long-term care policy summit suzanne crisp director of program design & implementation boston...
TRANSCRIPT
Balancing Incentive Program Purpose – Encourage States to rebalance
budgets Shift Medicaid dollars from institutions to the
community Enhanced FMAP to increase diversions and
access to HCBS 5% if less than 25% LTSS spending in non-
institutional settings 2% if less than 50% LTSS spending in non-
institutional settings Enhancement ends after two years
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Requirements
Aging and Disability Resource Centers (ADRC) Single point entry or no wrong door -
Uniform assessments process Eliminate conflict of interest
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Conflict Free Case Management Desire of CMS for years Eliminate:
Incentives for over or under utilization Retain as clients through failure to promote
independence Focus on agent or provider convenience rather
than person-centered practices Independent agent should not be influenced
by variations in local or State funding Service plan based on needs-based criteria
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Conflict Free Case Management Independent assessments and service plan
development may not be performed by a provider that will then provide services
Payment to the provider of services for evaluation and assessment cannot be based on the cost of the resulting plan of care
In rare instances, service providers may evaluate and assess but firewalls must be present
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Section 1915(k) Community First Option Section 6078 of the Affordable Care
Act 2010 Provides vehicle to use consumer
control to provide personal assistance services
Consumer control Individual exercises as much control as
desired to select, train, supervise, schedule, determine duties, and dismiss the attendant care provider
Community First Choice Option Attendant services & supports to assist in
accomplishing activities of daily living (ADLs), instrument ADLs, and health-related tasks through hands-on assistance, supervision, or curing
Back-up System must be in place Transitions costs required Allows for the provision of services that
increase independence or substitute for human assistance to the extent that expenditures would have been made for human assistance
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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
Support Services Required
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) 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)
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
The Possibilities
Include all participant directed program under one authority that offers enhanced match
Replace State Plan Personal Care and Waiver Attendant Care with Community First Choice and receive Enhanced Match (6%)
Section 1915(i) Targets those not meeting LoC
Use FMS Support Structure to Manage all PD
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Challenges of Community First Choice Create sufficient supports to ensure
program integrity Case Management, care coordination and
self-directed counseling –YIKES! Establish and maintain a comprehensive
continuous quality assurance system Collect and report information for Federal
oversight and the completion of a Federal evaluation
Serves a LoC population only
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Challenges of Community First Choice Option Must receive one waiver service to
maintain financial eligibility Consumer Control – how broad, how
narrow Coordinating assessment and service
planning with other authorities Who has final say in care coordination?
Waiver case manager Targeted case management Health Home coordinator
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States with less than 1,000 PD articipants
States with 1,000 but less than 5, 000 PD articipants
States with 5,000 but less than 10, 000 PD articipants
States with more than 10, 000 PD articipants
Majority of States have 1000 – 5000 Self-Direction LTSS Participants
WAAK
OR
CA
NV
ID
MT
WY
UT
AZ
CO
NM
TX
OK
KS
NE
SD
ND MN
IA
MO
AR
LA
MS
TN
KY
IL
WI
MI
INWV
AL GA
FL
SC
NC
VA
PA
NY
DC
MD
DE
NJ
RI
MA
NH
VT
ME
OH
CTHawaii
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Positive Impact of Life
Cash & Counseling participants were up to 90% more likely to be very satisfied
with how they led their lives.
Caregivers Better Satisfied
Primary caregivers were significantly more satisfied with their
lives in general.
Virtually No Fraud or Abuse
Cash & Counseling did not result in the increased misuse of Medicaid
funds or abuse of participants
Essential Elements of Participant Direction Person-Centered Practices Individual budget Information, Assistance and Supports Financial Management Services
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Commonly Used TermsParticipant-Directed Counselor: Individual who works with the participant in designing their plan. The person the participant goes to with questions.
McInnis-Dittrich, Simone, and Mahoney (April, 2006)
Understand Federal Employment Obligations Internal Revenue Services – uniform across states Payroll for participant-directed services is different Separate Employer Identification Number required? Are guidelines clear for completing forms, filing,
withholding, and depositing If reconciliation is necessary – can you perform this? A few forms: IRS Forms – 940, 941, 2678, W-3, W-
4, 1099, 1096 When are numbers retired? How do you calculate Federal unemployment taxes?
When do you deposit? How do you manage overpayments of SSA and
Medicare Taxes
Common Findings – Self Direction Rebalances Service Dollars Acute care and high costs services are lower
for those self-directing, however, basic service costs increase
Per capita Medicaid costs are less for self-directed participants than traditionally served participants
Costs per hour are lower for those using self-direction than for agency services
If the cost of counseling and FMS are considered in the design of the program, these are at least neutral
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Tangible Costs Considerations Hiring family members – reduce
unemployment or public assistance Income tax implications Service costs – Participants receive
services Case management – add on – PD in addition
to CM tasks Financial Management Services Admin staff to run a PD program – cost vs
efficiency
Intangible Considerations
Satisfaction/Safety with PD QOL impacts health – health impacts $ Responsibility and authority can lead to
good stewardship Caregiver satisfaction