List of Audio Sections for ILRU Olmstead Course 3: Medicaid and Community Supports

• [No audio for Session 1]
• Session 2: “History of Medicaid”-- Lee Bezanson
• Session 3 & 4: “Medicaid State Plan”-- Lee Bezanson
• Session 5 & 6: “Medicaid Eligibility”
• Session 7 & 8: “Medicaid Waivers”--Alan Bergman & Lee Bezanson
• Session 9 & 10: “Medicaid and Community Supports”-- Lee Bezanson
• No Audio for the remaining sessions 11-15

Medicaid and Community Supports
Session 2: History of Medicaid
Lee Bezanson

Medicaid is not exactly the most exciting topic in the world, but we are going to try and walk through it so that we all at least have some understanding of this program that no one understands very well.

Basically, Medicaid was established in 1965, and if the truth be known, some of us think it was an afterthought. If you go back to 1965, the really big deal was that Congress enacted Medicare, and when they got done doing that, someone said gee, maybe we should have a health insurance program for particularly welfare moms and their dependent children, and low and behold Medicaid was born. Medicaid has grown since then, but in a really illogical fashion, as you will see, because it’s just been one fix after another.

Medicaid is a federal-state partnership. The state chooses to play in the Medicaid arena or the territories, and they all do now, states put up a certain amount of money and the federal government matches that money. Match rates vary, as we’ll see, depending on what state you are from based on your per capita income in your state.

The federal government in Medicaid has very broad requirements for the states. The states then figure out the particulars for their programs within those federal parameters. The way that the state administers a Medicaid program is to create something called a State Plan.

How many people in this room have read your Medicaid State Plan? Not many. Oh, we have one. They are huge. I can tell you I have not read the entire Medicare State Plan, even in New Hampshire. Those plans get approved by what was the Health Care Financing Administration and is now the Centers for Medicare and Medicaid Services or CMS.

If a state chooses to play in Medicaid, then there are certain services that are mandatory to be in that State Plan. You can think about them pretty much if you think about your own health insurance coverage. There are things like inpatient hospital lab services, doctor services, clinic services. There is also in the mandatory services something called a home health benefit and unfortunately something called a nursing home entitlement. There are also a whole host of optional services that states can choose to put in their State Plans but they don=t have to provide them, and there is a huge huge variation across this country in the types and amount of optional services in different States Plans.

Now this last bullet here says that Medicaid is a medical program that provides medical services, but we saw this morning, when Alan was talking, that in fact the enabling legislation for Medicaid has Paragraph A that is medical and Paragraph B that is psychosocial. So it really is broader than just a program of medical services.

Medicaid serves 37.5 million people who are seniors, who are low-income, who are people with disabilities. In some states they are beginning to expand the population base they cover by including adults without disabilities, who are among the working poor. You are going to see more of this probably as the childrens health insurance programs expand to include the parents of those children.
End of Session 2 audio

Medicaid and Community Supports
Session 3 & 4: Medicaid State Plan
Lee Bezanson

If you think about what is going on in this country since 1965, the private insurance market sort of systematically eliminated coverage for people who were high cost and high risk. And each time that has happened, those groups of people have turned to Medicaid for coverage, primary health care coverage and long-term care coverage. As they have done that, Medicaid has essentially become the safety net for this country. But each time they did that, whether they added a new group or a new service or waivers each little addition had its own eligibility rules, and its own coverage rules. And so you have this blob of things, sort of all attached to that basic beginning of Medicaid. And that’s why it really doesn’t make any sense.

Some of the services that you can begin to add are rehabilitation services, occupational therapy, speech therapy, physical therapy, speech and language hearing services, school-based programs for children with special needs, clinical services, and a really big one is assistive technology. Another one of the options I think you heard mentioned this morning is targeted case management. We can do personal care services, medical supplies, dental services, prescription drugs, and, of course, we all have in our states the opportunity at least to do nursing home services, ICFMR’s, although many of us are moving away from the ICFMR at least. Inpatient mental health services for children under 21.

