROCESS

Source: Calamos Investments. There can be no assurance the fund will achieve its investment objective.

FIGURE 9. COVERED CALL WRITING: INCOME GENERATION FROM OPTION PREMIUMS

Source: Calamos Investments. This is an illustration of how the fund seeks to generate income and does not necessarily represent fund performance.

10 WWW.CALAMOS.COM

From a return perspective, we do have an equity participation

piece. Even though we have call writing in this strategy, we still

have the flexibility to participate in a positive equity market.

In our view, maybe the most important return component,

or where we add the most value, is from options trading and

rebalancing. There is some overlap whether you’re actually

capturing the income that you’ve already sold or at times

just creating a better forward-looking payoff scenario for the

strategy. Sometimes we are able to do both, which makes this

piece an integral part of what we do and where we have an

edge. This sets us apart from the passively-managed covered call

strategies that continuously roll monthly and quarterly call write

positions with no downside protection management.

What Advantage Does Calamos Offer Vs. Advisors/

Investors Replicating Call Writing?

Jason Hill: Our strategy isn’t constrained by specific notional

values, “moneyness,” or maturity criteria. Because of that, we

have the ability to be proactive and reactive to market swings

and moves in volatility. We’re able to take what the market gives

us to fit current and anticipated environments.

This leads me to our “North Star” or model options trade, this

serves as a reference point of how we look at our collared options

position. We start with an 80% call write 2.5% out of the money

and 40% put protection, which is 5% out of the money, both

being a 60-day maturity option. This trade serves as a reference

point in three main areas—skew, the portfolio’s carry, and

the delta hedge ratio that falls out. To explain skew briefly, it’s

the relationship between calls and puts. A simple way to think

about it in this context is how many calls do you have to sell in

order to pay for the protection that you want or the income and

protection that you want. The portfolio’s carry is the annualized

income that you’re taking in for that trade. The hedge is going to

be the aggregate delta hedge that results from the trade.

There are some reasons why we might deviate from our model

trade. These include equity market swings, large moves in

implied volatility, time in general can change complexion of

that option trade, you might not have enough carry, or the

hedge ratio isn’t where you want it—for example, in the current

environment. Right now, if we were to put on our model trade,

you’d have a delta hedge ratio of about 0.3. That’s most likely

too low for us on where we want to be protected in the current

environment. Additionally, changes in our views of the market

and volatility overall could make us deviate from our model.

What Does the Current Option Environment

Look Like?

Jason Hill: Recently, we are seeing relatively lower implied

levels. It’s led us to err on the side of purchasing what we

believe are cheap outright puts, meaning we might not

concurrently sell as many calls as usual because we don’t think

we’re being compensated enough on selling those calls to have

our upside capped.

From a longer-term perspective, the skew of our model trade

is still around the ninetieth percentile (100% being most

expensive), and is therefore still a prevailing headwind for

us. Over the last year or even a little longer because of that

long-term view, we have found put spreads to be a valuable

tool in the portfolio. By using slightly closer to the money calls

and adding near the money put spreads, we’ve been able to

construct a more cost effective hedge, while maintaining a

similar delta and profile to that of our desired risk/reward.

We try to take advantage of where we see the current

environment by looking at our option book both in real time and

going forward as we focus on our option hedge. We are looking

over a range of scenarios, both up and down for a given date

and time. We’ve built out an implied volatility surface in order to

estimate where we believe those levels will be in the future. This

gives us the ability to look out to any date and any corresponding

equity move. We focus on what our participation will look like.

Meaning, how much equity exposure do we have in the future.

In addition, we also focus on what our resulting delta hedge

ratio will look like because we do have minimum exposure/

protection levels that we want to have on and we don’t want a

Moneyness refers to the intrinsic value of an option in its present state. It is a description of a derivative relating the price of its underlying asset to its strike price. A call or put option is out of moneyness when it is a call option with a strike price that is higher than the market price of the underlying asset, or a put option with a strike price that is lower than the market price of the underlying asset.

11

group of options expiring in the future and us not knowing what

type of protection we have a week from now or a month from

now. Because our hedges aren’t always linear in nature—they

increase and decrease as markets move—we focus on that as

we’re monitoring our current hedge and especially when we’re

constructing trades to adjust going forward.

Would You Describe the Fund as “Market Neutral”

Despite Convertibles Having Some Inherent

Equity Sensitivity?

Eli Pars: Yes, on the convertible side we’re really hedging out on

our normal trades and the bulk of the equity market sensitivity.

Currently, we’re essentially on a theoretical delta. From a

theoretical standpoint, you don’t really have any equity market

sensitivity. From a practical standpoint, the convertible market,

like a lot of markets, does have a bit of a risk-on and risk-off

component to it on a daily basis. I would say the convertible side

is very market neutral. The covered call slide does have a little

higher sensitivity to the market, but you end up with a fund

with a 0.25 or 0.30 beta* and a relatively low sensitivity to the

overall market.

How Is the Relative Contribution of the

Complementary Strategies Determined?

David O’Donohue: In general, we keep the strategies around

50/50**, but there’s no real definitive mandate that we have

to. Convertible arbitrage has a much better risk-adjusted return

profile, but the one limiting factor is the absolute returns,

especially in a zero interest rate environment. If we thought there

was a lot of great opportunity for convertible arbitrage or in a

spot where we had higher overnight money and higher absolute

returns, we could definitely overweight the strategy and be as

much as 70% or 80%.

But given the current low interest rate environment, we still

feel like the better blend is closer to 50/50. It’s a little harder

to overweight the covered call side just because of that market

sensitivity. It’s a higher beta strategy and we’re still looking to

deliver more stable returns with an overall lower beta and lower

volatility. It would be hard to get covered call over 60% of the

allocation without meaningfully increasing the volatility and

equity exposure of the fund.

What Are the Expectations for the Fund In a Rising

Interest Rate Environment?

Eli Pars: Convertibles tend to do well in a rising interest rate

environment generally because the equity market does well. But

we’re hedging that out so you don’t see that as much in the

market neutral strategy. You do see the benefit of the increase in

overnight money and our short credits, which is meaningful. But

that net equity sensitivity would show through on the covered

call side. Overall, I think the fund should do okay in that kind of

environment, with the potential to do quite well.

Where Should a Client Use This Fund in

An Asset Allocation?

Eli Pars: Many investors consider the fund as part of the anchor

of an alternative allocation. Someone doing a larger allocation to

alternatives may allocate a big piece to Market Neutral Income

and then maybe have a few more high-flyer type funds around

the edges. Most of the interest we’ve seen over the recent years

has been as a fixed income component based on the fund’s

steady return profile compared to what you can get out of the

fixed income market today, particularly considering some of

the risks that you have to take to even generate any kind of

moderate return in fixed income.

For additional commentary from our investment team, visit our Investment Team Blog at www.calamos.com/blog and commentary library at www.calamos.com/insights.

*As of 3/31/16, the fund’s class A shares had a 0.25 beta versus the S&P 500 Index since the fund’s inception in 9/4/90.

**As of 3/31/16, the fund had a 50% allocation to covered call and a 50% allocation to convertible arbitrage.

Calamos Investments LLC 2020 Calamos Court | Naperville, IL 60563-2787 800.582.6959 | www.calamos.com | caminfo@calamos.comCalamos Investments LLP 62 Threadneedle Street | London EC2R 8HP Tel: +44 (0)20 3744 7010 | www.calamos.com/global©2016 Calamos Investments LLC. All Rights Reserved. Calamos® and Calamos Investments® are registered trademarks of Calamos Investments LLC.

