national council on aging webinar with autism now june 21, 2011

8/6/2019 National Council on Aging Webinar with Autism NOW June 21, 2011

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Improving the lives of older Americans

Medicaid Home and Community

Based ServicesJoe Caldwell


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2011. National Council on Aging A nonprofit service and advocacy organization

Medicaid is a Lifeline

Med icai d is a lif e line for chil d re n, in d ivid uals withd isabiliti e s, an d se niorsMed icai d provide s e sse ntial h e alth cov e rag e to ov e r46 low-incom e child re n an d par e ntsMed

icaid

provide

s he

alth and

long-te

rm se

rvice

s toove r 8 million in d ivid uals with d isabiliti e s.Ove r 15% of se niors r e ly on Med icai d

Med icai d pays Med icar e pre miums for almost 5 million low-incom e be ne ficiari e sMed icai d cove rs se rvice s not cov e red by Med icar e (e .g.de ntal car e , h e aring ai d s, e ye glasse s)


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Medicaid Basics

Means t e st ed program (must b e poor)Strict incom e and asse t limitsIn ge ne ral, most in d ivid uals with d isabiliti e s qualify through SSI(Supple me ntal S e curity Incom e ) pathway

In 39 stat e s an d ind ivid uals r e ce iving SSI automatically r e ce ive Med icai d .

In ge ne ral, in d ivid uals must hav e e arnings l e ss than $1,000/month (unabl e to work) an d have countabl e asse ts l e ss than $2,000.

Joint F ede ral an d Stat e funded programFede ral shar e ranging from 50% to about 76%, de pe nd ing on p e rcapita incom e .

Re fe rred to as F MAP (Fede ral Med ical Assistanc e Pe rce ntag e )


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Federal Medical Assistance Percentages (FMAP)

50 percent (13 states)

61 to


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S tates submit S tate Medicaid PlanMandatory and Optional Benefits

All Stat e s hav e to provi de man d atory b e ne fitsStat e s can choos e to provi de optional b e ne fits

Howe ve r, som e tim e confusing b e caus e many so call ed optional b e ne fits ar e not r e ally optional (for ex ampl e ,pre scription d rugs)Mand atory an d Optional B e ne fits must b e provide insuffici e nt (a k e y prot e ction for b e ne ficiari e s):

AmountDurationScope

Se rvice s need to b e stat e wide and comparabl e

Medicaid Benefits


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Medicaid Benefits

Physician services

Laboratory and x-ray services

Inpatient hospital services

Outpatient hospital services

Early and periodic screening,diagnostic, and treatment(EPSDT) services forindividuals under 21

Family planning

Rural and federally-qualifiedhealth center (FQHC) services

Nurse midwife services

Nursing facility (NF) servicesfor individuals 21 or over

Prescription drugs

Clinic services

Dental services, dentures

Physical therapy and rehab services

Prosthetic devices, eyeglassesPrimary care case management

Intermediate care facilities for thementally retarded (ICF/MR) services

Inpatient psychiatric care for individuals

under 21Home health care services

Personal care services

Hospice services

Mandatory Items and Services Optional Items and Services


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Enrollees Expenditures

Medicaid Enrollees and Expenditures

Children 19%

Elderly26%

Disabled43%

Adults 12%Children

48%

Elderly9%

Disabled16%

Adults27%

Total = 52.4 million Total = $252 billion


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Long-Term Services and SupportsOve r 10 million Am e ricans curr e ntly n eed long-t e rmse rvice s an d supports (LTSS)

Approximat e ly 42% are unde r 65 y e ars of ag eNeed s for LTSS will mor e than d oubl e in coming de ca de s withaging of population

Informal family car e give rs provi de vast majority of long-te rm

Medicaid is the primary funding source for formalLTSS


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L ong-Term Services and Supports in the US

Long-Term Care Paid Long-Term Care

Unpaid

78%

Both Paid &Unpaid 14%

Paid Only8%

Medicaid48%

Medicare18%

Out-of-Pocket

20%

PrivateInsurance

9%

Other6%


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Medicaid HCBS ProgramsIn ge ne ral thr ee main programs account for th e majority ofMed icai d HCBS

