At the Crossroads: Providing Long-Term Services and Supports at a - - PowerPoint PPT Presentation

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“At the Crossroads: Providing Long-Term Services and Supports at a Time of High Demand and Fiscal Constraint”

2007 (actual) to 2013 (projected) Personal Income, Corporate, and Sales Taxes

Source: HMA analysis of data from National Association of State Budget Officers (NASBO), Fall Fiscal Survey of States, 2007–2010 reports, and Fall 2012 Report for 2013. Notes: Data are not adjusted for inflation. The 2013 figures are enacted. For Illinois, this map uses projected revenue from NASBO's 2006 report because 2007 revenue data were not available.

HI WA MI AK CA WI OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

Percent Change

< -15.0%

• 9.9% to -14.9%
• 5.0% to -9.9%
• 0.0% to -4.9%

0.0% to 4.9% +5.0% to 9.9% > +10%

Percent Change in State Tax Revenue

• 40.0%
• 20.0%

0.0% 20.0% 40.0% 60.0% 80.0% 2008 2009 2010 2011 2012 2013

Percent change in state nominal revenue from 2007 baseline

2010: All but a handful of states have revenues below the 2007 baseline. 2013: Six years later, 16 states still have revenues lower than 2007 levels. 2008: One year into the recession, 13 states experience budget declines.

State Revenue Changes for 50 States through and beyond the Recession

Source: Computed from data reported in National Association of State Budget Directors and National Governors' Association Fiscal Survey of the States, Spring 2012 for 2011, 2012, and 2013 (projected) and from Fiscal Survey of the States, Fall 2011 for 2010.

Average annual % difference from 2007 baseline

2008 to 2013 (projected)

Source: HMA analysis of data from National Association of State Budget Officers (NASBO), Fall Fiscal Survey of States, 2007–2012 reports. NOTE: The data are the average of each state’s percentage difference from the 2007 baseline revenue over the 6 years. No states fell within +10% to 15%, or -15% to -20% ranges.

MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

Average % Difference

0% to -5% 0% to +5% +5% to +10% +15% to +20% > +20%

• 5% to -10%
• 10 % to -15%

< -20%

Cumulative Revenue Experience

Source: "Medicaid Today; Preparing for Tomorrow: A Look at State Medicaid Program Spending, Enrollment and Policy

• Trends. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2012 and 2013"; Vernon K. Smith,

Kathleen Gifford, Eileen Ellis, et al.; Kaiser Commission on Medicaid and the Uninsured; October 2012. Note: Enrollment percentage changes from June to June of each year.

• 1.90%

0.40% 3.20% 7.50% 9.30% 5.60% 4.30% 3.20% 0.20%

• 0.50%

3.10% 7.80% 7.20% 4.40% 3.20% 2.75%

• 3%
• 1%

1% 3% 5% 7% 9% 11%

Medicaid annual enrollment growth 1998–2013 (projected)

Medicaid Enrollment Growth Has Slowed Significantly

Annual Growth in Total and State Medical Spending, 2003–2013

Source: "Medicaid Today; Preparing for Tomorrow: A Look at State Medicaid Program Spending, Enrollment and Policy

• Trends. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2012 and 2013"; Vernon K. Smith, Kathleen

Gifford, Eileen Ellis, et al.; Kaiser Commission on Medicaid and the Uninsured; October 2012. Note: Years are state fiscal years. 8.5% 7.7% 6.4% 1.3% 3.8% 5.8% 7.6% 6.6% 9.7% 2.0% 3.8% 5.5% 4.9% 10.1% 3.0% 4.0% 5.7%

• 10.9%
• 4.9%

16.1% 27.5% 2.3%

• 0.13
• 0.08
• 0.03

0.02 0.07 0.12 0.17 0.22 0.27 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Adopted Total State General Fund

ARRA Enhanced FMAP (2009–2011) Enhanced FMAP/Federal Fiscal Relief (2003–2005)

HCBS Waiver Recipient Change 2010–2013 (projected)

26 27 36 34 4 7 7 10 3 3 4 3 5 10 15 20 25 30 35 40 2010 2011 2012 2013 (projected) Number of States Decrease No Change Increase

