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Medicaid Long-Term Services and

SupportsEric Saber, Health Policy Analyst

Long Term Care and Community Support ServicesMaryland Department of Health and Mental Hygiene

December 19, 2011

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Agenda National Context for Rebalancing Efforts Affordable Care Act

Money Follows the Person Extension Balancing Incentive Payments Program (BIPP) Community First Choice (CFC)

Status Updates

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Nationally, rebalancing efforts have reduced the proportion of LTSS spending on nursing facilities from 73.4% to 66.6% between 2004 and 2009.

Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.

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Percentage of Medicaid Long-Term Services and Supports Spending for HCBS: Older Adults and Persons with Physical Disabilities 2009

Maryland is behind these national trends and in 2009, ranked among the poorest in home and community-based services (HCBS) financing. . .

Maryland = 14.9%

Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.

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Change in the Percentage of Medicaid Long-Term Services and Supports Spending for HCBS: Older Adults and Persons with Physical Disabilities 2004-2009

. . . indeed, Maryland was nearly alone among the states in going backwards between 2004 and 2009.

Maryland = -5.0%

States

Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.

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While Maryland Medicaid’s payment rates to nursing facilities are higher than average. . .

States

Maryland = $193.21

National Average: $154.13

Source: Harrington, et al. (2008). State Data Book on Long Term Care, 2007. US Dept of Housing and Urban Development.

7Sources: Maryland Medicaid Long Term Care Rate Changes. (2011). Department of Health and Mental Hygiene and U.S. Bureau of Labor Statistics, Occupational Archives. 1999-2010 and www.cms.gov.

Average Annual Increase: +4.6%

Average Annual Increase: +1.4%

Average Annual Increase: +5.9%

. . . payments to nursing facilities haven’t kept up with medical inflation (and things are much worse for home- and community-based service providers).

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Affordable Care Act Supports most integrated setting, person-centered planning,

and individual control. Includes increased focus on quality and accountability. Offers new or improved home and community-based services

(HCBS) State Plan options. Offers enhanced Federal funding to help states modify

delivery systems. Key Provisions

Money Follows the Person Extension Balancing Incentive Payment Program Community First Choice: 1915(k)

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MFP Overview Federal demonstration created by the Deficit Reduction Act of

2005, offered through the Centers for Medicare and Medicaid Services (CMS) and designed to:

Assist states in rebalancing long-term care systems Increase the use of Home- and Community-Based Services

(HCBS) Remove barriers to receiving services in the community

Maryland is one of 30 jurisdictions currently participating in the demonstration

Affordable Care Act extended the demonstration and offered grants to additional states Transitions through December 31, 2016 Spending through 2019

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MFP Overview To access MFP funds, states must transition individuals

receiving Medicaid services from “qualified institutions” to “qualified residences”

MFP Eligibility 90 days in institution 1 day of Medicaid eligibility in the institution

The State receives enhanced federal matching funds for services provided to demonstration participants for 365 days

Enhanced matching funds result in “savings” to the State States are required to spend savings on approved

rebalancing initiatives Savings can not:

Pay for services Off-set ongoing state costs

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Federal Requirements Qualified Institutions

Nursing Facilities (NFs) State Residential Centers (SRCs) Institutions for Mental Disease (IMDs) Chronic Hospitals

Exploring expansion to include Psychiatric Residential Treatment Facilities (PRTFs)

Qualified Residences A home owned or leased by the individual or the individual's

family member; An apartment with an individual lease, with lockable access

and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control;

A residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside.

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Existing WaiversMaryland will serve MFP participants using five

home- and community-based waiver programs

The Traumatic Brain Injury (TBI) waiver Serves adults in chronic hospitals and State-owned nursing

facilities

The Community Pathways (CP) waiver Serves adults with developmental disabilities

The New Directions (ND) waiver Self-directed waiver for adults with developmental disabilities

The Living at Home (LAH) waiver serves people with physical disabilities between 18 and 65

The Older Adults Waiver (OAW) serves adults with disabilities over the age of 50

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Rebalancing Initiatives Increase outreach to institutional residents

Peer Outreach Contracts Program Education Application Assistance

Improve the transition process Enhance Transitional Case Management Housing Assistance

Enhance existing community-based services Peer Mentoring New Waiver Services

Improve Systems Statewide ADRC sites

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Balancing Incentive Payments Program (BIPP) Offers an enhanced federal medical assistance percentage

(FMAP) for all HCBS covered during the “balancing incentive period” through September 30, 2015. Maryland qualifies for a 2% enhanced payment rate. All enhanced federal payments must be used to fund new and

expanded Medicaid community-based LTSS.

Within six months, states must initiate “structural changes” to their LTSS systems that include: Creation of a Single Point of Entry system for LTSS Development of a Standardized Assessment Instrument Implementation of Conflict Free Case Management

By the end of the BIPP period states must: Increase HCBS to 50% of total Medicaid LTSS spending Implement required structural changes

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BIPP Updates – Financial Received CMS assurance that Maryland is eligible to

apply for a 2% enhanced match based on the Federal Fiscal Year (FFY) 2009 LTSS spending percentages included in BIPP Application Maryland’s calculated percentage in the BIPP

Application was 36.8% Services included in this percentage are

waiver programs (including DD waivers), home health and personal care expenditures.

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Community First Choice (CFC) Optional State Plan benefit to offer Attendant Care and related

supports to individuals, providing opportunities for self-direction. Includes 6% enhanced FMAP. CMS is still discussing policy decisions.

Specifically, CMS is discussing whether all CFC participants must meet the State’s institutional level of care, or whether CFC also is available for people who require attendant care but are not at institutional level of care.

Final Federal regulations may not be available until 2012.

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Community First Choice (CFC) We propose to offer all required and optional services allowed

under CFC regulations. Specifically, CFC would offer: Personal / Attendant Care; Personal Emergency Response Systems (PERS); Voluntary training for participants; Transition Services; and Services that increase independence or substitute for human assistance.

Services offered under CFC would no longer be covered as a waiver service, but rather covered as a State Plan service. Waiver participants are eligible to receive all State Plan services.

The State will: Refine this concept as federal guidance emerges, especially regarding the

potential institutional level of care qualifying criteria Seek technical assistance from CMS on policy decisions; Establish an Implementation Council; and Analyze further policy decisions and implementation plan for CFC.

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Community First Choice (CFC) CFC is not creating a new eligibility standard.

CFC is a consolidation of current State Plan eligible participants who receive personal care into one robust program offering additional services and self-direction.

The program is expected to grow based on increased utilization due to: Increased services to certain current participants, Participation of currently eligible participants not

receiving services, and Improved reimbursement to most providers.

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Improvements possible under CFC In addition to services offered under CFC, with the

enhanced match the State would be able to also provide the following: Enhanced quality assurance. A provider registry. Trainings to providers. Coordinated rates across programs. An option to develop a back-up system.

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Status Updates Long Term Care Reform Workgroup is submitting

a report to the legislature in December 2011. Long Term Care Reform Workgroup will transition

to the Money Follows the Person Workgroup and the Community First Choice Implementation Council in January. MFP-BIPP stakeholder meeting on January 10, 2012 Community First Choice Implementation Council will

meet in January after council selection is complete. Core Standardized Assessment stakeholder

meetings were held on December 12 and 15 for stakeholder input.