state presentations

Minnesota’s Medicaid Buy-In

Medical Assistance for Employed Persons with Disabilities (MA-

EPD)

• The goal of the program is to encourage people with disabilities to work and enjoy the benefits of being employed, and

• Promote competitive employment and the economic self-sufficiency of people with disabilities

Medical Assistance for Employed Persons with Disabilities

MA-EPD Goals

Background


• Grassroots effort by advocacy groups led to Minnesota legislature’s adoption of Medicaid Buy-In program

• Efforts began in the early ’90s to demonstrate the need for allowing workers with disabilities to retain their Medicaid eligibility


• “It’s a great program. I don’t know what I would do without it.” Bill

• “I want to make sure my premium is there on time. I don’t want to lose this great coverage.”

Kathy


MA-EPD Monthly Enrollment September 1999- December 2006

2000

2500

30003500

4000

4500

5000

5500

60006500

7000

7500

Sep

-99

Dec

-99

Mar

-00

Jun-

00

Sep

-00

Dec

-00

Mar

-01

Jun-

01

Sep

-01

Dec

-01

Mar

-02

Jun-

02

Sep

-02

Dec

-02

Mar

-03

Jun-

03

Sep

-03

Dec

-03

Mar

-04

Jun-

04

Sep

-04

Dec

-04

Mar

-05

Jun-

05

Sep

-05

Dec

-05

Mar

-06

Jun-

06

Sep

-06

Dec

-06

Data Source: MMIS

General Enrollment Data


Changes in MA-EPD Policy

EARLY MA-EPD POLICY WORK INCENTIVE POLICYEARNEDINCOME

Total gross monthly earned income of $1.00 or higher to qualify

(No earned income requirements)

$65 earned income disregard (More than $65 total gross

monthly earned income to be eligible)

Effective 1/01/04PREMIUMPAYMENT

Premium payment for individuals whose combined total monthly gross income meets or exceeds 100% FPG. Payments begin at $7/month.

Effective 11/01/01

$35 minimum premium payment for all enrollees using current premium structure

Effective 1/01/04

TAXWITHHOLDIN

G

Certain employers are exempt from withholding taxes (sheltered workshops and day activity centers)

Effective 11/01/01

To be considered employment, Social Security and Medicare taxes must be withheld

Effective 1/01/04

“There really is a program that doesn’t make you be poor before you can use it? Wow!”

Nancy


MEDICAREPART B

All Medicare Part B premiums reimbursed using State funds for enrollees not QMB/SLMB eligible (county reimburses enrollee, state reimburses county

Medicare Part B premiums reimbursed only if enrollee is not eligible for QMB/SLMB and has total income at or below 200% FPG

Effective 11/01/03

UNEARNED

INCOME

No additional fee tied to unearned income

Enrollees must pay one-half of one percent of total monthly unearned income

Effective 11/01/034-MONTHELIGIBILIY(MEDICAL

)

Two-month continuation of eligibility due to medical reasons

Effective 11/01/00

Four-month continuation of eligibility due to medical reasons

Effective 11/01/01

4-MONTHELIGIBILIY(JOB

LOSS)

Not applicable Four-month continuation of eligibility due to job loss for reasons other than conduct

Effective 1/01/04


Changes in MA-EPD PolicyEARLY MA-EPD POLICY WORK INCENTIVE POLICY

With today’s economy and job market, we’ve seen many people lose their jobs, through no fault of their own. Like Ed, who is a software developer. Ed had worked for the company for 13 years when he was laid off due to down-sizing. Without the 4-month job loss leave he would have been without medical coverage. He was able to find another job before his 4 months expired and had continuous medical coverage.


MA-EPD Safety Net


Name ofProgram

Incomeguideline

s

AssetGuidelines

WorkRequirement

CostSharing

EarnedIncomeDisregards

MedicalAssistance

(MA)

100% FPG$851 single$1141

couple

$ 3000 single$ 6000 couple

None MA with spend down (if above $851

single,must spend down to75% FPG = $639single)

First $65 ½ of

remaining

MedicalAssistance forEmployedPersons withDisabilities(MA-EPD)

No upper income limit

$20,000 perindividual; alsoexcludes

spouse’sassets,

retirementaccounts, andmedical expenseaccounts set up

byan employer

Must be employed

or self-employed,

earning more than

$65 (average)monthly, and Medicare andSocial Securitytaxes paid orwithheld

Sliding fee scalepremium based onincome and

householdsize. Minimum of

$35.