502B 0616O R

Opinions and estimates offered constitute our judgment and are subject to change without notice, as are statements of financial market trends, which are based on cur-rent market conditions. We believe the information provided here is reliable, but do not warrant its accuracy or completeness. This material is not intended as an offer or solicitation for the purchase or sale of any financial instrument. The views and strategies described may not be suitable for all investors. The opinions and views of third parties do not represent the opinions or views of Calamos Investments LLC. Opinions referenced are as of May 24, 2016 and are subject to change due to changes in the market, economic conditions or changes in the legal and/ or regulatory environment and may not necessarily come to pass. This information is provided for informa¬tional purposes only and should not be considered tax, legal, or investment advice. References to specific securities, asset classes and financial markets are for illustrative purposes only and are not intended to be, and should not be interpreted as, recommendations. Indexes are unmanaged, not available for direct in¬vestment and do not include fees and expenses. Unmanaged index returns assume reinvestment of any and all distributions and do not reflect any fees, expenses or sales charges. Investors cannot invest directly in an index. The Citigroup 30-Day Treasury Bill Index is an unmanaged index generally considered representative of the performance of short-term money market instru-ments. U.S. Treasury Bills are backed by the full faith and credit of the U.S. government and offer a guarantee as to the repayment of principal and interest at maturity. The Barclays Capital U.S. Government/Credit Bond Index is composed of long-term government and investment-grade corporate debt securities and is generally considered representative of the performance of the broad U.S. bond market. The Barclays Capital U.S. Aggregate Bond Index is an unmanaged index comprised of U.S. investment grade, fixed rate bond market securities, including government, government agency, corporate and mortgage-backed securities between one and ten years to maturity. The S&P 500 Index consists of 500 stocks chosen for market size, liquidity, and industry group representation. It is a market-value weighted index (stock price times num-ber of shares outstanding), with each stock’s weight in the index proportionate to its market value. The “500” is one of the most widely used benchmarks of U.S. equity performance. The MSCI EAFE Index is an arithmetic, market value-weighted average of the performance of securities listed on the stock exchanges of selected countries in Europe, the Far East and Australia. The index is calculated on a total return basis, which includes reinvestment of gross dividends before deduction of withholding taxes. The Credit Suisse High Yield Index consists of US-denominated high yield issues of developed countries. Issues held in the index must be publicly registered in the U.S. or issued under Rule 144A with registration rights, must be rated “BB” or lower, and the minimum amount outstanding (par value) must be at least $75 million. The FTSE NAREIT All Equity REITs Index measures the performance of all publicly traded equity real estate investment trusts traded on U.S. exchanges. Skewness describes asym-metry of returns from the normal distribution. CBOE Volatility Index (VIX) measures market expectations of near term volatility conveyed by stock index option prices. London Interbank Offered Rate (LIBOR) is the rate at which many leading banks globally offer to participating banks for short-term loans. Tracking error is a measure of the volatility of excess returns relative to a benchmark.An investment in the Fund(s) is subject to risks, and you could lose money on your investment in the Fund(s). There can be no assurance that the Fund(s) will achieve its investment objective. Your investment in the Fund(s) is not a deposit in a bank and is not insured or guaranteed by the Federal Deposit Insurance Corporation (FDIC) or any other government agency. The risks associated with an investment in the Fund(s) can increase during times of significant market volatility. The Fund(s) also has specific principal risks, which are described below. More detailed information regarding these risks can be found in the Fund’s prospectus. The principal risks of investing in the Market Neutral Income Fund include: equity securities risk consisting of market prices declining in general, convertible securities risk consisting of the potential for a decline in value during periods of rising interest rates and the risk of the borrower to miss payments, synthetic convertible instruments risk, convertible hedging risk, covered call writing risk, options risk, short sale risk, interest rate risk, credit risk, high yield risk, liquidity risk, portfolio selection risk, and portfolio turnover risk. The principal risks of investing in the Hedged Equity Income Fund include: covered call writing, options, equity securities, correlation, mid-sized company, short sale, interest rate, credit, liquidity, portfolio selection, portfolio turnover, foreign securities, American depository receipts, and REITS. Convertible Arbitrage Principal Risks: Convertible Securities Risk- The value of a convertible security is influenced by changes in interest rates, with investment value declining as interest rates increase and increasing as interest rates decline. The credit standing of the issuer and other factors also may have an effect on the convertible security’s investment value. Convertible Hedging Risk- If the market price of the underlying common stock increases above the conversion price on a convertible security, the price of the convertible security will increase. The fund’s increased liability on any outstanding short position would, in whole or in part, reduce this gain. Covered Call Writing Principal Risks: As the writer of a covered call option on a security, the fund foregoes, during the option’s life, the opportunity to profit from increases in the market value of the security, covering the call option above the sum of the premium and the exercise price of the call. Short Sale Risk: The Fund may incur a loss (without limit) as a result of a short sale if the market value of the borrowed security increases between the date of the short sale and the date the Fund replaces the security. The Fund may be unable to repurchase the borrowed security at a particular time or at an acceptable price.

Before investing carefully consider the fund’s investment objectives, risks, charges and expenses. Please see the prospectus and summary prospectus containing this and other information or call 1-800-582-6959. Read it carefully before investing.

AVERAGE ANNUAL RETURNS

AS OF 3/31/16

1-YEAR

3-YEAR

5-YEAR

10-YEAR

SINCE A SHARE INCEPTION

(9/4/90)

SINCE I SHARE INCEPTION (5/10/00)

Calamos Market Neutral Income FundI shares – at NAV 0.93% 2.58% 3.34% 3.39% N/A 4.47%

A shares – at NAV 0.66 2.35 3.08 3.13 6.39% N/A

A shares – Load adjusted -4.13 0.70 2.07 2.63 6.19 N/A

Barclays U.S. Government/Credit Index 1.75 2.42 4.04 4.93 6.44 5.63

MEMORANDUM

Date: November 27, 2017

To: LAI Board of Directors

From: LAI Finance Committee

Subject: 2018 Budget Recommendation

Highlights of the 2018 budget as recommended to the board for approval on October 23, 2017:

Revenue • Member Dues-Based on actual millage data and growth of new members. Budget projects 100

percent retention rate but does not new members anticipating will yet join this year for 2018. • Associate Membership- Budget is based on 75 associate members which we believe is

achievable based on current membership. • Sponsorships-General sponsorships budgeted at one less Bronze Sponsor than 2017. Unsure

whether there will be a change but worry may lose one based on noticed lack of engagement. • Professional Development-Revenue is budgeted down from projection for 2017 but up from

budget in 2017. The association does not anticipate the same demand for educational topics in 2018 in an off-implementation year of the RoPs.

• Publications-This line-item is down again related to the transition of the wage and benefit survey into a “participating” membership benefit and further enhance membership value. This was a planned strategic goal to drive member value in 2015. The 2016 transition increased participation in the survey as members completing the survey received the results at no cost and thus fewer purchases than anticipated by non-participants. Participation continued to grow as in 2017.

• Group Purchasing-Budgeted revenue is less than projected but the same as budget for 2017. This will be a focus area for growth in 2018 as staff accountabilities are being shifted to devote more time to marketing and implementation of the redesigned member discount program with Martin Bros. to include rebates.

• Investment Income-Budgeting for anticipated realized income per Matt Meline with Morgan Stanley.

• Nurse Consulting-Down from budget but relatively consistent with forecast. As a new service, this has been difficult to gauge utilization so the budget was done conservatively.

• Other Revenue-The decline in budget from 2017 to 2018 in this overall category relates to misc. sales of office equipment which were higher in 2017 due to the office move.

Expenses • Staff salaries and benefits-Overall increase in of 1.2 percent. Planning a 3 percent wage increase

for staff. The hold on expenses relates primarily to a 10 percent reduction in health insurance premiums for 2018 based on favorable claims experience.

• Professional Development-Expenses are down from the forecast due to less programming but up from 2017 budget due to expense growth at venues.

• Legislative Day & Special Events-New resources have been allocated to host a “Future of Aging Services Summit” in May 2018 to raise awareness on the future of delivery model and challenges to get there including workforce among policy makers and members.

• Legal & Accounting-Accounting contract was three-year contract from 2015-2017. The workload was much higher than anticipated so the 2018-2020 contract increased by $9,900 with a three percent inflation factor each year. Still less than previously paid for accounting services before transitioning to current partner.

• Consulting-This expense relates the last portion of the board’s visioning work which occurs in February 2018 as well as $5,000 for a lobbying contract to help cover the legislative session while Matt is gone.

• Occupancy-Much lower in 2018 due to the decreased rental expense at new office location. • Depreciation-Capital expenditures for 2018 include replacement of computer server, new desk

chairs for staff, replacement of conference room chairs, and a tablet to use for consulting. Overall, depreciation costs budgeted for less than 2017. The committee requested that LAI examine the capitalization policy by asking accounting for a reasonable policy for an organization this size and in this field. The depreciation schedule was adjusted to remove any item beneath the $1,000 policy for the board's consideration at the December 5 meeting.