Medicaid HCBS 1915(c) Waiver State Plan Personal CareServices (PCS) Option

Medicaid Home Health

$25 Billion

1,107,358 Participants

$ 8.5 Billion

881,762 Participants

$ 4.5 Billion

873,607 Participants

The Kaiser Commission on Medicaid and the Uninsured (KCMU) and The University of California at San Francisco's (UCSF)analysis based on The Centers for Medicare & Medicaid Services (CMS) Form 372, December 2009


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Wh at is a W aiver?Driving forc e of ex pansion in community-bas ed se rvice sEstablish ed in 1981Called a waiv e r be caus e it waiv e s c e rtainre quir e me nts in Med icai d law:

Allows state

s to targe

t populationsAged , Aged and Disabled , Physically Disabl ed , MR/DD,TBI, Child re n, Mental H e alth, HIV/AIDS

Allows stat e s to s e rve ce rtain g e ographic ar e asAllows stat e s to limit th e numb e r of in d ivid uals s e rved


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Stat e s can de sign waiv e rs to inclu de any of th e followingse rvice s:

Case manag e me ntHome make r s e rvice sHome he alth ai de se rvice sPe rsonal car e se rvice sAd ult d ay h e alth s e rvice sHabilitation s e rvice sRe spit e car eDay tr e atm e nt an d oth e r partial hospitalizationse rvice s, psychosocial r e habilitation s e rvice s, an d clinical s e rvice s for in d ivid uals with chronic m e ntalillne ssOthe r se rvice s

1915( c) W aiver Services


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Othe

r se

rvice

s can include

a wide

range

of se

rvice

s and

supports approv ed by th e Se cre tary such as:

Assistive t e chnologyBe havior manag e me nt

Support ed e mploym e ntDe ntalFamily/car e give r trainingInde pe nde nt living skillsCommunity transition

1915( c) W aiver Services


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Medicaid 1915( c) HCBS W aiverMust qualify for Med icai d and mee t an institutionalle ve l of car e need se t by th e stat e .Curre ntly 314 d iffe re nt Med icai d HCBS waive r programsapprov ed by CMS

Most stat e s hav e multipl e waive r programs e ach with d iffe re nte ligibility an d se rvice s (e .g. Flori d a has 12 d iffe re nt programs)One of th e be st r e sourc e s to fin d out what HCBS waiv e rprograms ex ist in your stat e is th e Ce nt e r for P e rsonalAssistanc e Se rvice s:http://www.pasc e nt e r.org/stat e_ bas ed_ stats


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Center for Personal Assistance Services

Medicaid Waiver Data

Please choose a State, or select the

entire US

Select a state from the map or the list


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Maryland Medicaid 1915(c) HCBS Waivers, 2006.

In 2006, there were 14,466 participants in the 6 waiver programs in Maryland ( Table 1 )

with expenditures totaling $508,706,175 (an average expenditure of $35,166 per

participant) ( Table 2 ).

Table 1. Maryland 1915(c) HCBS Waiver Participants, by Waiverand Waiver Target Group, 2006

Waiver Name by WaiverTarget Group

Number of Maryland

Participants

MarylandParticipants per

1,000 Population

US Participantsper 1,000

Population

Total MR/DD note 9,663 1.73 1.49

MR/DD 9,663 1.73 -

Total TBI/SCI note 12 0 0.04

Traumatic BrainInjury 12 0 -

Total Aged 3,284 0.59 0.42

Senior housing 3,284 0.59 -

TotalDisabled/PhysicallyDisabled

430 0.08 0.20

Adult with PhysicalDisabilities 430 0.08 -

Total Children 1,077 0.2 0.06

Children with AutismSpectrum Disorder 873 0.16 -

Disabled children 204 0.04 -


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Maryland Medicaid HCBS W aiver for Individuals wit h Developmental DisabilitiesW aiver target group: MR/DDS tate:MD

W aiver name:MR/DD

Description:This waiv e r allows p e rsons with DD who m ee t ICF-MR le ve l of car e to r e main living at hom e

and in th e community as an alt e rnativ e to institutionalization. S e rvice s off e red unde r thiswaive r inclu de : d ay habilitation, r e side ntial option s e rvice s, r e spit e car e , s e rvice scoor d ination, e nvironm e ntal mo d ifications, an d AT.