Unearned incomeobligation (½% ofgross unearnedincome)

First $65

Compare: MA and MA-EPD


“I could work more but I make sure I don’t work more than 18 hours each week so I don’t lose my SSDI.”

Doug

• Manual Billing System

• Lack of clear definition of “work”

• SSDI Cash Cliff


Challenges


“I started working to get on MA-EPD but now I’m working because I like it. It gives me something to do and I work with some really fun people.”

Laura

Stay Well, Stay WorkingBenefit PackageHealth Care Services (modeled on Medicaid State Plan) – Medica / UBH

Wellness Employment Navigator Services – MN Resource Center

Employee Assistance Program – Optum

Intensive Employment Assistance Services as needed – MN Resource Center

Peer-Facilitated WRAP Services – Consumer Survivor Network

• Employment stability & job performance

• Health management

• Quality of life

• Frequency of symptoms of mental illness

• Access to employer-sponsored health benefits

• Benefits of person-centered supports

• How employees access support services

Stay Well, Stay WorkingOutcomes to be Studied

For further information contact:

Beth Grube, Policy [email protected] 431-2412

Or

MaryAlice Mowry, Director, Pathways to Employment & Stay Well, Stay [email protected] 431-2384


WORK(Work Opportunities Reward Kansans)

Mary Ellen O’Brien WrightKansas Health Policy Authority

Work Opportunities Reward Kansans WORK

Approved under the Deficit Reduction Act – State Flexibility in Benefit Packages (Section 6044)

A Secretary Approved Benchmark Benefit package

A “package” of benefits designed for adults with disabilities who are employed and enrolled in the Kansas Medicaid Buy-In program, Working Healthy

“Cash and Counseling” Model

Goes a step beyond consumer self-direction

Allows consumers to directly manage their funds

Offers flexibility in terms of what services are purchased, and how they are purchased

Working Healthy Eligibility

Two Optional Medicaid Categories: “Basic” and “Medically Improved”

Federal Requirements 16-64 years of age Determined disabled by SSA

State Requirements Verified earned income subject to

FICA/SECA Kansas resident

WORK Eligibility

Consumers must meet the Working Healthy eligibility requirements, plus:

Eligible for the Physical Disability, Developmental Disability, or Traumatic Brain Injury Waivers, or

On the waiting lists for these waivers, or Meet the same level of care as individuals on

these waivers, and Competitively employed in an integrated setting,

and Residing in a home or property that is not owned,

operated, or controlled by a provider of services not related by blood or marriage

Working Healthy/WORK Benefits

Full Medicaid coverage Personal and other services for those who need them Countable earned income up to 300% Federal Poverty

Level Cash assets up to $15,000 Retirement accounts (no limit) Individual Development Accounts (no limit) Elimination of spend down (Premiums for those >100%

of FPL) Medicare coverage paid by Medicaid (sometimes

employer premiums paid) Benefits planning

WORK Services Package

Assessment

Personal Services

Assistive Services

Independent Living Counseling

Assessment

Determination of a consumer’s need for personal assistance services based on his/her functional limitations

Personal Services

One or more persons assisting, or cuing/prompting, consumers with activities of daily living they would typically perform themselves in the absence of a disability

Alternative and cost-effective methods of obtaining assistance to the extent that expenditures would otherwise be used for human assistance, e.g., meal or laundry service, purchase of equipment that decreases the need for human assistance

Personal Services

Work related services include assisting, or cuing and prompting, consumers to understand job responsibilities, in interacting appropriately with other employees and the general public, in appropriate work behavior, in practicing safety measures, in symptoms management

Monthly Allocation

Personal Services are paid directly by the consumer with a monthly allocation that is determined during the assessment.

Flexibility in spending the allocation:

Wages for assistants can vary based on required tasks, time of day, etc Funds can be used to pay for assistant’s vacations or health insurance Unspent allocation funds can be rolled over into a designated savings

account to be used the next month or for approved savings Consumers can be creative!