LeadingAge Iowa2018 Proposed Budget

2015 2016 2017 2017 2017 2017 2018 2018ACTUAL ACTUAL ACTUAL YTD BUDGET FORECAST VARIANCE BUDGET VARIANCE

Member Dues 314,142 347,083 250,159 399,597 376,411 (23,186) 398,000 21,589 Associate Member Dues 33,550 38,300 26,372 37,400 39,600 2,200 41,250 1,650 Sponsorships 50,000 50,000 36,667 52,500 55,000 2,500 52,500 (2,500) Spring Conference 148,310 156,975 178,930 - - Fall Conference 63,290 65,220 - - Professional Development 405,974 350,354 285,327 347,130 398,878 51,748 360,210 (38,668) Publications/Advertising 10,210 1,300 865 1,300 865 (435) 700 (165) Revenue Sharing-GPO 134,211 139,191 91,021 142,000 135,850 (6,150) 142,000 6,150 Nurse Consulting 19,544 27,516 25,478 27,000 25,500 (1,500) 25,000 (500) Investment Income (16,541) 26,010 37,657 5,500 30,000 24,500 5,000 (25,000) Other Income 740 535 1,114 2,000 1,164 (836) 525 (639)

Total Revenue 951,830 980,289 754,660 1,014,427 1,063,268 48,841 1,025,185 (38,083)

Staff Salaries & Benefits 584,699 605,987 410,891 637,526 632,267 (5,259) 645,366 13,099 Professional Development 226,603 143,819 119,315 184,436 191,272 6,836 189,723 (1,549) Member Resource Tools 7,500 9,800 8,000 10,000 9,000 (1,000) 9,500 500 MCO Contract Comparison 9,500 - - - - Legislative Day & Special Events 626 418 600 - (600) 3,000 3,000 Board & Committee 3,558 3,965 2,376 4,000 4,000 - 4,000 - Travel 17,218 15,142 11,602 18,000 17,000 (1,000) 17,000 - Legal & Accounting 37,711 36,300 26,694 37,050 37,100 50 47,150 10,050 Consulting 4,800 12,500 10,000 15,000 15,700 700 7,000 (8,700) Occupancy 64,579 66,157 47,150 67,600 66,500 (1,100) 54,250 (12,250) Office Administration 13,564 14,957 9,389 15,500 15,250 (250) 14,750 (500) Computers 12,870 15,042 10,006 16,500 16,276 (224) 15,500 (776) Depreciation 6,469 7,206 4,654 7,376 7,509 133 6,156 (1,354) Other Expense 5,817 7,701 4,951 8,000 9,745 1,745 10,400 655

Total Expense 995,514 938,994 665,028 1,021,588 1,021,619 31 1,023,795 2,175 Net Increase(Decrease) in Assets (43,684) 41,295 89,632 (7,161) 41,649 48,810 1,390 (40,258)

REVENUE

EXPENSE

MEMORANDUM

Date: November 27, 2017

To: LeadingAge Iowa Board of Directors

From: Shannon Strickler, President/CEO

Subject: Medicaid Retroactive Eligibility and MCO Update

The legislature approved a cut to Medicaid Retroactive Eligibility during the 2017 session with a fiscal impact of $4.2 million, of which $262,000 related to long-long term supports and services. CMS approved the state plan amendment on October 26 for all elibility groups except pregnant women and infants under the age of 1. Upon implementation on November 1, 2017, there is much discrepancy as to the fiscal impact with providers estimating that it will far exceed $4.2 million, the fiscal estimate and intent of the legislature. Just one long-term supports and services brain injury member estimated that the elimination of retroactive eligibility will have a $600,000 impact because 15-20 percent of the individuals they serve rely upon retroactive eligibility to help cover the costs of their care. Retroactive eligibility applies to individuals newly enrolled in the Medicaid program whereas Medicaid looks back 90 days prior to the first of the month when the application was filed and pays medical bills during that period. Retroactive eligibility is critical to providers like nursing homes and long-term rehabilitation who cannot control the timing of the Medicaid application process by families and yet continue to serve the resident. For instance, retroactive eligibility is critical for providers of brain-injury rehabilitation whereas that timely rehab is crucial to the patient’s recovery and the need for Medicaid generally is due to a catastrophic event whereas the family is most worried about survival, not immediately filing a Medicaid application. Other cases include residents who exhausts their personal funds while living in a nursing home, and it takes weeks for the family to gather the necessary information and complete the Medicaid application. The Administrative Rules Review Committee met on November 14 to consider the rule which had been implemented on an emergency basis. A procedural motion to object to the rule did not receive the necessary 2/3 votes. Committee members expressed concern that they did not have the authority to suspend and delay the emergency rule but discussed the need to revisit the issue once the legislature convenes. Additionally, committee members were unsure in the true fiscal impact of the change as the Department of Human Services continue to insist the

impact is much smaller than the provider community estimates. Regardless, the state savings of the rule as implemented is well beyond the $4.2 million state share approved by the legislature per data provided by the department in the chart below:

LAI will work with other stakeholders in support of legislative action. The General Assembly must direct the Department of Human Services to reinstate retroactive eligibility to ensure that providers receive payment for services rendered for Medicaid Eligibles.

HF653 Sec 97 – LTSS and Dementia Specific Care November 17, 2017

Prioritization

Votes

101

Topic #1 What are some options for coordination between state agencies and private entities to promote increased access to long-term care supports and services (LTSS) including dementia-specific care in both residential and home and community-based settings?

20 Develop more comprehensive simplified effective reimbursement for Assisted Living Programs and Adult Day; Reimbursement rates (i.e. billing multiple entities)

19 LTSS financing options beyond Medicaid – potential partnership with private, long-term care insurance plus state catastrophic back drop; Incentive for more private funding; Design effective benefit package

13 Telehealth not a replacement but a support; Use technology 12 Workforce – delay in background checks. Need privatization of system; Losing workers,

takes 3+ weeks; More strategic efforts with direct care worker training - blended online and clinical; Sustainability.

10 Bringing state funding agencies together under one umbrella; We are leaving federal money on the table; Redesign – refocus; Strong leadership

8 More standardized education for direct care workers 8 What are the best practices from other states regarding dementia care; Evaluate and

implement those strategies 4 Ongoing dialogue between private entities and state; Best practice, policy development;

Solutions – actions = Lean Event? (Do not need legislation to do this) 4 Dementia screen included in yearly Medicare wellness check? Driver’s license, other,

physical 1 Engage business / private entities in direct care worker work force on caregiver issues;

Broaden the stakeholder pool • SHRM • DOC • DOT • IAB • Physicians

1 Caregiver education to employers; Economic impact to increase; Start within the State of Iowa

1 Dementia friendly communities / dementia friendly state 0 No Wrong Door dementia screen before crisis/nursing home placement protocols;

Iowa with increase percentage of low-care needs; ADRC more robust on the front end 0 Continued collaboration with both federal and state agencies i.e. DIA & CMS 0 Create evaluation / crosswalk of agencies in streamlining LTSS & workforce funding

programs; Analyze across the spectrum 0 Duplicative existing state services; Also leaving state money on the table; SHIIP, RSVP –

currently under Economic Development, CIL, etc.; Fractured disability community

Prioritization

Votes 101

Topic #2 What are the barriers to, gaps in and opportunities for increased access to LTSS including dementia-specific care?

Opportunities 19 Build capacity of increased adult day with a payment reimbursement model to support 16 People enter LTSS at crisis; Public education; System (NWD/ADRC) to respond; Look to

rural communities for solutions and best practices; Tap into older Iowans/caregivers for information; Inform healthcare providers

14 Re-evaluate regulation and funding to allow increased flexibility in service provision; Improve provider services with focus on existing providers through regulation changes and pilot programs; Employ / re-evaluate regulation interpretation and consistent application; Allow flexibility

12 Center of Excellence: Workforce Innovation; Education & inter disciplinary ; Research; Innovations into practice; Dementia research center; Research – actionable solutions such as walkability;

9 Technology / centralized monitoring; Smart technology; 5 Prevention to delay onset; Research into best practices ; Funding 4 Pursue joint policy making (e.g mental health & service taxonomy for payment) 4 Access (centralized) to community data; Ensure aging related questions included in

health assessment/CHNA/HIP; Focus on local level 4 Family supports; Tax credits 4 Evaluation of workforce needs and training, including technical skills 3 Evidence based training on diffusing aggressive behavior / behavior modification;

Increase availability to more facility/ caregivers; Bereavement care for family members 1 Stigma / Privacy; Addressing stigma that can be addressed with interventions; Education

e.g. churches, HDM; Research into behavior changes/monitoring/triggers/ social media and technology

0 Define dementia LTSS System; Use lay person terms; Change language around dementia 0 Develop/ identify evidence based programs for dementia care / caregivers 0 Promote work / success in addressing workforce direct care worker issue (model state) 0 Use “homegrown” expertise 0 CMS – determine requirements / allow ability of technology for monitoring e.g. –

cameras, GPS 0 Technology to electronic verification of service deliver; Efficiency / cross platform in

home (non continuous care) 0 Access to broadband 0 National accreditation body for multi –services 0 Discussions/informed decision on choice of residence most appropriate 0 Technology applied with individualized approach 0 Use person center participation to adult / senior population; Service designed around;

Surveys that have a PCP approach

Gaps/Barriers 3 Lack of family supports; Cost to caregiver/ mental impact on caregiver 1 Multiple regulatory bodies when a single provider/entity with multiple service

lines/products can deter innovation & flexibility 1 Facilities moving away from specialized care; Resident & family members moving away

(to facility in another community/state); Healthcare facilities 1 Pay scale for workforce 0 Focus on care for older adult; Responsibility for care for parent 0 Silos / lack of coordination / duplication; Knowledge/initiatives; Funding request;

Program/services/outcomes (agency/organization specific); Lack of communication flow 0 Camera/privacy; Personal choice/dignity; Are these considered restraint? 0 Regulations that area applied across populations

Prioritization

Votes 96

Topic #3 What is the availability of LTSS including dementia-specific care services in home and community-based settings as an alternative to residential settings?

