Medicaid Advisory Committee October 24, 2018 9:00am-12:00pm 1 - - PowerPoint PPT Presentation

Medicaid Advisory Committee

October 24, 2018 9:00am-12:00pm

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Webinar Housekeeping

• Register: https://attendee.gotowebinar.com/register/3721828556762702851
• MAC website: https://www.oregon.gov/oha/HPA/HP-MAC/Pages/index.aspx
• Join audio by calling in:

1-888-398-2342 Code: 3732275 (public line) *Member code on calendar invite*

• Public line is muted. Please don’t put the line on hold!
• Those on the member line – remember to mute your phone when not

speaking

• Send questions using the “Questions” box in the control pane
• Public comment at 11:45. Please let us know in the “questions” box if you

would like to submit written comment.

• Meeting/webinar is being recorded and will be posted online

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Welcome & Introductions

Bob DiPrete recently passed away after a battle with cancer. Bob was a Medicaid Advisory Committee member and former director of the MAC. He helped Oregon become a national leader in health policy, including helping lead the launch and early administration of the Oregon Health Plan in 1989, and serving as the Deputy Director of the Office of Health Policy and Research for 10 years. Bob will be greatly missed.

Remembering Bob DiPrete

Meeting objectives

• Regular business (e.g. approve minutes)
• Understand the latest updates for the Medicaid program from OHA and

DHS

• Understand the current federal proposal to amend public charge rules;

potential implications for Medicaid

• Understand Oregon Governor’s office and agency work to analyze and

respond to proposals

• Understand and discuss various options for the Medicaid Advisory

Committee to engage in this work

• Better understand the Long-Term Services and Supports (LTSS) system and

coordination with CCOs from the perspective of the Office of Developmental Disabilities Services at DHS and OHA

• Receive public comment related to the Medicaid program

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AGENDA

Time Item Presenter Purpose 9:00 Welcome and Introductions

• Adopt minutes
• Recruitment

Co-chairs Action 9:15 OHA/DHS Medicaid update OHA Staff Informational 9:45 Public Charge Jeannette Taylor, OHA Linda Roman, Office of Governor Brown Informational 10:20 Stretch/rest break 10:40 Long-term Services & Supports (LTSS) system coordination, Part 2 Anna Lansky, DHS Bruce Baker, DHS Rhonda Busek, OHA Informational 11:45 Public Comment 11:55 Closing comments Co-chairs

OHA/DHS Medicaid Update

Chris Norman, Lori Kelley, OHA Anna Lansky, DHS

Public Charge and Medicaid Jeannette Taylor, OHA Linda Roman, Office of Governor Brown 8

Review of Public Charge Proposed Rule

Presentation to the Oregon Medicaid Advisory Committee October 24th, 2018 Jeannette Taylor Government Relations, OHA

Background

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Overview of Public Charge Proposed Rule

• October 10, Department of Home Security, published proposed rule,

Inadmissibility on Public Charge Grounds

– 60 day comment period; comments due December 10

• Rule proposes to change how DHS determines whether

immigrants—entering the U.S., extending their stay, changing their visa type, or adjusting their status to become a lawful permanent resident—are “likely at any time to become a public charge” (i.e. dependent on the government for financial support

• The proposed rule:

– Expands the list of public benefits considered – Increases the importance of income and benefits used in the public charge analysis

• Impacts: consumers, states, localities and providers

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Current Public Charge Definition

• An individual may be considered to be (or likely to become) a public

charge if he/she is “primarily dependent” on public benefits

– May be denied entry or, if they live in the U.S., barred from changing their temporary status to permanent residency

• Totality of Circumstances:

– Age – Health – Family Status – Assets, Resources, & Financial Status – Education & Skills – Two types of government assistance: cash assistance and “institutionalization” for long-term care *Affidavit of support for certain immigrants

12 Sources: Field Guidance on Deportability and Inadmissibility on Public Charge Grounds (“Field Guidance”), 64 Fed.

• Reg. 28689 (May 26, 1999); Inadmissibility on Public Charge Grounds, 83 Fed. Reg. 51114 (October 10, 2018),

available at: https://www.gpo.gov/fdsys/pkg/FR-2018-10-10/pdf/2018-21106.pdf

Key Changes to Public Charge

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Immigrants Subject to Public Charge

