North Carolina Division of North Carolina Division of Medical Assistance Medical Assistance Medicaid Clinical Policy Medicaid Clinical Policy and Programs and Programs Update on Medicaid In- -Home Home Update on Medicaid In Personal Care Services (PCS) Personal Care Services (PCS) Presented Larry Nason, Ed.D. Chief, Medicaid Facility by: and Community Care Karen Feasel, Ph.D. Medicaid Policy Analyst
Purpose of Presentation • Describe Medicaid PCS and the scope of authorized services • Illustrate PCS cost and utilization increases over the last eight years • Provide a demographic profile and detailed analysis of cost and utilization for current PCS participants • Describe the actions DMA is taking to comply with the legislative mandate contained in S.L. 2009-451
What is In-Home PCS? C. Scope of Services.--Personal care services (also known in States by other names such as personal attendant services, personal assistance services, or attendant care services, etc.) covered under a State’s program MAY include a range of human assistance provided to persons with disabilities and chronic conditions of all ages that enables them to accomplish tasks that they would normally do for themselves if they did not have a (functional) disability. Source: CMS State Medicaid Manual
Scope of Authorized PCS States MAY provide the services of a paraprofessional aide to provide: • Person-to-person hands-on assistance to help a functionally disabled individual to perform a task • The task itself, if the individual is fully dependent on others • Cueing or prompting the individual to perform the task Source: CMS State Medicaid Manual
Scope of Authorized PCS (Continued) Services MAY include assistance with: • Activities of Daily Living (ADLs), such as eating, dressing, mobility, bathing, and toileting • Instrumental Activities of Daily Living (IADLs), such as light housework, laundry, meal preparation, transportation, using the telephone, shopping, etc. Source: CMS State Medicaid Manual
Services Not Authorized Under PCS Skilled services that may be performed only by a licensed health professional are NOT considered personal care services Source: CMS State Medicaid Manual
How do States Provide PCS Under Medicaid? In 2006, State Medicaid agencies provided PCS through 238 different programs • Thirty-one through state plan programs (i.e., as an optional service) • Two-hundred and seven through Medicaid waivers Source: Office of the Inspector General United States Department of Health and Human Services
PCS Waiver vs. Optional Service PCS Provided under a NC PCS Benefit under §1915(c) HCBS Waiver State Medicaid Plan Need for RN for a minimum of Paraprofessional service that eight hours per day does not include skilled medical or nursing care Daily observation and Not covered when recipient is assessment of resident needs not medically stable by a licensed nurse Administration and control of Not covered when recipient medication that must be needs ongoing supervision performed by a licensed nurse Need for dialysis or mechanical Not covered when RN or LPN ventilation that is required at services are required least ten hours per day Source: NC Medicaid Clinical Coverage Source: NC Medicaid Policy for In- Policy for Nursing Facility Services Home Personal Care Services
Hierarchy of LTC Programs Nursing Facility Adult Care Homes PACE Waiver Programs CAP/DA Private Duty Nursing Personal Care Services
National Expenditures for PCS CY 2005 NH: $510,956 25 Other States Percent Increase 2004 to 2005 Range NC: $286,650,908 30% Texas: $459,179,146 10% NY: $2,045,068,149 6% 10% California: $2,857,270,000 Source: Kaiser Commission on Medicaid and the Uninsured
Increase in PCS Participation SFY 2002 thru 2009 45,000 A v e r a g e M o n th l y P a r ti c i p a n ts 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2002 2003 2004 2005 2006 2007 2008 2009 15,687 20,902 25,267 31,589 34,670 33,484 34,130 38,569 Series1 State Fiscal Year Source: Medicaid Program Expenditure Reports-June of each SFY
Increase in PCS Costs SFY 2002 thru 2009 $400,000,000 $350,000,000 A n n u a l E x p e n d i tu r e s $300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $- 2002 2003 2004 2005 2006 2007 2008 2009 SFY Source: Medicaid Program Expenditure Reports-June of each SFY