13 CCDI units are decreasing and memory care units in Assisted Living Programs are growing (Federal vs State issue). Need a place for those who need more care and have no place to go

11 Caregiver support groups/ AAAs / Alzheimer’s Association/ Powerful Tools (not strong) 11 Look at creative ways to bring new practices into Iowa 9 Adult Day - $/lack of referrals (not strong) 9 Elder Group Homes / Critical review/ Iowa models never went anywhere/

What do other states successful elder group home models look like? 6 Dementia-friendly communities (not strong) 6 Workforce / Whole healthcare system (not strong) 5 Telemedicine/tele monitoring (not strong) 5 Develop and implement plans 3 Caregiver training (not strong) 3 Corrections (unfortunately)/ Public safety (silver alert) (not strong) 3 Assisted living (moderately good) 2 Iowa is not an age in place state - Have to move from ALP when . . . / Other states ALP =

“old” nursing home and now nursing homes are rehabilitation centers 2 Family caregivers program – inconsistent (disagreement among the groups on the status of this program) 2 Affordable housing (not strong) 2 Smart Home (not strong) 1 Options counseling provided by Alzheimer’s Association and LifeLong Links (moderately good) 1 Palliative care (moderately good) 1 Difference between knowledge and access of LTSS 1 Comprehensive/holistic health (Public health entities, Local level hub, ADRC/AAA) 0 Geriatric Case Management 0 Guardianship / Conservatorship not for profits are needed 0 Information, Assistance &Referrals (moderately good) 0 Home Health (AAA, VNA, CDAC) (moderately good) 0 General public education (not strong) 0 Senior Independent living 0 Financial planning (moderately good) 0 Legal support (moderately good) 0 Guardians/legal reps/POAs (moderately good) 0 Respite care (not strong) 0 Senior centers (moderately good) 0 Meals on Wheels (moderately good) 0 Home health care agencies – for profit 0 Long term – people think nursing home 0 Veterans HCBS Assessment – identify needs (doing)

Prioritization

Votes

Topic #3 (continued) What is the availability of LTSS including dementia-specific care services in home and community-based settings as an alternative to residential settings?

0 Communication/outreach to educate on what programs are what the programs do 0 Extension offices/ISU faculty/IDPH Co Office/AAA 0 Health, wellness and aging 0 Overlapping missions, lack of communication 0 Very few residential care; Reimbursement down – Medicaid; More private pay

Prioritization Votes

68

Topic #4 What changes in law are necessary to better address the LTSS needs, including dementia-specific care, of individuals and their families? (Code citations are helpful)

12 Workforce (Future Ready IA); Central database/LTSS – DIA houses, federal funds; Grants or scholarships; College of direct support – include dementia; More training for assisted living and nursing home staff; Streamline different pots of money

10 Assisted living challenges; Change/update definition (Create a new category for housing with services); Needs of people creates challenges; Focus on continuity of care; Issues with door locks and security; More flexibility to meet their needs

10 Re-structure/consolidate who is in charge of LTSS population; Eliminate redundancies between departments; No Wrong Door

8 CARE Act; Patients can designate a caregiver 5 Designate ADRCs as “No Wrong Door” via state legislation

5 Privatize provider background checks; Move to national database;Legislate this 4 Adult day care vs. group respite; Can nursing homes provide this?; DIA rules are difficult,

needs to be simple; Help providers establish group respite. 3 CMS changes; HCBS “settings” rules need to be tailored to each population; Ongoing

conversation about civil penalties; Medicaid plan should be more clear on penalties (state plan amendment)

3 Greater support for family caregivers 3 Financing of LTSS; Re-think; Not just Medicaid; Education of public/providers/insurance

division 2 Create “silver alert” program 1 Utilize National survey data; Cost?; LTSS specific data; Utilize the University 1 Review of definitions of services for HCBS/elderly waiver 1 Review CMP grant rules 0 Bed tracking system; Include dementia-specific beds; Track non-active beds 0 State investment in ADRCs; Offset Medicaid spend; Fully utilize Medicaid match 0 ODSM; Utilize Medicaid match 0 CNA’s; Go beyond education 75 hours; Encourage reciprocity with other states; Fix

registry at federal level 0 Training for ADRC employees – dementia-specific

MEMORANDUM

Date: November 27, 2017 To: LeadingAge Memberrs From: Barbara Gay Subject: Position on Tax Reform Legislation

Because of its potential impact on our members and those they serve, LeadingAge urges Senators to vote against tax legislation, H.R. 1, which is likely to come to the floor within the next 10 days. Specific provisions of the legislation, as discussed below, would be problematic. Our overarching concern, however, is about the impact the bill as a whole will have on the federal budget and on the future availability of essential resources for Medicare, Medicaid, senior housing and home- and community-based services. The nonpartisan Joint Committee on Taxation projects a $1.5 trillion increase in the federal budget deficit resulting from H.R. 1 over the next decade. The budget deficit for fiscal 2018 already stands at $440 billion. And the $1.5 trillion figure likely underestimates the future budget trough, since it presumes that Congress will allow tax cuts to sunset after 2026. With a massive revenue loss widening an already large budget gap, it is completely foreseeable that enactment of H.R. 1 would lead to calls for huge cutbacks in federal spending on programs serving elders. We have already seen budget proposals calling for hundreds of billions of dollars in Medicare and Medicaid cuts. And resources for housing and home- and community-based services programs, already inadequate to meet existing needs, likely would fall even farther behind, if these programs even were to survive. Aging services providers must focus on the future, planning for our potential residents’ and clients’ long-term services and supports needs in coming decades. We urge individuals to do this kind of planning for themselves; we also have a responsibility to see that groundwork is laid and resources are available to meet future long-term services and supports needs on a population-wide basis. The tax legislation now before Congress would hamstring our members’ ability to continue providing essential housing and long-term services and supports to future generations of elders. Although the bill as passed by the House of Representatives on November 16 differs in some provisions from the Senate measure, both versions of the legislation contain specific provisions that are problematic for our field and also would enormously expand the federal budget deficit. The following provisions of the legislation cause us particular concern:

Medical expense deduction

The House-passed legislation would eliminate the present individual tax deduction for medical expenses. While the bill increases the standard deduction, people aged 65 and over who have high out-of-pocket medical expenses relative to their incomes still could end up paying higher taxes. Residents of life plan communities who now can deduct a portion of their entry and/or monthly fees as advance payment of medical expenses would lose this deduction. The Senate version of the legislation retains the medical expense deduction.

Private Activity Tax Exempt Bonds

The House bill as passed eliminates private activity tax exempt bonds. This is a major source of funding for development of life plan communities by our members as well as a critical source of funding for low-income senior housing (as well as hospitals and colleges/universities). Unlike the for-profit sector which has access to a variety of sources of capital, including equity, LeadingAge members are largely reliant on tax-exempt bond financing. It is estimated that eliminating this tax exemption would raise the cost of capital to LeadingAge members by 25-35%, significantly impairing the development of new communities at a time when demand is growing and will continue to grow as the baby boomer generation ages. Any increase in the cost of financing ultimately will be borne as higher costs to the senior consumer. The Senate bill preserves tax-exempt status for private activity bonds.