Assistive Services

Assistive Technology not covered under the Kansas Medicaid State Plan

Services that assist consumers to use assistive technology

Home modifications

Independent Living Counseling

Assisting consumers to:

develop, and obtain approval for, their Individualized Budgets and Emergency Back-Up Plans

access training

locate service providers

coordinate their services

report problems

etc…

Benefits Specialists

o Collect data on individual’s current benefits status

o Provide a critical analysis of work, earning, and resources on a consumer’s benefits in order to help him/her make an informed choice about employment

o Provide options to the individual and their support network if appropriate about the impact of employment or increased employment on benefits

o Provide information about Working Healthy and WORK

Temporary Unemployment

Working Healthy has a six months “grace” period. Consumers may remain in the program for six months while they seek employment or recover

Reasons for WORK The DRA Benchmark Benefits provision, under which

WORK was authorized, provided the most flexibility for designing an innovative program that meets the needs of a working population requiring personal assistance services to work and live in the community.

The Kansas Health Policy Authority (KHPA), which administers Medicaid in Kansas, believes that Working Healthy, combined with the WORK services necessary to support employment, will increase the number of Kansans with disabilities who are employed.

Unlike most waivers, WORK allows consumers with various disabilities, including developmental disabilities, to be served within the same program. KHPA believes this will promote competitive, integrated employment for adults with developmental disabilities.

Reasons for WORK

WORK provides consumers with the ability to “control” their services, rather than to just “direct” them, potentially increasing consumer satisfaction.

WORK permits direct cash payments to consumers to pay for their services, which may facilitate more cost-effective decision-making regarding services and service providers.

Kansas received a Medicaid Infrastructure Grant to Support the Competitive Employment of People with Disabilities, and believes that WORK will contribute to success in meeting employment goals.

Cash & Counseling: An Innovative State

ProgramCongressional Briefing on Health and Disability Policy

July 12th, 2007United States Senate Finance Committee

William A. B. Ditto, DirectorDivision of Disability Services

New Jersey Department of Human Services

Cash & Counseling: Program Overview Funders

The Robert Wood Johnson Foundation US DHHS/ASPE Administration on Aging

Waiver and Program Oversight Centers for Medicare and Medicaid Services

National Program Office Boston College Graduate School of Social Work

Evaluator Mathematica Policy Research, Inc.

Original Cash & Counseling Demonstration Overview• Original Demonstration States

• Arkansas, Florida, New Jersey

• Study Populations• Adults with disabilities (Ages 18-64)• Elders (Ages 65+)• Florida: Both groups above & children with developmental

disabilities

• Feeder Programs• Arkansas and New Jersey: Medicaid personal care option programs• Florida: Medicaid 1915c Home and Community-Based long-term

care waiver programs

Original (3) and Expansion(12) Cash & Counseling States

• Consumer Directed Services Definition:

– A philosophy and orientation to the delivery of services whereby informed consumers assess their needs, determine how these needs should be met, determine who can best meet them and monitor the quality of services received. The consumer exercises substantial control over the resources available to meet their needs.

Basic Model for Cash & Counseling

• Step 1: Consumers receive traditional assessment and care plan

• Step 2: A dollar value is assigned to that care plan

• Step 3: Consumers receive enough information to make unbiased personal choice between managing individualized budget or receiving traditional agency-delivered services.

Basic Model for Cash & Counseling

• Step 4: Consumer and counselor develop spending plan to meet consumer’s personal assistance needs

• Step 5: Individual provided with financial management and counseling services (supports brokerage)

• Note: Can make use of a representative or surrogate decision maker, if desired.

New JerseyPersonal Preference ProgramReasons New Jersey Implemented Program

• Demographics• Prudent Purchasing/Effective Use of Resources• Consumer Empowerment• Increase Personal Responsibility• Address Consumer Complaints & Lack of

Flexibility• Support of Family Caregivers

New JerseyPersonal Preference ProgramDetails of Program Design

• Utilizes a Section 1115 Research & Demonstration Waiver

• Cashes out NJ Medicaid Personal Care Benefit (Optional State Plan Service)

• Individual Budget Based on Standard Clinical Assessment

• Rates are $15.50 weekdays, $16.00 holidays & weekends

• 10% Deduction to Cover Cost of Fiscal Employer Agent and Counseling Services (Maintains Cost Neutrality)

New Jersey Personal Preference ProgramDetails of Program Design

• Participant Designs Cash Management Plan (CMP) with assistance from Counselor

• Can Select & Use Unpaid Representative to help• Participant Serves as “Employer of Record”• Participant Recruits, Hires, Determines Pay &

