Medicaid HCBS Policy Issues Nearly every state is facing record - - PDF document

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Figure 1

Medicaid Home- and Community-Based Service Programs: A Data Update

Presenting the Findings: Jhamirah Howard, Policy Analyst, Kaiser Family Foundation

Report Authors: Terence Ng and Charlene Harrington University of California, San Francisco Jhamirah Howard Kaiser Commission on Medicaid and the Uninsured Kaiser Family Foundation February 7, 2011

Figure 2

Medicaid HCBS Policy Issues

• Nearly every state is facing record budget deficits, which

are expected to persist well into FY 2012

• Continued demands of institutional provision
• Mounting pressures to address institutional bias
• Consumer preferences—especially among the

disabled population

• Legal pressures—Olmstead decision (1999) and

Americans with Disabilities Act (1990)

• Federal policies to promote HCBS and consumer

direction

• Patient Protection and Affordable Care Act (ACA)

provides incentives to move toward more HCBS

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Figure 3

Medicaid HCBS Study

• HCBS waivers (CMS Form 372 Reports)
• Optional, provides range of HCBS e.g. personal care
• Must be nursing home eligible, selective recipient

groups

• Slots, geography & expenditures can be limited
• Financial & medical eligibility vary across states
• Waiting lists can be established
• Personal Care optional benefit (UCSF Annual Survey)
• Optional, actively available in 32 states (2009)
• Must be statewide, available to Medicaid categorically

eligible groups

• Home Health (UCSF Annual Survey)
• Mandatory in all states for those eligible for Medicaid

institutional care

Figure 4

Medicaid HCBS Participants & Expenditures by Program, 2007

Home Health 813,848 (29%) Personal Care 826,951 (29%) HCBS Waivers 1,175,220 (42%) HCBS Waivers $27.2b ( 66%) Home Health $4.9b (12%) Personal Care $9.5b (22%)

Total Participants Total Expenditures

2.82 million $41.6 billion

SOURCE: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys.

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Figure 5

Growth in Medicaid Home and Community Based Services Participants, by Program, 1999-2007

680 704 705 766 851 877 864 1112 814 528 578 582 683 720 761 918 815 826 688 769 841 766 983 1009 1060 879 1175

1999 2000 2001 2002 2003 2004 2005 2006 2007 Home Health Personal Care Waivers

1.9m 2.1m 2.1m 2.4m 2.6m 2.7m 2.8m 2.8m 2.8m Note: Figures updated annually and may not correspond with previous reports. Source: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys.

Percent Change:

+8% +4% +12% +8% +4% +7%

• 1%

+0.3%

In thousands

Figure 6

Total Medicaid Home and Community Based Services Participants, by State, 2007

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

10,000-35,999 participants (21 states) < 10,000 participants (10 states and DC) 36,000-99,999 participants (13 states) SOURCE: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys. 100,000 or more participants (6 states)

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Figure 7

Growth in Medicaid Home and Community Based Services Expenditures, by Program, 1999-2007

$2.1 $2.3 $2.5 $2.7 $2.8 $4.1 $4.4 $4.6 $4.9 $4.1 $4.6 $5.3 $5.5 $6.5 $7.2 $7.7 $8.5 $9.5 $11.0 $12.6 $14.3 $16.9 $18.5 $20.5 $23.2 $25.1 $27.2

1999 2000 2001 2002 2003 2004 2005 2006 2007 Home Health Personal Care Waivers

$17 $19 $22 $25 $28 $32 $35 $38 $42 Note: Figures updated annually and may not correspond with previous reports. Source: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys.

Percent Change:

+13% +14% +14% +13% +13% +10% +9% +9% In billions Figure 8

Medicaid Home and Community Based Services Average Expenditures Per Person Served, by state, 2007

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

$10,000-$14,999 per person (17 states) < $10,000 per person (10 states and DC) $15,000-$22,999 per person (13 states) SOURCE: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys. $23,000 or more per person (10 states)

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Figure 9

Waiver Participants and Expenditures by Target Group, 2007

40% $19.8 b, 73% 50% $5.6 b, 21% 10% $1.9 b, 6% Participants Expenditures MR/DD Elderly/Disabled Others

SOURCE: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys.

Figure 10

Consumer Direction & Cost Controls, 2009

HCBS Waivers (n=286) State Plan PCS (n=34) Home Health (n=51) Cost Controls Hourly/Service Limits 15% 50% 41% Cost Limits 31% 12% 10% Geographic Limits 7% 32 active states n/a Waiting Lists 49% n/a n/a Consumer Direction Consumer Direction 37% 38% 10%

SOURCE: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys.

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Figure 11

Waiver Slots and Waiting Lists, by Target Group, 2009

Others 141,908 (11%) MR/DD 564,836 (42%) Elderly/Disabled 639,111 (47%) Others 36,092 (9%) Elderly/ Disabled 107,563 (30%) MR/DD 221, 898 (61%)

Total Slots: 1,345,855 Waiting List total: 365,553

SOURCE: Kaiser Commission on Medicaid and the Uninsured and UCSF analysis of CMS Form 372 data and program surveys.