Low-income housing tax credit

The elimination of the tax exemption for private activity bonds under the House tax measure would effectively end the 4% low-income housing tax credit program. Using multifamily housing bonds, a type of private activity bond, is the only way to trigger the availability of 4% low-income housing tax credits. Eliminating one ends the other. Nationally, more than 50% of all low-income housing tax credit transactions were done through the 4% credit (the remaining transactions were done through the 9% credit) in 2016. More and more, states are relying on 4% low-income housing tax credits to produce and preserve affordable housing.

Advance Refunding

Both the House and the Senate bills eliminate what is called "advance refunding". This occurs when a borrower seeks to refinance the bonds at a lower interest rate during the “call protected period” (typically 10 years), meaning the holder of the bonds can’t call and demand payment. Existing tax law allows one of these refinancings in the life of a bond. It is very common for LeadingAge members to use advance refunding, typically in two scenarios. A member might obtain financing in a higher interest rate market and when rates drop, advance refunding would lower their capital costs. And a start-up typically has a higher interest rate because of the risk associated with a new campus, but after they stabilize the risk goes down so they are able use advance refunding to lower their rate and costs. In both scenarios, advance refunding ultimately saves the senior consumer money since the payments they make include the cost of capital. The elimination of this provision therefore would lead to higher costs for the consumer.

Deduction for state and local taxes

The House-passed tax measure would eliminate the current deduction for state and local taxes, with an exception for up to $10,000 in local property taxes. The Senate bill would completely eliminate the deduction.

Eliminating or reducing the deduction for state and local taxes will make it harder for states to increase taxes to make up for any cutbacks in federal funding for Medicaid and other aging services programs. In addition, the loss of this deduction could put pressure on state legislatures and communities to cut taxes. Since Medicaid is the largest item in most state budgets and most, if not all states have balanced budget requirements, this tax provision poses a long-term, double-barrelled threat to Medicaid funding. Local efforts to cut property tax rates also could intensify efforts to subject not-for-profit organizations to property taxes.

Conclusion

As the Senate prepares to vote on H.R. 1, we are urging Senators to oppose the legislation. The bill would increase taxes on many elders, threatens our members’ ability to develop new housing properties and would inevitably lead to substantial cuts in Medicare, Medicaid and other essential programs that serve elders.

MEMORANDUM

Date: November 27, 2017

To: LeadingAge Iowa Board of Directors

From: Shannon Strickler, President/CEO

Subject: ROP Enforcement Moratorium & 5 Star Changes

On November 24, CMS issued S&C 18-04-NH delaying enforcement for certain F-Tags for Phase 2 of the Long Term Care Requirements of Participation (RoPs). Phase 2 becomes effective on November 28, 2017 simultaneous with the start of the new survey process. This moratorium extends the moratorium previously announced in S&C 17-36-NH on June 30, 2017 by 6 months.

Enforcement Moratorium

Specifically, CMS will provide an 18-month moratorium on the imposition of CMPs, discretionary denials of payment for new admissions and discretionary termination when related to of the F-Tags listed below. NOTE: This moratorium does not apply to mandatory provisions such as mandatory denials of payment for new admissions and mandatory termination for failure to achieve substantial compliance within required timeframes.

• F655 (Baseline Care Plan); §483.21(a)(1)-(a)(3) • F740 (Behavioral Health Services); §483.40 • F741 (Sufficient/Competent Direct Care/Access Staff-Behavioral Health); §483.40(a)(1)- (a)(2) • F758 (Psychotropic Medications) related to PRN Limitations §483.45(e)(3)-(e)(5) • F838 (Facility Assessment); §483.70(e) • F881 (Antibiotic Stewardship Program); §483.80(a)(3) • F865 (QAPI Program and Plan) related to the development of the QAPI Plan; §483.75(a)(2) and, • F926 (Smoking Policies). §483.90(i)(5) • (CMS is not applying the enforcement moratorium to F608 related to reporting reasonable

suspicion of a crime due to the concerns about significant resident abuse going unreported.)

CMS has directed state survey agencies to follow the standard enforcement process with all available remedies for all the other F-tags. Note that the moratorium may not prevent all CMPs and discretionary penalties for phase 2 depending on how the state survey agency classifies the citation. For example, F758 (psychotropic medications) is on a moratorium, but F757 (unnecessary drugs) is not; the state survey agency could potentially cite the noncompliance under F757 not F758 depending on the circumstances resulting in an enforcement action. CMS explicitly states that this 18 month moratorium does not change the implementation date for the Phase 2 provisions and state survey agencies should cite these tags as appropriate and continue to forward their findings to the RO as normal. State

survey agencies will continue to follow standard enforcement procedures related to Phase 1 and will utilize additional new remedies for the F-tags included in the moratorium as explained below.

Additional Remedies During Moratorium

In lieu of the CMPs and discretionary remedies for the Phase 2 F-Tags listed above, CMS has created two additional remedies that may be applied for noncompliance, Directed Plan of Correction (DPOC) and/or Directed In-Service Training (DIST). Once the moratorium is over on May 29, 2019, enforcement for all cited tags will return to the normal enforcement policy.

A Directed Plan of Correction (DPOC) is a remedy developed by CMS or the state survey agency requiring the facility to take action within a specified timeframe to correct cited non-compliance. The DPOC will address the structures, policies and processes needed by the facility to demonstrate and maintain substantial compliance. It will be completed as verified by CMS or the state upon a revisit or credible written evidence that can be verified without a site visit. Site re-visits will be expected for any of the tags within the moratorium were cited for Substandard Quality of Care (SQC) or for actual harm or immediate jeopardy.

A Directed In-Service Training is an enforcement remedy that may be used when CMS or the state survey agency believes that education is likely to correct the deficiencies and achieve substantial compliance. This remedy will require the relevant staff of the facility to attend an in-service training program that will address a demonstrated knowledge deficit. The training programs should be developed by well-established centers of geriatric health services education. After the training has been completed, CMS or the state survey agency will assess whether substantial compliance has been achieved or as verified by CMS or the state upon a revisit or credible written evidence that can be verified without a site visit.

Application of Discretionary Enforcement Remedies During 18-Month Moratorium

Discretionary Enforcement Remedies

Phase 1 Tags Only

Both Phase 1 and Phase 2 Tags

Phase 2 Tags Only

Normal Enforcement Remedies Apply OR 18-Month Moratorium Enforcement Policies Apply (DPOC and/or DIST)

Normal Enforcement Policies Apply

Normal Enforcement Policies Apply for the Phase 1 tag(s); and DPOC/DIST only may be imposed for Phase 2 tag(s) listed in moratorium (F655, F740, F741, F758, F838, F881, F865, F926)

18 Month Moratorium Enforcement Policies Apply (DPOC/DIST) to tag(s) listed in moratorium (F655, F740, F741, F758, F838, F881, F865, F926)

5-Star Changes

CMS also elaborated on the 5-Star “freeze” announced on June 30, 2017. CMS will be holding constant or “freezing” the health inspection star rating for health inspection surveys and complaint investigations conducted on or after November 28, 2017. They anticipate this freeze to begin in early 2018 and last approximately 1 year. Any survey activity conducted prior November 28, 2017 regardless of whether it is closed by then will be included in the rating as the survey was conducted prior to November 28, 2017.

Additionally, CMS stated that the health inspection star rating will no longer use information of the third oldest cycle of the health inspection survey and complaint investigation data. CMS will be dropping the third oldest year just as it would have been dropped from the score due to its age as part of the normal update process. This change will occur in early 2018 for all facilities. At that time, the most recent cycle will be weighted at 60 percent and the prior cycle will be weighted at 40 percent.

In addition to the freeze in score, CMS plans to add a summary of the facility’s most recent survey findings on nursing home compare to ensure transparency. This summary will include (minimally) the total number of deficiencies cited and the highest scope and severity level cited.

New Survey Process

CMS also release S&C 18-05-NH affirming that the new survey process will be effective November 28, 2017 and that Appendix P will no longer be assessible beginning November 28, 2017. Resources on the new survey process are available here.