There is a funny quirk in Medicaid and it is called an IMD exclusion. So inpatient psychiatric services you can provide to children under 21; and you can provide to seniors over 65, but from 18 to 64, Medicaid does not cover inpatient psych. And that has been one of the difficulties as states have tried to create home and community based waivers for people with mental illness. Day treatment and habilitation is particularly common in our developmental disability programs.
End of Session 3 & 4 Audio

Medicaid and Community Supports
Session 5 & 6: Medicaid Eligibility
Lee Bezanson

How do you get Medicaid benefits? Well this is an interesting issue. Remember we talked about adding all of those little pieces over the years. Those are eligibility doors to get a Medicaid card. The last time I counted, I believe in little tiny New Hampshire, there was something like 101 doors and when anybody comes in to apply for Medicaid, in the district office in our state, they have to keep going through a cascade of all the doors until they have exhausted all 101. So it=s a very administratively intense process. The doors are different for children and adults. The way you change access is you either create more doors or you make the doors you have wider. It is terribly important to understand that in order to get the services we are talking about these three days, you have to get the card. So you have to find a door through which you can get the Medicaid card. You get the Medicaid card, you’re entitled to all of those State Plan services, everybody who has a card has that entitlement. If in addition to having the Medicaid card you qualify for a waiver program or another specialized program within the Medicaid program in your state, then you may also have access to, for example, home and community based services. Not everybody gets that second waiver service entitlement. There is a second eligibility phase, but everybody who has a Medicaid card gets the basic State Plan services.

The story for Medicaid for kids is very different than it is for adults. Kids enjoy, on Medicaid, enjoy probably the richest insurance package in the country and it’s mandatory. There is something called EPSDT. Lets see if I can remember this acronym now, early periodic screening diagnosis and treatment, and states are mandated to periodically screen kids and then if they find that there is anything medically necessary that that child needs, to provide it if it could be in your Medicaid State Plan, which really means almost everything is covered. This is a mandatory program. It is probably not utilized as effectively as it could be in any state in the union, but it really opens the door to do the right thing for our kids.

So who gets a Medicaid card? Kids on SSI generally do, kids from low-income households. In many states, expansions have been made to cover children who are above the poverty level and this is particularly true with the Title 21 Programs, the Child Health Insurance Programs. Normally, we look at a family’s income but those states that have exercised the Katie Beckett option, for youngsters who would otherwise be in an institution, look at eligibility even on the financial side of the child’s income and assets alone. So the family’s income is not counted and this is what allows children with severe disabilities to get into the Medicaid program, which probably is as important as any program we have.

Medicaid is always the payer of last resort. So if a person has a private insurance and Medicaid, you always exhaust the private insurance first and then Medicaid picks up the rest. When we start talking about wrap around services and community based services for people with disabilities, you can expect that that is going to be something Medicaid will pick up because Medicaid is the only act in town for long-term support services. When we get to adults, there isn=t any requirement like there is in EPSDT. The adult benefits in most states are significantly less robust than they are for children. Usually there are more limits and in some cases a much smaller package. I think it is particularly true with dental services that you will see much better benefits for children than you do for adults.
End of Session 5 & 6 audio

Medicaid and Community Supports
Session 7 & 8: Medicaid Waivers
Alan Bergman & Lee Bezanson

There are basically three kinds of waivers. Waivers are exactly what the word means, waiving some existing rules or regulations that states typically have to follow to get certain kinds of Medicaid money.

1915B Waivers are what are called [whoops, too much (referring to the lights dimming in the conference hall)], Freedom of Choice Waivers, [you can come back about half way (referring again to the lights)]. The Freedom of Choice Waivers are the ones that you will hear about in states that do mandatory managed care. They ask to waive the Freedom of Choice regulation, which states generally have been asking to do. We will see a few of those in a few minutes.

Then there are the Section 115 Research and Demonstration Waivers, these waivers are truly research projects, they have to go through unbelievable scrutiny.

1915C Waivers are the ones we primarily have talked about yesterday and will talk about today, these are the home and community based services waivers. These waivers are the ones where the state asks to waive the rules around institutional placement to create the alternative and then they get to waive several components. They can waive what is called State Wideness, because Medicaid, if you will remember from yesterday’s 101/102, has to be offered statewide with reasonable access.
A state can do a home and community based waiver, and we are picking Connecticut now, and they could choose to do it only in Hartford, Connecticut. It’s perfectly legal to do so, and a number of states have done waivers in certain targeted communities within a state, you’re waiving State Wideness. So, if you live in the right community you could get it, if you live some place else equally needy, the same profile of disability, you could get nothing.

