Se lf Dir e c tion in the Ne w Wor ld Or de r of Soc ial Pr - - PowerPoint PPT Presentation

Se lf Dir e c tion in the Ne w Wor ld Or de r

• f Soc ial Pr
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ams: An Innovative Oppor tunity for Community L iving Connie Gar ne r May 8, 2017

“Signs”

“Signs, signs, everywhere they’re signs Blockin’ out the scenery, breakin’ my mind Do this, don’t do that, can’t you read the sign? Now, hey you, mister, can’t you read? You’ve got to have a shirt and tie to get a seat You can’t even watch, no you can’t eat You ain’t supposed to be here”

Choice

Self Determination

Self Direction

Self Care

Health Insurance Enhancement

(Addressing Services and Supports for Individuals Under Age 65)

• This proposal assumes guaranteed coverage remains

intact and some components of a major medical benefit are defined.

• The proposal is based on the policy principles of:
• 1. Access to LTSS coverage across the lifespan;
• 2. Simplicity/building on existing coverage systems and

insurance products;

• 3. Risk pools and portability; and
• 4. Quality integrated care.

Policy Components to the Proposal

• Target Population:
• All individuals who receive healthcare coverage under employer-sponsored insurance who

demonstrate continuous enrollment.

• Question: Should this also apply to small businesses and the individual market as an optional

benefit?

• Enrollment Options/Delivery Mechanisms:
• Enrollment through employer- sponsored insurance options, including family coverage.
• Question: Should enrollment through products purchased through an exchange or through

Medicaid expansion include this benefit?

• This proposal does not include Medicaid recipients.

Policy Components to the Proposal

• Program Characteristics and Benefit Design:
• With guaranteed coverage being maintained, the addition of this benefit within

commercial insurance provides an efficient, risk-adjusted mechanism for providing LTSS support to beneficiaries.

• The proposal would add an additional piece to the major medical benefit called LTSS.

When triggered, this benefit would be a daily and/or monthly dollar allotment. The allotment would be available to roll over month to month, but not year to year.

• Question: Should this benefit be all cash or a mix of cash and services?
• Question: Should this benefit be gradated based on the intensity of need?
• Question: Should this benefit be managed by the primary insurance carrier or should it be

contracted to the LTC insurance industry OR should it be left open to primary carrier choice?

Policy Components to the Proposal

• Include a new section under coverage that defines the trigger that executes this benefit.
• Question: Should the trigger be defined as a functional limitation either consistent with HIPAA

(2 ADLs/3 ADLS/IADLs or the cognitive equivalent)?

• Question: Should it be set at 3 ADLs/IADLs?
• Question: Should we define the trigger completely differently?

Benefit Triggers

• A benefit trigger for provision of benefits that requires a determination that an individual

has a condition, as certified by a licensed health care practitioner, that results in substantially reduced functional capacity to undertake one or more of the following activities:

• 1. Communication
• 2. Social interaction
• 3. Learning
• 4. Mobility
• 5. Self-care
• 6. Self-management
• 7. Impairments that affect the person’s capacity for social or economic participation
• The impairment is expected to last for a continuous period of more than 90 days.
• Construction clause: Nothing in the above paragraphs precludes individuals in

remission from meeting eligibility criteria triggering the benefit.

Benefits to the Design

• This model gives individuals and employers:

1) Portability 2) Tax advantage via health insurance 3) A safety net across the lifespan to Medicare 4) Simplicity building off of existing insurance models 5) Risk pool security 6) Predictable expenditures via allotted monthly benefit

• Cash model:
• Once participant becomes eligible for benefits, the beneficiary gets cash benefits possibly

deposited to a debit card to purchase supports, with deposits posted monthly.

• Dollars can be rolled over month-to-month, but not year-to-year.

Transitions are Tough…Let’s Self- Direct

Change for the Future

“If you don't like something change it; if you can't change it, change the way you think about it.”