2018 Legislative Agenda

Protect Medicaid Funding Nursing facilities and HCBS providers are struggling. Between Medicaid reimbursements below the cost of care in nursing facilities, an increasingly burdensome and costly regulatory environment, and a workforce shortage, aging services are struggling to maintain the high quality of care Iowans have grown to expect. With Iowa’s budget issues, LAI’s top priority is protecting the care of residents served by Long Term Supports and Services (LTSS). The populations utilizing LTSS are some of the most fragile Iowans. These people often have no viable options for paying for the intensive level of care. LTSS Medicaid funding covers a wide range of aging services, including:

• In-Home Health Services • Adult Day • Assisted Living • Residential Care Facilities • Nursing Facilities

The importance of Medicaid funding for LTSS cannot be overstated. Nursing facilities and HCBS providers are dependent on Medicaid to keep their doors open and provide care for Iowans. LTSS funding for Medicaid makes up almost half of the entire Medicaid budget, while only serving six percent of the total Medicaid population. For nursing facilities, nearly one out of every two residents in Iowa are using Medicaid to pay for services. For HCBS providers, the growing complexity of managed care has led to more administrative costs, new payment procedures, and reduced payments for services provided. LTSS and the populations they serve are dependent on keeping Medicaid fully funded. LAI supports protecting all funding for LTSS at its current levels. No cuts should be made to services for vulnerable Iowans or to their providers. Retroactive Eligibility Additionally, LAI supports the roll back the administrative rule eliminating Medicaid Retroactive Eligibility that became effective November 1, 2017 after CMS approved the state plan amendment on October 26, 2017. Retroactive eligibility applies to individuals newly enrolled in the Medicaid program whereas Medicaid looks back 90 days prior to the first of the month when the application was filed and pays medical bills during that period. Retroactive eligibility is critical to providers like nursing homes and long-term rehabilitation who cannot control the timing of the Medicaid application process by families and yet continue to serve the resident. For instance, retroactive eligibility is critical for providers of brain-injury rehabilitation whereas that timely rehab is crucial to the patient’s recovery and the need for Medicaid generally is due to a catastrophic event whereas the family is most worried about survival, not immediately filing a Medicaid application.

The legislature approved a cut to Medicaid Retroactive Eligibility during the 2017 session with a fiscal impact of $4.2 million, of which $262,000 related to long-long term supports and services. Upon implementation, this cut is estimated to far exceed the fiscal estimate and intent of the legislature. Just one long-term supports and services brain injury provider estimated that the elimination of retroactive eligibility will have a $600,000 impact because 15-20 percent of the individuals they serve rely upon retroactive eligibility to help cover the costs of their care. The Administrative Rules Review Committee was not confident that they had the authority to suspend and delay the emergency rule in November 2017 but discussed the need to revisit the issue once the legislature convenes. The General Assembly must direct the Department of Human Services to reinstate retroactive eligibility to ensure that providers receive payment for services rendered for Medicaid Eligibles. Rebuild Iowa Infrastructure Funding To support the renovation and replacement of Iowa’s aging long-term care infrastructure, the legislature has historically appropriated Rebuild Iowa Infrastructure Fund (RIIF) dollars to offset some of the costs of modernization by providing additional Medicaid reimbursement to nursing homes with a high percentage of Medicaid residents. This has been a very successful program that assists the modernization of facilities which would otherwise be difficult due to the high percentage of Medicaid residents with reimbursement rates below the cost of care. Unfortunately, these renovation and replacement dollars have not been dispensed by the department because of changes to the payment system with the transition to managed care. The department requires a technical fix to the distribution methodology to ensure that the Medicaid payments are made as intended to those nursing homes who have applied for this program and are relying on those enhanced payments appropriated by the legislature. LeadingAge Iowa supports continued RIIF appropriations to this program and the adoption of the technical modifications necessary to ensure that the funds are matched and distributed as the legislature has intended in the new Medicaid managed care system. Iowa’s Aging Services Workforce Crisis Iowa is in the midst of a workforce crisis for aging services. The number one issue for nearly every nursing facility and HCBS provider is finding quality staff to care for the Iowans they serve. With Iowa’s low unemployment rate, it is becoming more and more difficult to hire staff to care for aging Iowans. Reports show that providers will need 2.5 million LTSS workers by 2030 nationwide. Here in Iowa, there are an average 9,000 job postings a month for RNs, LPNs, and CNAs, with only 2,500 of those positions being filled. With the impending “grey tsunami” of baby boomers needing aging services, finding enough caretakers will be a critical issue for years to come. Iowa must act now to prepare its workforce to care for Iowa’s aging adults. Below are four policy recommendations that Iowa can pursue to tackle the workforce crisis:

• Invest in Iowa’s workforce. We need to make aging service careers a top priority to ensure quality care and experienced caregivers. Training for careers in aging services must be accessible and affordable to effectively grow the workforce and meet the demand.

• Fight the aging stigma. Iowa must take steps to raise awareness of issues related to aging and promote careers working with older adults.

• Aging service providers and managed care organizations must work together to provide value,

high quality care, and ensure access for Iowa’s seniors. ow

• The state of Iowa should develop a strategic plan to prepare for Iowa’s aging future. If Iowa takes the above steps, we can move forward with solving Iowa’s workforce crisis. Iowa’s Aging Services System The percentage of Iowan age 65 and older is expected to grow from 15 percent in 2010 to 22.5 percent in 2030. Between 2013 and 2030, the percentage of Iowans age 85 and older is expected to grow by 52 percent. These demographic changes will place unprecedented demands on the Long-Term Supports and Services (LTSS) system, and Iowa needs to begin planning now for a system that is more efficient and ensures availability of full continuum of services for older adults. A task force created by the legislature in House File 653, Section 97, to examine access to LTSS, including dementia, met on November 17, 2017. The task force prioritized several issues needing attention including, among others:

• Development of a more comprehensive, simplified and effective Medicaid reimbursement rate and system for assisted living programs and adult day programs to build increased capacity, particularly for adult day.

• Develop effective and affordable LTSS financing options beyond Medicaid through potential partnerships between the state and private, long-term care insurance plans.

• Re-evaluate regulatory environment to allow for a full continuum of services and increased flexibility in service provision and the availability of care, particularly related to dementia.

• Align system to ensure that individuals seeking LTSS, particularly in a crisis, can navigate the system and easily connect with services.

Iowa needs to start working now to resolve fractures, holes and inefficiencies in the LTSS delivery and financing system. LAI, the voice of non-profit aging services providers across the care continuum, looks forward to helping shape the solutions. With the wave of baby boomers entering the system, time is of the essence. About LeadingAge Iowa LeadingAge Iowa (LAI) is the strong and distinct voice for not-for-profit aging services providers in Iowa as we strive to expand the world of possibilities for aging through advocacy, education and collaboration. Our members represent a spectrum of non-profit providers including skilled nursing, assisted and independent living, home health, adult day care, respite, hospice, Programs for All-inclusive Care for the Elderly (PACE) and home-delivered meals.

10.17% 6

11.86% 7

15.25% 9

62.71% 37

Q1 How long have you been a leader in a senior living/aging servicesorganization?Answered: 59 Skipped: -1

TOTAL 59

0-3 years

3-5 years

5-7 years

7+ years

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

0-3 years

3-5 years

5-7 years

7+ years

1 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

54.24% 32

54.24% 32

77.97% 46

86.44% 51

22.03% 13

38.98% 23

5.08% 3

3.39% 2

Q2 What are the biggest challenges you currently encounter to keep yourorganization viable and successful? Please check all that apply:

Answered: 59 Skipped: -1

Total Respondents: 59

# OTHER (PLEASE SPECIFY) DATE

1 Dwindling funds to access capital in order to expand into other service lines due to financialposition - looking at developing specialized niches to also expand services and differentiate fromother competing facilities/companies.

11/2/2017 3:42 PM

2 Agency use and the draw that agencies have due to pay is a constant concern. In other statesLeading Age has helped create regulations that Agency’s cannot pay their staff more than $1.50-$2.00 above the average wage for any position.

11/2/2017 11:09 AM

Recruiting newresidents/cl...

Reductions/delays in...

Challengingregulatory...

Recruitmentand retentio...

Static ordwindling...

Need fornew/redesign...

Dwindlingpopulation i...

Other (pleasespecify)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

Recruiting new residents/clients to your community

Reductions/delays in Medicare/Medicaid reimbursement

Challenging regulatory requirements

Recruitment and retention of qualified staff

Static or dwindling reserve funds

Need for new/redesigned facilities

Dwindling population in my service area

Other (please specify)

2 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

59.32% 35

67.80% 40

81.36% 48

38.98% 23

79.66% 47

8.47% 5

Q3 What challenges do you anticipate in the future? Please check all thatapply:

Answered: 59 Skipped: -1

Total Respondents: 59

# OTHER (PLEASE SPECIFY) DATE

1 Baby Boomers don't want to "join" a member based organization like ours. 11/16/2017 1:33 PM

2 Financial piece is personally very worrisome not just as an organization but for those who reallyneed help or a place to go and facilities won't accept you if you can't pay.