Second thing is the waiver of what’s called comparability or comprability. That is that in regular Medicaid, if you offer a service it has to be eligible to all appropriate groups who have a Medicaid card if it’s medically necessary. In the case of home and community based waivers, as you know, they are typically done by diagnostic groups and therefore you could have a MR waiver, an aids HIV waiver, a kids with special health care needs waiver and there are no legal protections for people who could benefit from waiver services who have another diagnosis.

The way the waivers are written, you could, a state, many states have as many as 12-14 waivers for different parts of the population, different issues, different part of the state, all very very legal.

Lee Bezanson
States can choose to cover the services, cover a service in their Medicaid State Plan or they can take the service that could have been in the State Plan and put it in a waiver. What they can’t do is duplicate and some times what states put in a waiver are additional benefits. For example, additional OT, PT, or speech they put in the waiver and keep it more restricted on the State Plan side.

Used to be there was a limit on how many people could be served in a waiver, that is no longer true. The real limits, in terms of how we can serve people and waivers, arises from really what a state has for resources to put up for the match and whether or not they have the infrastructure in their local communities to support people living there.

The waivers, because they are an alternative to institutionalization, really only serve the people with disabilities who have a pretty significant clinical disability. The waivers don’t serve people with disabilities that can’t meet that medical requirement, so if you are looking for gaps in your system, when you are looking at Olmstead, that is a group of people that we need to be mindful of because they are not being served in the Medicaid waivers.

Medicaid is not a cash assistance program, they don’t send out checks to people, instead they purchase services. Again, one of the reasons that states like to do waivers is that they feel they have some control. When you apply for a waiver, you have to prove that the aggregate cost of your waiver will be no more expensive than what it would have cost if those people were in an institution. So there is a ceiling on how much you can spend and because there is a cap, states tend to feel a little more comfortable on the waiver side of the equation.

Family members can be paid in waivers except for a parent of a minor and a spouse. Families and individuals with disabilities can direct their own services, they can be in the payment loop. There are untold different ways you can set these things up, in ways that empower families and consumers to be making the choices about their own lives,

And again, since Olmstead, sorry, Lois and Elaine, people living in a ICFMR or in a nursing home have a right to say I want out as long as the treatment professionals are agreeing with that, and again the one thing you can’t pay for in waivers is room and board. Medicaid will only cover that in an institutional setting like a hospital or a nursing home or a ICFMR and that really can be a barrier. But little by little I think we are persuading HUD that they have an obligation to step up here and do that piece of it.
End of Session 7 & 8 audio

Medicaid and Community Supports
Session 9 & 10: Medicaid and Community Supports
Lee Bezanson

[The corresponding audio section starts at the end of the Section 1: Medicaid Waivers]
Family members can be paid in waivers except for a parent of a minor and a spouse. Families and individuals with disabilities can direct their own services, they can be in the payment loop. There are untold different ways you can set these things up, in ways that empower families and consumers to be making the choices about their own lives,

And again, since Olmstead, sorry, Lois and Elaine, people living in a ICFMR or in a nursing home have a right to say I want out as long as the treatment professionals are agreeing with that, and again the one thing you can’t pay for in waivers is room and board. Medicaid will only cover that in an institutional setting like a hospital or a nursing home or a ICFMR and that really can be a barrier. But little by little I think we are persuading HUD that they have an obligation to step up here and do that piece of it.

In recent years personal assistant services have been broadened so that under Medicaid they can happen in the home, outside the home, in the school, in the workplace, and this is a really important step forward.

As you know in the Medicare program, you have to be enslaved in the four walls of your house, under the homebound rule, in order to get home health. Increasingly, you are going to see Medicaid programs moving toward programs that offer self-direction and that are consumer directed and historically, that was an option that was only available to people who could direct their own services. It is now being expanded so that families can use it for children and people with cognitive disabilities can also enjoy consumer direction.

You really need to know what your state is doing and is going to do with Medicaid, and it is very state specific, I really don’t encourage you to read the whole State Plan but if you have waivers in your state, do read those, do read the home health part of the State Plan, do look at other services that you feel are important, read those sections of the State Plan, and a lot of the State Plan stuff you can get off the web.
End of Session 9 & 10