Current (1999 Field Guidance) ✓ Individuals seeking to legally enter the U.S. ✓ Individuals legally in the U.S. and seeking to become a Lawful Permanent Resident (i.e., obtain a “green card”) Proposed Rules adds:  Individuals seeking an extension of stay (e.g., extending a current visa)  Individuals seeking to change visa types (e.g., from a student to employment visa)

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EXEMPT: Refugees, asylees, and certain Cuban, Haitian, Central American and various

• ther categories of immigrants are statutorily exempt from public charge. DHS also

proposes to allow victims of trafficking, witnesses or informants, and several other categories of immigrants to apply for waivers so that the public charge determination is not applied to them.

Public Charge Defined

Current (1999 Field Guidance) ▪ An individual may be considered to be (or likely to become) a public charge if he/she is “primarily dependent”

• n public benefits

✓ Use of benefits is one component of the “totality of circumstances” analysis used to make a public charge determination Proposed Rule  An individual may be considered a public charge if he/she “receive[s] one or more public benefits” ✓ Use of benefits is one component of the “totality of circumstances” analysis used to make a public charge determination

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The proposed rule indicates that DHS will not consider benefit use by an immigrant’s dependent’s when determining whether the immigrant is likely to become a public charge; benefit use by members of the Armed services also will not be considered.

How are Public Benefits defined?

Source: State Health and Values Strategies, October 10, 2018, “Examining the Public Charge Proposed Rule”

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Public “Health” Benefits Considered

Non-emergency Medicaid

• Does not include emergency Medicaid, school-based Medicaid

benefits, Medicaid benefits under the Individuals with Disabilities Education Act [IDEA], and Medicaid for certain children of U.S. citizens with pending citizenship) Medicare Part D Low Income Subsidy Not currently included:

• Children’s Health Insurance Program (CHIP) – not included in the

proposed list of benefits, but DHS is seeking comment on whether to include CHIP

• Marketplace subsidies

Potential Impacts of Proposed Rule

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Impact on Individuals and Families

• Chilling effect deters legal immigrants and their family members

from using public benefits they are entitled to receive

– Increase poverty, loss/reduced productivity & educational attainment, adverse health effects, increase medical expense due to delayed health care

• Direct (health programs) impacted:

– Non-emergent Medicaid (w/exemptions) – Medicare Part D Low Income Subsidy (not administered by OHA)

• Indirect (health/public programs) impacted

– CHIP (DHS is seeking comment on whether to include CHIP) – Citizen/Alien Waived Emergency Medical (CAWEM)/CAWEM Plus – Cover All Kids – Reproductive Health Equity program – Women, Infants, and Children (WIC) – Others…

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Impact States, Localities & Providers

• Implementation Costs
• Uncompensated health care

– More uninsured – Increase in costly emergency and acute care

• Added costs for social services/safety net

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Questions

JEANNETTE.T.TAYLOR@dhsoha.state.or.us

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Long-term Services and Supports Overview Part 2: Office of Developmental Disabilities Services Anna Lansky, DHS Bruce Baker Rhonda Busek, OHA 22

Anna Lansky, ODDS Deputy Director Bruce Baker, Manager, Children’s Services

Office of Developmental Disabilities Services October 24, 2018

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Our Vision

People and families access quality supports that are simple to use and responsive to their strengths, needs and choices, while they live and thrive as valued members of their community.

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Our Commitment to Those We Serve

Choice, self- determination and person-centered practices Children and families together Health, safety, and respect Community inclusion and community living Strong relationships Service equity and access

ODDS Strategic Plan

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Who We Serve

We serve over 27,000 people who experience Intellectual and/or Developmental Disabilities (I/DD). This includes down syndrome, cerebral palsy, autism spectrum disorders, acquired brain injury (children), drug and alcohol affected children.