11/2/2017 1:20 PM

3 Continuing regulatory changes / increasing requirements. 11/2/2017 9:36 AM

4 As an independent organization, partnering with others in certain areas will be key. 11/2/2017 9:27 AM

5 Regulatory Climate 11/2/2017 9:21 AM

Baby boomersdon’t want t...

Emergingseniors don’...

Reduction inMedicare and...

Ability tosurvive as a...

Difficultyrecruiting...

Other (pleasespecify)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

Baby boomers don’t want the same model of senior living

Emerging seniors don’t have sufficient financial resources

Reduction in Medicare and Medicaid funding

Ability to survive as an independent organization (if you are one)

Difficulty recruiting qualified staff

Other (please specify)

3 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

35.71% 20

53.57% 30

39.29% 22

53.57% 30

71.43% 40

5.36% 3

Q4 Given the emerging future challenges, what do you anticipate needingto do to remain successful? Please check all that apply:

Answered: 56 Skipped: 2

Total Respondents: 56

# OTHER (PLEASE SPECIFY) DATE

1 Come up with creative ways to leverage family members as shared caregivers if possible 11/9/2017 1:06 PM

2 Replace old nursing home. 11/9/2017 9:21 AM

3 Continue to upgrade our facilities to avoid becoming dated. 11/3/2017 1:25 PM

Expandservices to...

Provide abroader rang...

Change orsupplement t...

Considerpartnership ...

Possiblypartner with...

Other (pleasespecify)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

Expand services to reach a broader geographic area

Provide a broader range of services to include a younger audience

Change or supplement the traditional 3- step residential model

Consider partnership or affiliation with other organizations

Possibly partner with other types of healthcare providers to link services

Other (please specify)

4 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

98.28% 57

56.90% 33

70.69% 41

34.48% 20

24.14% 14

31.03% 18

48.28% 28

0.00% 0

Q5 How do you best remain current, informed about trends, and thinkingstrategically about future challenges?

Answered: 58 Skipped: 0

Total Respondents: 58

# OTHER (PLEASE SPECIFY) DATE

There are no responses.

LeadingAgeIowa/LeadingAge

Other seniorliving/aging...

Industry news

Other seniorliving/aging...

US news sources

Otherconferences

Education

Other (pleasespecify)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

LeadingAge Iowa/LeadingAge

Other senior living/aging services leaders

Industry news

Other senior living/aging services associations

US news sources

Other conferences

Education

Other (please specify)

5 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

Q6 How important is it for the Association to be involved in these issues?Answered: 59 Skipped: -1

86.44%51

13.56%8

0.00%0

0.00%0

0.00%0

59

1.14

66.10%39

33.90%20

0.00%0

0.00%0

0.00%0

59

1.34

54.24%32

38.98%23

6.78%4

0.00%0

0.00%0

59

1.53

71.19%42

27.12%16

1.69%1

0.00%0

0.00%0

59

1.31

41.38%24

43.10%25

12.07%7

3.45%2

0.00%0

58

1.78

35.59%21

37.29%22

20.34%12

6.78%4

0.00%0

59

1.98

50.85%30

35.59%21

13.56%8

0.00%0

0.00%0

59

1.63

39.29%22

26.79%15

26.79%15

3.57%2

3.57%2

56

2.05

Advocacy

Communication

CEUEducation/Ce...

ComplianceResources/Po...

SpringConference

Fall Conference

GeneralEducation

MemberDiscount...

0 1 2 3 4 5 6 7 8 9 10

EXTREMEIMPORTANCE

ABOVEAVERAGEIMPORTANCE

AVERAGEIMPORTANCE

BELOWAVERAGEIMPORTANCE

NOTIMPORTANT

TOTAL WEIGHTEDAVERAGE

Advocacy

Communication

CEUEducation/Certification

ComplianceResources/PolicyTemplates

Spring Conference

Fall Conference

General Education

Member DiscountProgram

6 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

Q7 What support, or services might LAI provide to help your success thatis difficult to create or provide for yourself?

Answered: 21 Skipped: 37

# RESPONSES DATE

1 Connection with other Senior Centers across the state. 11/16/2017 1:33 PM

2 Marketing Adult Day Services and their importance. 11/16/2017 8:37 AM

3 More educational opportunity 11/15/2017 4:03 PM

4 IASN: continue to support network/ contracting services growth Continue to provide tools andresources for managing emerging member needs Continue to strengthen LAI association(membership) brand

11/15/2017 3:17 PM

5 None 11/15/2017 2:42 PM

6 Continued review and education on legislative and regulatory changes that effect our industry 11/6/2017 4:14 PM

7 Not sure that LAI can help us find residents or staff. 11/3/2017 1:25 PM

8 advocacy with legislators for a bigger voice; timely information and interpretation of changesannounced by DHS/IME and getting answers when we don't have information; education andtraining for staff and leadership

11/3/2017 7:31 AM

9 Advocacy 11/2/2017 8:26 PM

10 Legal advice, education on new state and federal codes, industry challenges, opportunities andeducation, lobbying.

11/2/2017 5:52 PM

11 Establishing alliances with capital funding; in education/conferences covering topics to assist ruralfacilities which are stand alone and are not a continuum of care; covering ideas/concepts toexpand service lines beyond a CCRC; covering what hospitals are looking for in partnering withfacilities for SNF care; topics covering MCO's from admission process through out the stay anddischarge planning and follow-up; regulations & reimbursement; tying financial aspects of the MDSand not just the clinical side of the MDS (this is a major weakness of AANAC and some of theadivisors themselves do not understand what, why and how to expand financial gains from theMDS.

11/2/2017 3:42 PM

12 put members in touch with specialized service providers like 3rd party billers 11/2/2017 10:17 AM

13 Continued data and metric comparisions 11/2/2017 10:15 AM

14 Otherwise, just continue to filter through all the items and give us the "need to know". It isextremely difficult to keep up with when trying to handle day to day operations as well. It isreassuring to know you are doing that for us. Thank you. Like the virtual learning. Those are veryhelpful as it is difficult to get out of the building with multiple key employees. More of thoseopportunities or even live streaming.

11/2/2017 9:53 AM

15 Help maneuvering the MCO system for billing issues. We don't have a separate billing department,or tech or legal department.

11/2/2017 9:41 AM

16 *recognize different needs of large metro area multi-level facilities vs. small, rural, independentfacilities. *continue with the Communique --- I get LOADS of info from this every time it arrives inmy inbox. *offer a generic Policy & Procedure book --- electronically editable to fit specific needs ofthe organization. I would expect to PAY for this.

11/2/2017 9:36 AM

17 Continued networking opportunities. Also, continued assistance with policies and changes that areoccurring. LAI is certainly on the right track.

11/2/2017 9:27 AM

18 strategically growing our organization for long-term sustainability. IASN will help us. Continuededucation on ROPs and resources is extremely helpful. Partnerships, understanding all the dataavailable and the impact, aggregating data, etc...

11/2/2017 9:25 AM

19 Industry New Development Education Consulting (such as Liz's work) 11/2/2017 9:24 AM

7 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

20 For independent organizations we need resources and services to help us address issues inquestion 4. Beyond that it is hard to say without giving it more thought.

11/2/2017 9:15 AM

21 Challenges with time constraints for new ROP's 11/2/2017 9:01 AM

8 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

Q8 How else may LAI help you or your organization succeed that is notcurrently done at this time?

Answered: 13 Skipped: 45

# RESPONSES DATE

1 ? 11/16/2017 8:37 AM

2 More education 11/15/2017 4:03 PM

3 I think we are making great strides as an association: education, advocacy, tools/resources, 11/15/2017 3:17 PM

4 Nothing 11/15/2017 2:42 PM

5 would it be possible and/or cost effective to have quarterly meetings at various places in the stateto review what is going on? Also have some sort of revelant topic for CEUs

11/9/2017 9:21 AM

6 Nothing comes to mind 11/3/2017 1:25 PM

7 Nothing comes to mind. Love the new adult day quarterly calls! 11/3/2017 7:31 AM

8 Lobbying to educate legislatures to understand the industry and what some of theirlaws/reimbursement changes/survey issues where Iowa has been found to be towards the top ofquality standards, but yet is also leading in the $ amounts of fines assessed by the state - theentire structure of the state survey process should be looked at empirically in comparison to otherstates and why have two departments dealing with surveys. Educate Grassley, as he doesn't havea clue!