Benefits for Workers• Workers can be Family, Friends or Others• Individual Budget can also be Used for Purchasing

Services, Equipment and Home Modifications related to meeting Personal Care Needs

New Jersey Personal Preference ProgramDetails of Program Design

• Fiscal Employer Agent/FEA (also known as Fiscal Intermediary Service Organization) handles all payroll and other payments

• FEA claims Medicaid Funds each Month and Maintains Individual Account for Participant

• Counselor visits Participant Quarterly to Monitor

• Nurse Reassesses Participant Every Six Months

Policy Implications For Workers with Disabilities

• Provides opportunities to hire co-workers and friends to provide workplace PAS

• Enables participants to control when and how services are delivered

• Budget can be used to purchase equipment or devices to increase independence in the workplace

• May reduce employer concerns about job accommodations

General Policy Implications• Can increase access to care

• Greatly improves quality of life (all ages)

• Family caregivers also benefit greatly

• Community integration is enhanced

• Consumers are prudent purchasers

• It Works !!!!!

Deficit Reduction Act (PL 109-171) February 8, 2006

States traditionally needed to use Section 1115 (Research & Demonstration Waivers) or Section 1915(c) (Home & Community Based Waivers) to offer Cash & Counseling

Section 6087 of the Deficit Reduction Act (DRA) is entitled:

Optional Choice of Self Directed Personal Assistant Services (Cash and Counseling)

This provision became effective 1/1/07

Deficit Reduction Act (PL 109-171) February 8, 2006

One potential impediment for States:

Section 6087 (j)(6)

“. . . Payment for the activities of the financial management entity shall be at the administrative rate established in Section 1903(a).”

For more information:

www.cashandcounseling.orgor

William A. B. Ditto, Director

NJ Personal Preference Program

New Jersey Division of Disability Services

[email protected]

Personal ChoicesPersonal ChoicesOffering Consumers Choice and FlexibilityOffering Consumers Choice and Flexibility

Alabama first state to make consumer-directed (also known as self-directed) care for Medicaid home and community-based services a permanent part of its State Plan.

Alabama worked closely with Centers for Medicare and Medicaid Services to ensure successful completion of the application.

Consumer-Directed Care in Alabama

DRA 2005

The state plan option is available to states under the Deficit Reduction Act (DRA) of 2005, Section 6087 or 1915(j)

• 1915 (j) is specific to self-directed care, such as the Personal Choices program, to offer consumers more control in managing their daily lives

Program Value

• Budget-neutral

• Offers consumer satisfaction and enhanced quality of life

• Reduces unmet care needs, and

• Increases access to authorized services

• Increased access to paid personal care

• Increased satisfaction with services

• Increased overall quality of life

•Positive health and safety outcomes

•Decreased stress on families and informal caregivers

Expected Consumer Outcomes

Expected Outcomes for the State

Making consumer-directed care a permanent part of the State Plan will relieve Alabama of the intensive and repeated waiver renewal process.

Potential cost reduction and quality improvements

Program Validity

Personal Choices program based on “Cash and Counseling” model.

Model tested over the past decade in Arkansas, Florida, and New Jersey in partnership with Robert Wood Johnson Foundation and CMS.

Personal Choices Program

• Allows participants of two of Alabama’s HCBS Waivers to self-direct certain services

• Up to 700 older adults and people with disabilities in seven west Alabama counties eligible to participate

• Program to begin August 1, 2007

Working Together for Consumers

• Administering Agency Alabama Medicaid Agency

• Operating AgencyAlabama Department of Senior Services in partnership with Alabama

Department of Rehabilitation Services

Eligible Individuals

• Must currently receive personal care or personal assistance services under Elderly and Disabled (E&D) Waiver or State of Alabama Independent Living (SAIL) Waiver

• Live in one of the seven pilot counties

• Must accept responsibilities of program participation

Program Integrity

• Personal Choices designed to ensure the integrity of services provided

• “Counseling” system plays a crucial role in working with the consumer to prevent fraud and abuse

• Clear definition of goods and services that may and may not be purchased

• Close review of budgets to ensure that only authorized goods are included, and

• Review of workers’ time sheets and participants’ check requests before payment to ensure consistency with the budget plan

One's philosophy is not best expressed in words;

it is expressed in the choices one makes ...

and the choices we make are ultimately our responsibility.

Eleanor Roosevelt

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