Supports We Provide

ODDS services support people with I/DD to have the

• pportunity to have fulfilling and meaningful lives

allowing them to contribute to and enjoy their communities:

• Attendant Services
• Employment Services
• Environmental Modifications and Assistive Technology
• Transportation
• Nursing Services and Professional Behavioral

Services

• And other services

History of I/DD System in Oregon

– 1982 fist HCBS Waiver approved in Oregon (Comprehensive Waiver) – February 24, 2000 Fairview Training Center closed

– 2000 Staley v. Kitzhaber Lawsuit, settled in 2001.

Settlement established specific conditions for the development and implementation of support services throughout the state over a multi-year period and led to ICF/IDD. Support Services Waiver established in

2001. – 2001: Medical Fragile (Hospital) Model and

Behavioral ICF/IDD Model Waiver established

– 2008 Medically Involved Children’s Waiver

– 2009 Closure of the last institution for people with I/DD in Oregon – July 1, 2013: K-Plan implemented (Community First Choice Option)

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I/DD Budget by Fund Type: 66% Federal Funds

General Fund (32%): 724,941,366 Other Funds (2%): 36,491,665 Federal Funds (66%): 1,505,588,119

2015-17 ODDS Total Budget: $2,267,021,150

GF OF FF

General Fund (33%): 885,640,676 Other Funds (1%): 27,952,491 Federal Funds (66%): 1,808,925,375

2017-2019 ODDS Total Budget: $2,722,518,542

GF OF FF

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Challenges and Opportunities

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K Plan Services

The K Plan Provides:

– Access to services for any eligible child/adult with I/DD – Assessment based service authorization – Choice of service setting – Life Span Services

Children Receiving Services

528 745 1379 715 3065 620 3736 589 3989 602

500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Children's In-Home Children's Residential

19-21 17-19 15-17 13-15 11-13

Adults Receiving Services

6293 5664 6840 5957 7856 6230 8521 6482 8728 6628

1000 2000 3000 4000 5000 6000 7000 8000 9000 10000

Adult In-Home Adult Residential

19-21 17-19 15-17 13-15 11-13

Changes due to CFCO Implementation

• CFCO removed caps on I/DD adult in-home

services that existed in the Support Services 1915c Waiver:

– $21,562 per plan year

• Transition to needs assessment-based

service authorization:

– Oregon functional needs assessment authorizes number of hours of services for each individual

Challenges of CFCO Implementation

• Language and philosophical change

– From “community inclusion” – to – “ADL/IADL supports”

• Perception of returning to a medical model

for I/DD system

Next Steps for ODDS

• ODDS Strategic Plan
• Oregon I/DD Program is in process of

implementing new Functional Needs Assessment instrument

• Oregon I/DD Program joined Community of

Practice and will be restructuring its Assessment and Person-Centered Planning Process to more effectively incorporate natural supports and community resources and move towards “Whole Life” rather than “Paid Service Life” vision

CCOs and I/DD System

• Currently no formal agreements between

ODDS and CCOs

• Each Case Management Entity (CME)

develops their own way of working with CCO(s) in their area of operations

• Challenges and opportunities differ from

CME to CME and from CCO to CCO.

Coordination with CCOs

• Unclear understanding of roles between

I/DD CMEs and CCOs for care coordination

• Based on input from self-advocates and

families it is confusing from client’s perspective how to access CCOs and what CCOs’ role is

Service Access

• Access to Mental Health, medical, dental,

and other services remains a challenge for people with I/DD

• Improved partnerships with CMEs and

CCOs to assist in outreach to clients on how to access services and supports

Assistive Devices

• Some services such as assistive devices are required to be covered

under State Plan

• CCOs may be different on how they handle the process and what

they will allow or deny Challenges:

• Lack of clarity in who is responsible for what costs (LTSS funding

should be used only when regular State Plan funds do not cover a specific service) Opportunities:

• Connect CMEs and CCOs to explore ways to work together in

providing services for ODDS clients.

Opportunities

• Additional education and more clear

information about how CCOs and CMEs work is needed including processes for members and advocates

• Clear points of contact and lines of

responsibilities

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Public Comment

Thank you!

Next MAC Meeting: Dec 5, 2018 9:00 – 12:00 pm Oregon State Library, Salem

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