N = 33 for 2010 N = 37 for 2011 N = 47 for 2012 and 2013

29 34 37 1 3 5 4 7 2 10 20 30 40 2011 2012 2013 projected Number of States Decrease Stay the Same Increase

N = 34 for 2011 N = 44 for 2012 and 2013

HCBS Expenditure Change from Previous Year 2011–2013

MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

2011–2012

District of Columbia expenditures decreased less than 5%

MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

2012–2013

District of Columbia expenditures increased less than 5%

Percent Change +=>15% + 5% to 8%

• <5%

+< 5% + 8% to 15%

• 5% to 8%
• 8% to 15%

No Change

Percent Change in HCBS Expenditures

7 13 7 9 15 20 20 18 18 5 10 15 20 25 2011 2012 2013 projected Number of States Decrease Stay the Same Increase

N = 36 for 2011 N = 46 for 2012 N = 45 for 2013

Nursing Facility Census Change from Previous Year 2011–2013

19.4% 28.3% 15.6% 25.0% 32.6% 44.4% 55.6% 39.1% 40.0% 0% 20% 40% 60% 80% 100% 2011 2012 2013 projected % of Total Responding States Census Increased Census Stayed the Same Census Decreased

N = 36 for 2011 N = 46 for 2012 N = 45 for 2013

Nursing Facility Census Change 2011–2013

Funding Sources for State Aging and Disability Agencies

10 20 30 40 50 60 70 80 90 100 State appropriation Older Americans Act Medicaid U.S. Department of Labor U.S. Department of Agriculture Social Services Block Grant Other Targeted tax Local (i.e., county or city) funding Foundation/private grants Community Services Block Grant U.S. Department of Transportation U.S. Department of Education State lottery Federal Emergency Management Agency (FEMA) U.S. Department of Justice Percent of States

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Increased Decreased Stayed the same Do not know Percent of States SFY 2012 Changes in Non-Medicaid Expenditures SFY 2013 Anticipated Changes in Non-Medicaid Expenditures

Non-Medicaid Expenditures (SFY 2012 vs. SFY 2013)

SFY 2011–2012 State by State Changes in Non-Medicaid Expenditures

RI AK HI

SFY 2011–2012 Percent Change 11%–15% Decrease 6%–10% Decrease 5% or less Decrease Stayed the Same 5% or less Increase 6%–10% Increase Data Not Available

OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT

SFY 2013 Anticipated State by State Changes in Non-Medicaid Expenditures

RI AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT

SFY 2012–2013 Percent Change 11%–15% Decrease 6%–10% Decrease 5% or less Decrease Stayed the Same 5% or less Increase 6%–10% Increase Do Not Know Data Not Available

Strategies Used or Planned to Control Non-Medicaid Costs (SFY 2012 and SFY 2013)

5 10 15 20 25 Streamline state-level operations Form new partnerships Reduce staff Limit enrollment Freeze or reduce provider rates Streamline regional and/or local operations Reduce state's allotments to AAA and local providers Limit services Delay implementation of new programs Increase cost-sharing (copayments/contributions) Change from more local service delivery to regional Eliminate programs Eliminate services Number of States SFY 2012 SFY 2013

0% 20% 40% 60% 80% 100% 2010 2011 2012 Decreased Increased Stayed the same

Change in APS Caseloads: SFY 2010–2012 Percent of Responding States

Two-thirds of States Have or Are Planning Duals Integration Initiatives

MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

Implementation

Existing Program

(in 2012) Plan to Implement timing uncertain Plan to Implement in 2013 Plan to Implement in 2014

State Duals Integration Finance Structure

MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

Implementation

RBMC MFFS or PCCM Both RBMC and MFFS ACO Model

States Restructuring State Aging and Disability Agencies

AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT

States restructuring since 2011 (CT, DE, HI, IA, IN, KS, ME, NC, NH, OH, OR, PA, VT, VA, WA, WY) States with plans for restructuring (CO, DC, LA, NV, WV) States both restructuring since 2011 and with plans (AL, MD, NJ)

Factors Driving State Aging and Disability Agency Restructuring

5 10 15 20 Number of States Comprehensive vision Consistent policy making Administrative simplification Improved access to services (no wrong door) Accountability Quality management Consolidation of program authority Budget and personnel reductions Preparation for managed long-term services and supports Other Reduction of institutional bias Global budgeting Address functions that present conflict of interest

