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

• pportunity 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

• r 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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 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)

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

Section 1915(i) and FMS

 FMS & Information & Assistance must be available  FMS must meet the following requirements:

 FMS “manages Federal, State, and local employment tax, labor,

worker’s compensation, insurance, and other requirements that apply when the individual functions as the employer of service providers”

 FMS functions “as the employer of record when the individual

elects to exercise supervisory responsibility without employment responsibility”

Section 1115 Demonstrations

 Long standing regulation authorizing Secretary to

consider & approve experimental, pilot or demonstration projects likely to assist in promoting the objective of the Medicaid statue

 Waives multiple requirements  Requires Office of Management & Budget (OMB)

approval

 ACA requires detailed participant input process

State Programs

 First §1115 was the Arizona Health Care Cost

Containment (AHCCCS) for persons with disabilities (younger adults and elders) and developmentally disabled populations

 Provides health care through a prepaid, capitates

managed care delivery model

 Three original Cash & Counseling states  Entire State Medicaid Programs: AZ & VT  Pending: KS, MN, NJ, NM, & NY(?)

Section 1115 and Managed Care

 MN (submitting an (i) and (k) to replace personal

care program)

 Active Managed Care §1115 Demonstrations

DE, FL (pilot), MD, MA, MI, TN, & RI

Resources

 Section 1915(c) Lists Waivers:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Waivers/Waivers.html?filterBy=1915(c)#waivers

 Section 1915(b) Lists Waivers:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Waivers/Waivers.html?filterBy=1915(b)#waivers

 Section 1915(j):

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services- and-Support/Home-and-Community-Based-Services/Self-Directed-Personal-Assistant-Services- 1915-j.html

Resources

 Section 1915(i):

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services- and-Support/Home-and-Community-Based-Services/Home-and-Community-Based-Services- 1915-i.html

 Section 1115 Demonstrations:

http://www.gpo.gov/fdsys/pkg/FR-2012-02-27/pdf/2012-4354.pdf

 Section 1915(k) Final Regulations:

http://www.federalregister.gov/articles/2012/05/07/2012-10294/medicaid-program-community- first-choice-option

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