Figure 12

States with Largest Wait Lists for HCBS Waivers, 2009 (Total: 365,553)

Texas – 129,518 on 8 wait lists

• Avg. wait time: 19 months

Florida – 32,432 on 10 wait lists

• Avg. wait time: 33 months

Indiana – 30,686 on 4 wait lists

• Avg. wait time: 18 months

Louisiana – 27,359 on 5 wait lists

• Avg. wait time: 60 months

Pennsylvania – 20,460 on 2 wait lists

• Avg. wait time unknown

Oklahoma – 14,712 on 3 wait lists

• Avg. wait time: 62 months

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Figure 13

Conclusion

• In 2007, 49 states offered 270 waivers, VT and AZ uses

managed care waiver. RI started in 2009.

• 34 states had the personal care optional benefit but 2

states were not enrolling participants. The number of states with PCS is increasing.

• Medicaid HCBS participant growth has been relatively

flat although expenditures continue to grow.

• Wide inter-state variation in HCBS service provision,

spending on services and population served.

• Long waiting lists for HCBS waiver programs continue

in many states

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Medicaid’s Money Follows the Person Rebalancing Demonstration: A 2010 Snapshot

Molly O’Malley Watts Watts Health Policy Consulting, LLC for Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation Washington, DC February 7, 2011

Figure 1

Money Follows the Person Overview

• Authorized by Congress in the DRA of 2005 and extended in the

Affordable Care Act through 2016

• ACA changes broadened eligibility and extended funding
• Shortened length of institutional stay to 90 days (previously 180)
• Additional $2.25 billion available to states
• Goals to reduce reliance on institutional care and increase community-

based long-term services and supports options

• Enhanced federal funding to 30 states to transition individuals living in

institutions back to the community

• Enhanced FMAP for 12 months following discharge

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Figure 2

About the Survey

• Based on a KCMU survey of state MFP project

directors conducted in July/August 2010

• Covers MFP transition progress, key program

services, per capita costs

• Identifies program challenges related to housing,

community workforce and the economic downturn

Figure 3

127 106 464 161 2,364 410 2,913 1,118 3,034 1,850

Transitions Completed Transitions in Progress

Physical Disabilities Seniors Developmental Disabilities Duals Mental Illness

Distribution of MFP Transitions, by Target Population

NOTE: The total number of transitions in progress includes 341 individuals from CA which did not specify target population in their survey response. SOURCE: KCMU survey of state MFP programs, July /August 2010.

8,902 3,986

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Figure 4

Distribution of MFP Reinstitutionalizations, by Target Population

Seniors, 48% Physical Disabilities, 29% Developmental Disabilities, 17% Mental Illness, 1% Duals, 5%

SOURCE: KCMU survey of state MFP programs, July /August 2010.

Number of Individuals Reinstitutionalized = 322

Figure 5

Key MFP Services and Costs

• Comprehensive set of services to facilitate transition and establish

community placement

– Transition services such as expanded case management, counseling, help with one-time housing expenses, and home modifications – Assistive technology and transportation

• Partnerships with key community stakeholders

– Independent living centers, AAAs, state housing authorities

• MFP per capita costs lower than institutional costs and on par with
• ther HCBS participants

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Figure 6

Challenges Facing MFP Programs

• Housing remains an obstacle to transition

– 19 states have partnered with local public housing authorities to apply for vouchers – 6 states employ housing coordinators to assist with transitions and to secure housing

• Community workforce supply not meeting demands

– Half the states reported an inadequate supply of direct service workers – Strategies to increase the supply include a direct care service registry website, the hiring of family caregivers, and online training programs

• States face challenging budget situations

– Indirect impact of the economic downturn on MFP – Reductions in services and provider payment rates affect MFP

Figure 7

Ohio’s MFP Demonstration: “HOME Choice”

• Transition Progress

– Transitioned nearly 900 individuals back to the community and 600 transitions are in progress, as of January 2011 – Most of those transitioned have been individuals with physical disabilities – Average transition takes 134 days; most individuals transition to an apartment

• Benefits

– Participants receive services through Medicaid HCBS waivers with “wrap around” HOME Choice demonstration services for the first 365 days – Examples of services include: case management, independent living skills training, community support coaching, HOME Choice nursing services, counseling, emergency rental and utility assistance, community transportation services, etc. – Key partnerships with Public Housing Authority, Ohio Housing Finance Agency, Ohio Centers for Independent Living, Consumer Advisory Counsel

• Costs

– Average monthly cost is $6,778 per month when moving but varies by target population: DD ($8,554), physical disabilities ($4,519), and seniors ($2,379)

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Figure 8

Helping People Transition Home

Profile: Gail (78) lived in a nursing home for 3 years following a stroke. Location: Living with ex-wife at home in Wauseon, Ohio Health Needs: Requires help managing his diabetes and heart condition; takes 11 drugs daily Medicaid Coverage: Qualified for Medicaid after going through his life savings in the nursing home. MFP provides essential durable medical equipment to ease the transition home: Gail relies on an electric wheelchair, a hospital bed, ramps and a handicap accessible bathroom. He also receives 16 hours of personal care services each month and attends adult day care each day. On Living At Home: The best part about living at home, Gail says, is his ability to travel. Gail enjoys taking family trips to local campgrounds during the summer. “I feel better each day that I am home.” Figure 9

Looking Ahead

• New 90-day residency requirement may increase MFP transitions
• Health reform opportunities to expand Medicaid home and

community-based services could expand the number of transitions

• Lack of affordable, accessible housing will remain toughest

challenge for states

• Demand for HCBS will remain high and states will be pressed to

continue expanding access to Medicaid HCBS