Contact Information:MR/DD contact information 1

S tate waiver website:MR/DD we bsit e 2

Program Data:MR/DD 2006 participant d ata 3, MR/DD 2006 ex pe nd itur e d ata 4


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Maryland Autism W aiverW aiver target group: ChildrenS tate:MD

W aiver name:Child re n with Autism Sp e ctrum Disor de r

Description:This waiv e r allows chil d re n b e low 21 who ar e d iagnos ed with Autism Sp e ctrum Disor de r who r e ce ive more than 15

hours p e r wee k of sp e cial ed ucation an d re lat ed se rvice s an d who m ee t an ICF- MR le ve l of car e to r e main living athome and in th e community. S e rvice s off e red unde r this waiv e r inclu de : r e spit e car e , e nvironm e ntalmod ifications, int e nsive ind ivid ual support s e rvice s, th e rap e utic int e gration, an d family training.

Contact Information:Child re n with Autism Sp e ctrum Disor de r contact information 16

S tate waiver website:Child re n with Autism Sp e ctrum Disor de r we bsit e 5

Program Data:Child re n with Autism Sp e ctrum Disor de r 2006 participant d ata 17, Child re n with Autism Sp e ctrum Disor de r 2006

ex pe nd itur e d ata 18


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Autism Specific W aiversSome Stat e s with Autism Sp e cific Waiv e rs:

Ind iana approv ed 1990 s e rve s about 600 p e opleMarylan d approv ed 2000 s e rve s about 900 chil d re nWisconsin approv ed 2003, s e rve s about 3,000 p e opleColora d o approv ed 2005, s e rve s about 160 chil d re nSouth Carolina approv ed 2006, s e rve s about 600 chil d re nMain e approv ed 2007 s e rve s about 2,000 p e opleMassachus e tts approv ed 2007, s e rve s about 80 chil d re nKansas approv ed 2008, s e rve s about 50 chil d re nPe nnsylvania approv ed 2008, s e rve s about 200 a d ultsMontana approv ed 2008, s e rve s about 50 chil d re n

*Pe nnsylvania 1915(a) contract

Source :CMS (May, 2009). Autism Med icai d Waive r Programs: F ede ral an d Stat e

Pe rspe ctiv e s. We binar by Association of Univ e rsity C e nt e rs onDisabiliti e s (AUCD) .


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Medicaid 1915( c) HCBS W aiverIs th e foun d ation of th e De ve lopm e ntal Disabiliti e s Se rvice Syste mThree -fourths of all waiv e r sp e nd ing was for in d ividuals withde ve lopm e ntal d isabiliti e s.Still a lot of variation across stat e s.


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Federal- S tate HCB S W aiver Spending inUS Surpassed ICF/MR Spending in 2001

Source:Bra

ddock,

et al., 2011.


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2011. National Council on Aging A nonprofit service and advocacy organizationSource: Bradd ock, D. e t al., Stat e of th e Stat e s in De ve lopm e ntal Disabiliti e s, 2011.

75%6%

4%4%

6%5%

Nursing Faciliti e s

Privat e 16+

ICF/MR 7-15

Othe r 7-15

Stat e -Ope rat edInstitutions


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1. ALASK A

2. DISTRICT OFCOLUMBIA

3. HAW AII

4. INDIANA5. MAINE

6. NEW HAMPSHIRE

7. NEW MEXICO

8. OREGON9. RHODE ISLAND

10. VERMONT

11. W EST VIRGINIA

S tates that no longer use publicinstitutions for people with DD

(Bradd ock e t al., 2011)


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Per Capita Federal- S tate HCB S Spending

UNITEDSTATES $83

Source: Bradd ock, D., Stat e of th e Stat e s in De ve lopm e ntal Disabiliti e s, 2008.

