Participant Direction 201: Medicaid Authorities Supporting - PowerPoint PPT Presentation

Participant Direction 201: Medicaid Authorities Supporting Participant Direction June 28, 2012 Suzanne Crisp NRCPDS

Learning Objectives  Brief history of Medicaid  Examine specific authorities  Discuss significance for FMS vendors  Resources  Questions

Medicaid  President Lyndon Johnson’s Great Society  Enacted into law – Medicaid, Medicare and the Older Americans Act in 1965 with Social Security Act  Medical care for Americans with low income and resources  Joint Federal/State partnership  Offered mandatory and optional state plan services

Medicaid  Initially designed to pay for nursing home care for 21 & older and optional coverage for home health  Within Federal guidelines, States have great flexibility but all plans and changes must be approved by Centers for Medicare and Medicaid Services (CMS)  Financial Medical Assistance Percentage (FMAP)  50% for administration  50% to 83% - based on State’s per capita income

Home and Community-Based Service (HCBS)  Waivers are named after the Section of the Social Security Act that authorizes each  In 1981, Congress authorized certain Federal requirements may be waived (comparability & statewideness)  Allows services not usually covered by Medicaid so long as services are required to prevent institutionalization

A Watershed Moment  States adopt HCBS waivers from 1982 to 1990s  Growth is steady but system continued to support institutionalization  Olmsted decision 1999  “ Unjustified isolation….is properly regarded as discrimination based on disability”  By not providing HCBS, the Americans with Disabilities Act is violated  States are at risk of litigation if HCBS is not offered

Strong Federal Support  Since 1999 – CMS has aided States to avoid litigation by supporting HCBS  President’s New Freedom Initiative 2001  Deficit Reduction Act of 2005  Two authorities 1915(i) & 1915(j)  Affordable Care Act of 2010  Community First Option  Changes to the 1915(i)

Additional Support of HCBS  PACE – Program of All-Inclusive Care for the Elderly  MFP – Money Follows the Person  BIP – Balancing Initiative Program  ADRC – Aging and Disability Resource Centers  Health Homes

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Section 1915(c)  First of the modifications to the Social Security Act to directly support HCBS & community living  Targeted to individuals who could be admitted to an institution (level of care)  Complements State Plan services  Initially approved by CMS for 3 years, 5 year increments thereafter  Largest HCBS authority:  283 Programs; serving 1.2 million people at a cost of almost $27 billion

Section 1915(c) and Participant Direction  Introduces Independence Plus initiative 2002  Ability to mainstream introduced in 2005 with new application and instructions  CMS “ urges that all states afford waiver participants the opportunity to direct some or all of their waiver services ”  Substantial growth in PD occurs

Section 1915(c) and Participant Direction  First defined 1915(c) application instructions  Budget and employer authority  Financial management services (FMS)  Recognized F/EA and Awl models  Person-centered expectation  Identified support system  Information & assistance  FMS  Identified as a service or administrative function

Sections 1915 (a) and 1915(b)  Section 1915(a)  Allows States to use a voluntary managed care delivery system  Waives comparability, statewideness and free choice of providers  Thirteen states use this authority to administer 24 voluntary managed care programs  Section 1915(b)  Allows states to waive comparability, statewideness and free choice of providers  May require dual eligible's to participant  May be voluntary or involuntary  Currently 48 approved 1915(b)s operate in 28 states

Section (a) or (b) and 1915 (c)  Allows State to operate HCBS waivers and specified State Plan services under a managed care arrangement  Allows selective contracting with entities using capitation  Example states: MI, TX and NY

Section 1915(j)  Section 6078 of the Deficit Reduction Act of 2005  Effective July, 2007  Uses participant direction to provide personal assistance services  Follows the original Cash & Counseling program design  Cash payment may be prospectively paid  Requires employer and budget authority

Section 1915(j)  Allows goods and services that substitute or reduce the reliance on human assistance or increase independence  Goods and services must be tied to an assessed need  Seven states have active programs: AL, AR, CA, FL, NJ, OR, & TX  ACA disposition will not impact

Section 1915(j) & FMS  States must make available assistance with employment and insurance tasks  May perform:  Directly  Contract with an FMS entity or execute a provider agreement with an agency  Participant may manage  FMS reimbursed administratively only  Recognizes F/EA or Awl  FMS must flag significant budget variances  State must monitor activity

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Section 1915(k) Community First Option  Section 6078 of the Affordable Care Act 2010  Could be affected with Supreme Court Ruling  Provides vehicle to use self direction (consumer control) to provide personal assistance services  Self direction (consumer control)  Individual exercises as much control as desired to select, train, supervise, schedule, determine duties, and dismiss the attendant care provider

Section 1915(k) Continued  Allows a cash benefit  Prospective payments allowed  Target population must meet level of care  FMS reimbursed at service or admin rate  Requires creation of a Development and Implementation Council  Enhanced FMAP at 6%  Requires a face-to-face assessment (telemedicine) annually  Person-centered planning required

Section 1915(k) Continued  Services include ADL, IADL, & health related tasks  May be hands-on assistance, supervision, or cueing  Include acquisition, maintenance, and enhancement of skills  Back-up systems required  Voluntary training on how to select, manage or dismiss workers  Must offer transition services

1915(k) Recognizes Three Models  Agency-provider model  Entity contracts to provide services directly through employees or arranges for the services under the direction of the individual  Agency acts as the employer of record  Individual must have significant and meaningful role in management of services  Self-directed model with service budget  FMS must be available  Reimbursed at service or administrative FMAP rate  Cash or vouchers permitted  Participant is employer of record  Other service delivery model  States may propose other models

All Service Models Recognized by 1915(k)  Operate with person-centeredness  Provide support system  Assesses and counsels  Provides information  Includes information on risks and responsibilities including tools  Develops a backup plan  Assessors are free from conflict  Data collection

Section 1915(k) Continued  May offer goods and services  Home modification excluded unless tied to increased independence or sub for human asst.  Targeting not permitted  Must offer statewide  Current activity – CA, MN, AK, NY, AZ  Differences between the (j) and (k)  Enhanced funding (k)  Level of Care (k)  FMS reimbursement limited (j)  Development & Implementation Council (k)

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Section 1915(i)  Deficit Reduction Act of 2005 created  Affordable Care Act of 2010 modified  Proposed rule currently under review  Offers new flexibility in providing necessary and appropriate services  Eliminates requirement of admittance to a nursing home  Allows less stringent application of medical eligibility  Services include case management, homemaker, personal care, adult day health, habilitation, respite, behavioral health services and “other” (ACA change)  Must be statewide (ACA change)  May not limit number of individuals (ACA change)

Section 1915(i) Continued  Allows targeting – may define a specific population  More than one 1915(i) is allowed  Allows for a new eligibility group  Conflict free evaluation and assessments  Encourages self-direction  Must develop an independent advocacy system  May not limit participants

Section 1915(i) and Participant Direction  CMS “urges” states to offer  Recognizes employer & budget authority  Cash allowance not permitted  Person-centered planning required  Risk management process required