11/2/2017 3:42 PM

9 provide more education/networking opportunities for fund raising, as this will be the only way forproviders to bridge the gap between cost to provide care and reimbursement

11/2/2017 10:17 AM

10 see above 11/2/2017 9:53 AM

11 Provide contact information for Administrators / CEOs of member organizations. Some type of LAI"phone book" listing all member organizations, leaders with email addresses, types of careprovided.

11/2/2017 9:36 AM

12 I would like to see our organization be more involved with our legislatures - it's probably an areamore for us to work on than with LAI but the involvement together.

11/2/2017 9:25 AM

13 Facility and service assessments and recommendations. 11/2/2017 9:15 AM

9 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

32.20% 19

5.08% 3

35.59% 21

10.17% 6

16.95% 10

Q9 Which job title best identifies your position:Answered: 59 Skipped: -1

TOTAL 59

# OTHER (PLEASE SPECIFY) DATE

1 Marketing 11/16/2017 10:29 PM

2 director 11/16/2017 8:37 AM

3 Director of Memory Support 11/15/2017 4:41 PM

4 Executive Director 11/15/2017 4:30 PM

5 CFO 11/15/2017 2:55 PM

6 Executive Director 11/9/2017 1:06 PM

7 quality 11/2/2017 11:06 AM

8 Marketing Director 11/2/2017 9:52 AM

9 Director 11/2/2017 9:41 AM

10 Regional Director Operations/Administrator 11/2/2017 9:01 AM

CEO

COO

Administrator

DON

Other (pleasespecify)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

ANSWER CHOICES RESPONSES

CEO

COO

Administrator

DON

Other (please specify)

10 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

Q10 (Optional) Name of your organization:Answered: 15 Skipped: 43

# RESPONSES DATE

1 Siouxland PACE UnityPoint St. Lukes. 11/17/2017 1:12 PM

2 CASI 11/16/2017 1:33 PM

3 North Star Community Services- Newel Post 11/16/2017 8:37 AM

4 Northcrest 11/15/2017 2:55 PM

5 Mayflower 11/3/2017 1:25 PM

6 Aging Services, Inc. 11/3/2017 7:31 AM

7 Warneke Consulting Tripoli Nursing & Rehab 11/2/2017 3:42 PM

8 Hillcrest Home, Inc. 11/2/2017 1:50 PM

9 Bethany Life 11/2/2017 12:33 PM

10 Iowa Masonic 11/2/2017 9:53 AM

11 New Horizons Adult Day Center 11/2/2017 9:41 AM

12 Stacyville Community Nursing Home 11/2/2017 9:36 AM

13 Stonehill Franciscan Services 11/2/2017 9:25 AM

14 Mayflower Community Grinnell 11/2/2017 9:24 AM

15 Pleasantview Home 11/2/2017 9:15 AM

11 / 11

2017 LeadingAge Iowa Member Survey SurveyMonkey

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Leading Age Iowa (LAI) Summary of Interviews

November 2017 Interviewees:

Name Organization Mindi Baker Eventide Lutheran Home Gretchen Brown Stonehill Franciscan Services Randy Ehlers Siouxland PACE Lisa Gates Friendship Village Scott Halbach Lutheran Retirement Home Kris Hansen Western Home Communities Kathy Horan Abbe Health Laura Kopp Center for Active Seniors, Inc. Rob Kretzinger WesleyLife Robin Mixdorf Meth-Wick Community Brian Phillips Highland Ridge Heather Rehmer Bishop Drumm Retirement Center Hallie Salmen Sunrise Retirement Community Pat Stillwill On With Life at Ankeny Mark Teigland Calvin Community Julie Thorson Friendship Haven Millisa Tierney NewAldaya Lifescapes Bert Vigen Ridgecrest Village Jay Willshire Luther Park Community

Disclaimers:

• The results are listed with most frequently occurring answers to questions first, and on in descending order of frequency.

• Because most interviewees gave multiple answers to questions, these numbers will not add up the same in any given questions.

• Statements in parentheses following answers to questions are notable comments given by a single person interviewed.

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Question 1: What inspired you to serve on the LAI Board (or in a leadership position, for those not on the board)?

8 Networking with peers matters to me, and LAI is the way we do it. 4 Collaboration. There is great impact in working together. LAI provides the opportunity to

speak with one voice. 4 Information. The Board is at the cutting edge in the industry and I want access. 3 I wanted to be a part of building LAI. 3 Advocacy. LAI is the best option for advocating for the aging community. 3 LAI is well respected. Lots of value for our organization. 2 When asked, you serve 2 I like to offer my expertise to others in this industry. 2 I want to be proactive, to mold ideas within the community. 1 Shannon’s leadership vision 1 Inspired by being on Emerge Class 1 Passion for recreating the association.

Question 2: From your experience, what are the best ways that LAI serves its members? What do they do well that brings value and helps members’ continued success?

14 Communication and interpretation about laws, CMS guidelines and policies 13 Advocacy in Iowa’s legislature 11 Trainings / Education for members 9 Networking 3 Leveraging services, i.e. legal services 3 Shannon Strickler – her engagement/having a pulse of what’s going on 2 Conferences 1 Mentoring members 1 Work regarding payer contracting 1 Information about benchmarking ourselves against our peers 1 Forming an alliance for health benefits

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Question 3: What are the biggest challenges that you believe the members face today?

10 Employee turnover and staffing 8 Reimbursement policies and procedures 8 Regulatory changes 5 Inefficiency of single-site facilities. (Need to lower costs/expand services thru partners) 2 Unsustainable Medicaid model 2 Low census 2 Stuck on old vision of aging services/senior living 2 Sheer volume of changes – we can’t keep up 1 Baby boomers are a different generation who don’t want/cannot afford what we offer 1 Financial balance between managing costs and raising funds/revenues 1 Workforce aging and apathy of staff. (How do we attract millennials?) 1 Technology for transitions and coordination of care 1 Not enough formal education 1 Trying to keep communities informed. (Seniors are invisible.) 1 Growing behavioral dementia crisis 1 Showing communities the value in our services 1 Older facilities, need repair and repositioning 1 Paying others to support us. (Is LAI worth it?) 1 State and Federal: How we’re graded by the DIA and CMS is “archaic.”

Question 4: How does LAI help members overcome these challenges today?

7 Education. (Tools have gotten significantly better in the last 2 to 3 years.) 6 Advocacy 5 Networking and conferences 4 Information regarding regulatory changes 3 Helping us understand numbers and measurements 2 Wage and benefits data for staffing (but need more help with recruiting/staffing) 1 Fundraising. (For the adult day program) 1 Provider network 1 Marketing of services 1 LAI has been continuum-focused 1 Population health information is values-based 1 Helping us understand CMS’s 5-Star Matrix 1 LAI-embedded consultant helped us to stabilize 1 LAI is proactive and takes the lead 1 Being timely and relevant-Looking to future skill sets for evolving workforce needs

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Question 5: What future challenges do you see members facing?

8 Staffing and Workforce shortages (nurses and all categories) 7 Regulatory Demands 5 Reimbursement Policies 4 Training / Education/Communication 3 Lack of good leadership; strong leadership culture 2 Keeping our mission and message (favorable to non-profit) front and center 2 Strategic Planning 2 Technology 2 Funding streams 2 Financial viability – shrinking revenue + rising costs; independent financial struggle; debt 2 Boomer dislike for current residential model and lack of their finances 1 Lower demand for independent/assisted living 1 Quality of health in the elderly 1 Mental health in the elderly population 1 Speaking with a single voice to legislators 1 Collaboration & Partnerships 1 Population Health / Value-Based Association (A hole in the market. How can we fill it?) 1 The Affordable Care Act and all that is unknown about it 1 Cost of participation in LAI (Iowa Healthcare Association is also good.) 1 Competing in a market that favors for-profit providers

Question 6: In what ways would you like to see LAI evolve to be able to help members address those challenges?

4 Shannon’s leadership and more of the services LAI now provides 4 Grow in Advocacy (Like IACP) 3 More Training / Conferences / Education 3 Help us grow our own talent / workforce into leadership roles 3 Develop senior leaders; Develop/promote mentors on-site 3 Decide LAI’s mission and who they serve and make it well known to membership 2 Teach us to use one another as resources and not rely on LAI staff to solve problems 2 Innovate (What could be a totally new approach? Are there new ways to go to CMS?) 1 Membership push; need more members 1 Consolidation/Partnership of member organizations 1 Offer LAI association group health insurance 1 Continue on our trajectory 1 Consider a new LAI track (Maybe Consulting services?) 1 Provide or coordinate Management / Nursing / MDF / Data Services 1 Benchmarking. (We need to learn to use / collect data. Can members share tools?)

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