* Per capita of the general population

1 New York $247 18 South Dakota $113 35 Colorado $63

2 Maine $230 19 Wisconsin $106 36 New Jersey $57

3 Rhode Island $214 20 Kansas $104 37 Virginia $56

4 Minnesota $211 21 Delaware $100 38 Alabama $54

5 Vermont $205 22 Nebraska $93 39 California $52

6 DC $203 23 Maryland $91 40 South Carolina $51

7 Wyoming $178 24 Tennessee $90 41 North Carolina $51

8 New Mexico $139 25 Iowa $89 42 Utah $479 Connecticut $133 26 Massachusetts $88 43 Florida $47

10 Pennsylvania $131 27 Hawaii $82 44 Arkansas $45

11 North Dakota $131 28 Michigan $80 45 Idaho $44

12 West Virginia $127 29 Ohio $79 46 Kentucky $42

13 Alaska $124 30 Washington $76 47 Illinois $38

14 New Hampshire $124 31 Montana $72 48 Georgia $34

15 Oregon $121 32 Indiana $72 49 Texas $28

16 Louisiana $119 33 Missouri $66 50 Nevada $27

17 Arizona $115 34 Oklahoma $63 51 Mississippi $13


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W here do people with DD live (2009 data)?

Source:

Braddock, Hemp, & Rizzolo, Coleman Institute and Department of Psychiatry, University of Colorado, 2005,

based on Fujiura (1998).(Bradd ock e t al. 2011 bas ed on Fujiura, 1998)


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remember that 60% of people with DD live with family caregivers

Caregivers Aged 60+29,765

Caregivers Aged 41-5942,872

Caregivers Aged


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W aiting Lists

Ofte n ex te nsive waiting lists within stat e s for HCBSwaive r s e rvice s that can b e ye ars or de cade s longConse rvativ e ly, stat e s re port ov e r 393,096 in d ivid uals onwaiting listsWaiting lists hav e d oubl ed ove r th e past de ca de

Not all stat e s maintain official or accurat e waiting lists d ataSome stat e s hav e e stablish ed ce rtain crit e ria to de t e rmin e whore ce ived se rvice s typically e me rge ncy situations


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R ecent Improvements in Healt h R eformM

one

y Follows the

Pe

rsonAdd itional $2.25 billion provi ded in Affor d abl e Care ActDe monstration Grants to Stat e sProvide add itional f ede ral fun d ing (an e nhanc ed FMAP) forstat e s to transition in d ivid uals from institutional to hom e and community-bas ed se ttingsMajority of stat e s hav e or will soon hav e MFP grants (45+stat e s)

Med icai d HCBS State Plan OptionImprove me nts ma de in Afford abl e Care ActOnly a han d ful of stat e s curr e ntly hav e ad opt ed optionCan b e ne fit in d ivid uals who d o not m ee t institutional l e ve l-of-car e


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R ecent Improvements andNew Options in HCBS

Balancing Inc e ntiv e Payme nt ProgramAvailabl e Octob e r 2011Grants availabl e to stat e s to assist with balancing frominstitutional to community-bas ed se rvice sEligible to stat e s with gr e at e st institutional bias (l e ss than

25% or 50% of HCBS spe nd ing in th e community)

Community First Choic e OptionAvailabl e in Octob e r 2011Stat e plan option to provi de p e rsonal att e ndant s e rvice s an d supportsStat e s can r e ce ive add itional f ede ral fun d ing (6% e nhanc ed FMAP)


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Additional R esources

HHS (2010). Understanding Medicaid Home and Community Services: A Primer http://asp e .hhs.gov/ daltcp/r e ports/2010/prim e r10.p d f

Cole man Institut e (2011). State of the States inDevelopmental Disabilities.

https://www.cu. ed u/Col e manInstitut e /stat e ofth e stat e s/

national council on aging webinar with autism now june 21, 2011

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