Budget Reduction Goals for PCS SFY 2010 and 2011 • Budget for SFY 2009: $350,000,000.00 $318,021,185 $300,000,000.00 • Budget for SFY 2010: $250,000,000.00 $188,200,229 $200,000,000.00 • Budget Reduction: 41% $150,000,000.00 $100,000,000.00 • Budget Reduction Goal $50,000,000.00 for SFY 2010: $40 million $- state dollars 1 State Budget for PCS • Budget Reduction Goal for SFY 2011: $60 million SFY 2009 SFY 2010 state dollars
PCS Expenditures SFY 2009 Actual vs. Budgeted $31,000,000 $30,000,000 $29,000,000 $28,000,000 $27,000,000 $26,000,000 $25,000,000 $24,000,000 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Budgeted Actual Expenditures by DOS Source: Medicaid Monthly Claims Report January 2010
PCS Expenditures SFY 2010 YTD Actual vs. Budgeted $35,000,000 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $- JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Budgeted Expenditures by DOS Source: Medicaid Monthly Claims Report January 2010
CCME PCS Compliance Reviews April 2007-March 2009 • 7%- Two qualifying ADLs not documented in assessment • 347 Provider Agencies • 40%- RN review did not • 3,732 Recipients support recipient qualification • On-site desk review • DMA estimates 23% of current recipients do not qualify • RN home visit, interview, observation • Associated with more than $6.5M per month, $79M per year, $219,000 per day in PCS claims
Current PCS Participants Demographic Profile 12% 11% 10% PERCENT OF POPULATION 9% 8% 7% 6% 30% M 5% 4% 3% 70% F 2% 1% 0% 0 6 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 1 1 6 1 6 1 6 1 6 1 6 1 6 1 6 1 6 1 6 0 t t o o 0 t t t t t t t t t t t t t t t t t t o o o o o o o o o o o o o o o o o o 5 1 t o 0 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 1 5 0 5 0 5 0 5 0 5 0 5 0 5 0 5 0 5 0 1 0 0 6 AGE RANGE Source: Medicaid Claims Database
Current PCS Participants ADL Scoring Methodology Level Description Medicaid PCS Assessment Coverage Score Supervision Individual requires supervision, Not covered 1 Only oversight, encouragement, prompting, reminders, or cueing Limited Individual is highly involved in Must require 2 Assistance activity, but requires hands-on hands-on assistance from another person for limited, maneuvering of limbs for mobility, extensive, or full eating, bathing, dressing, and toileting dependence assistance with Extensive Individual performs part of activity, 3 at least two of Assistance but requires substantial or consistent the qualifying hands-on assistance from another ADLs person for mobility, eating, bathing, dressing, and toileting Full Individual is fully dependent on 4 Dependence another person for mobility, eating, bathing, dressing, and toileting
Current PCS Participants Prevalence of ADL Needs 100 90 80 Percent of Recipients 70 60 50 97.9 94.5 40 30 57.5 20 26.8 10 14.9 10.7 0 B D M T C E o a r o a o e i t t l n b h e i s n t i i i s l t n n g i i i t n g n y e g g n c e Source: PCS Recipient Assessments (N=35,047)
Recipient Functional Disability Sum of ADL Scores 42% 40% 38% 36% 34% 32% 30% 28% Percent of Recipients 26% 24% 22% Mean = 6.48 20% N = 35,047 18% 33.0% 16% 28.8% 14% 12% 10% 8% 14.4% 6% 4% 7.2% 2% 0% 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Recipient Functional Disability (Sum of ADL Scores) Source: PCS Recipient Assessments (N=35,047)
Current PCS Participants Average Number of Service Hours Authorized In Providers’ Plans of Care (POC) 60 55 50 45 Authorized Hours Provider Plans of Care 40 Medical Necessity Review 35 30 25 20 15 10 5 0 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 1920 21 22 23 24 Recipient Functional Disability (Sum of ADL Scores) Source: PCS Recipient Assessments (N=35,047 )
Implementation of S.L. 2009-451 • Evaluate current PCS participants to determine if utilization is related to functional disability and not excessive • Revise the current PCS Clinical Coverage Policy to address documented cost, compliance, and utilization problems • Strengthen the role of the recipient’s physician in the PCS admission process • Automate the PCS program administration process • Update, improve, and automate assessment tools, service authorizations, plans of care, audit reports, and reports
Implementation of S.L. 2009-451 (Continued) • Automate and integrate with other HCBS programs quality improvement, utilization review, compliance review, and financial performance metrics to monitor program performance • Integrate service authorizations with claims processing to ensure only authorized hours are paid • Implement independent assessment of new PCS admissions, continuation reviews, and change of status reviews
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