5 10 15 20 25 30 35 40 Health Homes Improved Care Coordination for Dually Eligible Individuals Section 1915(i) Medicaid State Plan Amendment Balancing Incentive Program (BIP) Community First Choice Option (CFCO) Number of States

Overview of State Interest in ACA Options That Impact LTSS Populations

States Involved in Health Homes for Individuals with Chronic Conditions

States with CMS Approval (AL, IA, ID, ME, MO, NC, NY, OH, OR, RI, WI) States that have SPA officially submitted to CMS (IA [2nd SPA], VT) States with Draft SPA Under CMS Review (IL, MA, MD, OK, RI [3rd SPA], SD, WA, WV) States in conceptualization phase (CO, DE, GA, HI, IN, MI, MN, ND, NH, TX) * States with planning request approved by CMS (AL, AR, AZ, CA, DC, ID, KS, ME, MN, MS, NV, NJ, NM, NC, WV, WI)

WA MA AK HI OR NV* UT AZ* SD NE KS* AR* LA WI* IN KY TN GA SC VA ME* MS* AL* WV* CA* ID* MT WY NM* TX ND OK MN* IA MI IL MO OH FL PA NY CO NC* VT NH MD DE NJ* DC* RI CT

States with or Pursuing Section 1915(i) HCBS State Plan Amendments

AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT

States with CMS approval (CA, CO, CT, IA, ID, LA, NV, OR, WI) States that have submitted proposed state plan amendments (IN, NC) States in conceptualization phase or considering the option (AK, AR, DC, IL, OH, KY, MA, NE, ND, SD, WA)

States Involved in Balancing Incentive Program

AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT

States with CMS approval (AR, CT, GA, IA, IL, IN, LA, MD, ME, MO, MS, NH, NJ, NY, OH, TX) States in conceptualization phase or considering the option (MA, ND, RI)

States Involved in Community First Choice Option

State with CMS approval (CA) States that have submitted application to CMS (AZ, LA, MN) States in conceptualization phase or considering the option (AK, AR, CO, DC, GA, MA, MD, MT, ND, NY, OR, TX)

AK HI OR NV UT AZ SD NE KS AR LA WI IN KY TN GA SC VA ME MS AL WV CA ID MT WY NM TX ND OK MN IA MI IL MO OH FL PA NY CO NC WA VT NH MA MD DE NJ DC RI CT

26 16 7 12 5 10 15 20 25 30 2013 2012 2011 2010 Number of States

N = 47 for 2012 and 2013 N = 37 for 2011 N = 38 for 2010

Number of States with HCBS Policy Changes 2010–2013 (planned)

15 10 4 8 1 3 3 6 10 2 2 4 6 8 10 12 14 16 2013 2012 2011 2010 Number of States Expanded Restricted Neutral

Number of States with HCBS Changes by Impact on Benefits 2010–2013

N = 47 for 2012 and 2013 N = 37 for 2011 N = 38 for 2010

5 3 1 1 1 5 2 1 6 1 2 4 6 8 10 12 14 2013 2012 2011 2010 Number of States Expansion Restriction Neutral

Number of States Making LTSS State Plan Changes

N = 47 for 2012 and 2013 N = 43 for 2011 N = 34 for 2010

Nursing Home provider rate change data source: "Medicaid Today; Preparing for Tomorrow: A Look at State Medicaid Program Spending, Enrollment and Policy Trends. Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2012 and 2013"; Vernon K. Smith, Kathleen Gifford, and Eileen Ellis, Health Management Associates; and Robin Rudowitz and Laura Snyder, Kaiser Commission on Medicaid and the Uninsured; October 2012.

LTSS Provider Reimbursement Rate Changes

25 10 8 8 4 30 4 5 6 2 28 9 5 11 2 20 4 3 7 2

N = 39 for 2010 N = 31 for 2011 N = 47 for 2012 N = 43 for 2013

3 3 5 2 21 4 3 5 2 23 4 6 7 2 30 9 11 12 3 26

States with Rate Increases States with Rate Decreases FY 2010 FY 2011 FY 2012 FY 2013 (planned) Nursing Home Home Health HCBS Other Services

Personal Care