North Carolina Division of North Carolina Division of Medical - - PowerPoint PPT Presentation

Medicaid Clinical Policy Medicaid Clinical Policy and Programs and Programs

North Carolina Division of North Carolina Division of Medical Assistance Medical Assistance

Update on Medicaid In Update on Medicaid In-

• Home

Home 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

• Illustrate PCS cost and utilization increases
• ver 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

• Describe Medicaid PCS and the scope of

authorized services

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

Source: CMS State Medicaid Manual

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

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

Source: NC Medicaid Policy for In- Home Personal Care Services Source: NC Medicaid Clinical Coverage Policy for Nursing Facility Services

Not covered when RN or LPN services are required Need for dialysis or mechanical ventilation that is required at least ten hours per day Not covered when recipient needs ongoing supervision Administration and control of medication that must be performed by a licensed nurse Not covered when recipient is not medically stable Daily observation and assessment of resident needs by a licensed nurse Paraprofessional service that does not include skilled medical

• r nursing care

Need for RN for a minimum of eight hours per day NC PCS Benefit under State Medicaid Plan PCS Provided under a §1915(c) HCBS Waiver

Nursing Facility Adult Care Homes PACE

Waiver Programs CAP/DA

Private Duty Nursing Personal Care Services

Hierarchy of LTC Programs

National Expenditures for PCS

CY 2005

Range NC: $286,650,908 NH: $510,956 Texas: $459,179,146 NY: $2,045,068,149 California: $2,857,270,000

25 Other States

6%

Percent Increase 2004 to 2005

10% 10% 30%

Source: Kaiser Commission on Medicaid and the Uninsured

Increase in PCS Participation

SFY 2002 thru 2009

5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 State Fiscal Year A v e r a g e M o n th l y P a r ti c i p a n ts Series1 15,687 20,902 25,267 31,589 34,670 33,484 34,130 38,569 2002 2003 2004 2005 2006 2007 2008 2009

Source: Medicaid Program Expenditure Reports-June of each SFY

$- $50,000,000 $100,000,000 $150,000,000 $200,000,000 $250,000,000 $300,000,000 $350,000,000 $400,000,000 2002 2003 2004 2005 2006 2007 2008 2009 SFY A n n u a l E x p e n d i tu r e s

Increase in PCS Costs

SFY 2002 thru 2009

Source: Medicaid Program Expenditure Reports-June of each SFY

Budget Reduction Goals for PCS

SFY 2010 and 2011

$- $50,000,000.00 $100,000,000.00 $150,000,000.00 $200,000,000.00 $250,000,000.00 $300,000,000.00 $350,000,000.00 1 State Budget for PCS SFY 2009 SFY 2010

• Budget for SFY 2009:

$318,021,185

• Budget for SFY 2010:

$188,200,229

• Budget Reduction: 41%
• Budget Reduction Goal

for SFY 2010: $40 million state dollars

• Budget Reduction Goal for

SFY 2011: $60 million state dollars

PCS Expenditures

SFY 2009 Actual vs. Budgeted

$24,000,000 $25,000,000 $26,000,000 $27,000,000 $28,000,000 $29,000,000 $30,000,000 $31,000,000 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Budgeted Actual Expenditures by DOS

Source: Medicaid Monthly Claims Report January 2010

$- $5,000,000 $10,000,000 $15,000,000 $20,000,000 $25,000,000 $30,000,000 $35,000,000 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Budgeted Expenditures by DOS

PCS Expenditures

SFY 2010 YTD Actual vs. Budgeted

Source: Medicaid Monthly Claims Report January 2010

CCME PCS Compliance Reviews

April 2007-March 2009

• 347 Provider Agencies
• 3,732 Recipients
• On-site desk review
• RN home visit, interview,
• bservation
• 7%- Two qualifying ADLs not

documented in assessment

• 40%- RN review did not

support recipient qualification

• DMA estimates 23% of current

recipients do not qualify

• Associated with more than

$6.5M per month, $79M per year, $219,000 per day in PCS claims

Current PCS Participants

Demographic Profile

0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% t

• 5

6 t

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1 1 t

• 1

5 1 6 t

• 2

2 1 t

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5 2 6 t

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3 1 t

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5 3 6 t

• 4

4 1 t

• 4

5 4 6 t

• 5

5 1 t

• 5

5 5 6 t

• 6

6 1 t

• 6

5 6 6 t

• 7

7 1 t

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5 7 6 t

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8 1 t

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5 8 6 t

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9 1 t

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5 9 6 t

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1 t

• 1

6 AGE RANGE PERCENT OF POPULATION

30% M 70% F

Source: Medicaid Claims Database

Current PCS Participants

ADL Scoring Methodology

4 Individual is fully dependent on another person for mobility, eating, bathing, dressing, and toileting Full Dependence 3 Individual performs part of activity, but requires substantial or consistent hands-on assistance from another person for mobility, eating, bathing, dressing, and toileting Extensive Assistance 2 Must require hands-on limited, extensive, or full dependence assistance with at least two of the qualifying ADLs Individual is highly involved in activity, but requires hands-on assistance from another person for maneuvering of limbs for mobility, eating, bathing, dressing, and toileting Limited Assistance 1 Not covered Individual requires supervision,

• versight, encouragement, prompting,

reminders, or cueing Supervision Only Assessment Score Medicaid PCS Coverage Description Level

B a t h i n g D r e s s i n g M

• b

i l i t y T

• i

l e t i n g C

• n

t i n e n c e E a t i n g

10 20 30 40 50 60 70 80 90 100

Percent of Recipients

97.9 94.5 57.5 26.8 14.9 10.7

Current PCS Participants

Prevalence of ADL Needs

Source: PCS Recipient Assessments (N=35,047)

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)

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 22% 24% 26% 28% 30% 32% 34% 36% 38% 40% 42%

Percent of Recipients

28.8% 33.0% 14.4% 7.2%

Recipient Functional Disability

Sum of ADL Scores

Source: PCS Recipient Assessments (N=35,047)

Mean = 6.48 N = 35,047

Current PCS Participants

Average Number of Service Hours Authorized In Providers’ Plans of Care (POC)

Source: PCS Recipient Assessments (N=35,047)

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)

5 10 15 20 25 30 35 40 45 50 55 60 Authorized Hours Provider Plans of Care Medical Necessity Review

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

CAP/DA Slot Allocation

History

Slots allocated in 2004 13,200 Slots originally funded 11,500 Slots not funded 1,700 Additional slots proposed: SFY 2009 600 SFY 2010 600 SFY 2011 500 NOT FUNDED

CAP/DA Slot Allocation

2010 SFY Budget Adjustment

• Reduce PCS slot allocations to

July 1, 2008 level

• Slots must be reduced to 11,214
• Reductions by county will be

achieved through attrition