"Medicaid and Individual Long-Term Supports: An Overview of How Medicaid Can be Used for Home and Community Services" Cathy Ficker Terrill Social Security Act Title XIX : Medicaid Medicaid was established as federal law in 1965 as a program for certain low income individuals and families. Medicaid (Title XIX of the Social Security Act) is a federal-state entitlement program for low income Americans. ! Administered by each state. ! Broad federal requirements and guidelines. ! Each state develops their own state Medicaid plan ! Approval by the federal government through the Health Care Financing Administration (HCFA). Have you seen your state Medicaid Plan? Have you read it? Medicaid covers basic health and long-term care services. Nationally about 65% of Medicaid dollars go for acute care. 35% Medicaid dollars spent on long term care. Medicaid benefits vary from state to state. Basic services that must be offered if a state has a Medicaid program. Examples of basic services: -Inpatient and outpatient hospital care -Laboratory and X-ray services -Skilled nursing for individuals 21 and older -Physician services -Immunizations and EPSDT for children -Home Health Services Medicaid: An important Resource for Olmstead Implementation. The Plan Optional Services Waivers ! States may choose to provide a number of optional services. ! Each state exercises a great deal of control over who is eligible for specific services. ! Medicaid by its name indicates a program to provide medical services. Medicaid Has Basic Rules States must specify: Amount: What Duration: How much, how long Scope: For whom ...and then there is Statewidedness State plan must be statewide. Amount ....Duration....Scope.... Must be the same statewide. 2 Exceptions to Statewide Waivers Targeted Case Management Medicaid serves 40.6 million poor, disabled, and elderly people. Annual cost $175 billion, 1998 FFP 50-83% Medicaid Covers Four Groups Elderly 3.9 million 10% Disabled 6.6 million 17% Children 18.9 million 52% Adults in families with children 7.9 million 21% 1998 data Who spends the money 1997 52% all Medicaid Beneficiaries were children Elderly spent 28% of the money Disabled spent 38% of the money No one designed Medicaid. It makes no sense. The definition of Medicaid funded services depends on what state you live in. There are 50 Medicaid programs. States have lots of flexibility In some states things are in the State Medicaid Plan. In other states things are in the waiver. It all depends on what you advocate for. States may choose to provide a number of optional services. Each state exercises a great deal of control over who is eligible for specific services. Medicaid by its name indicates a program to provide medical services/or aid to people. Medicaid was begun years ago as a program to eliminate the two class system of obtaining medical services. The purpose was to provide a federal government subsidy to low income people so they could purchase medical services from the doctor of their choice. States have the option of providing many other services and many states go well beyond the mandated requirements. Many states fund a comprehensive range of specialized services for people with disabilities. These optional services include: ! Outpatient rehabilitation services ! Occupational, physical, and respiratory therapy ! Speech-language-hearing services ! Clinical services, which can include mental health services, assistive technology ! Targeted case management for individuals with developmental disabilities or mental health needs ! Personal care services ! Home medical equipment, orthotics, and prosthetics ! Dental services ! Prescription drugs ! Other health professional services, often targeted to individuals with mental illness or other disabilities ! Services in institutional and community living situations though the ICF/MR program ! Inpatient mental health services for children under age 21 ! Home and community-based long term supports/services ! Day treatment and habilitation Rehabilitation Option "Any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under state law for maximum reduction of physical or mental disabilities and restoration of a recipient to his/her best functional level." COVERED BY REHAB OPTION ! Psychosocial rehabilitation ! In-home services ! Therapeutic foster care ! Early intervention services ! Crisis programs ! Services to youth in certain residential placements (e.g., group homes) ! Collateral services for encounters with family ! Day treatment ! Medication compliance activities Medicaid is America's largest single purchaser of nursing home services and other long term care. FFY 2000 Medicaid LTC $67.7 Billion Nursing Home Care $39.6 Billion Waiver $12. Billion Personal Care Services $3.8 Billion Most of the long term care paid for by Medicaid is delivered in nursing homes. Medicaid pays for 1/2 of all nursing home care in the US.....covering about 2/3 of the nearly 1.6 million nursing home beds. Kaiser Commission Report, 1999 The Social Security Act authorizes the Secretary of Health and Human Services to waive certain Medicaid statutory requirements in order to enable the states to cover a broad array of Home and Community Based Services. The waiver program is an alternative to institutionalization. A waiver offers broad discretion not generally afforded under the state's plan so that states can address the needs of individuals who would otherwise receive costly institutional care provided under the state's Medicaid plan. Authorization of HCBS Medicaid waiver programs was added to the Social Security Act (Section 1915 (c)) by the Omnibus Budget Reconciliation Act of 1981 (Section 2176 of P.L. 97-35). Oregon's waiver program was the first HCBS waiver approved by HCFA (December 1981). Waivers Average cost of HCBS DD Waiver $29,353 per person HCBS Waiver for Seniors $5362. Access (Getting to the benefits) ! "Doors" ! Doors are different for kids and adults ! Access mainly involves: -- Adding doors -- Widening doors Access, Access, Access ! The card is the ticket ! Many doors lead to the ticket booth ! No card - No services Getting the Medicaid Card... ! Two ways: --Person meets eligibility criteria by virtue of income and disability --People who need HCB waiver services often face less stringent tests ! For adults, family income doesn't count ! There are all manner doors available that states may select to make Medicaid available to adults Medicaid Eligibility ! Medicaid can be extended to any adult with a severe disability whose income from whatever source is less than roughly $13,000 ! It can go even higher ! All issues in Medicaid eligibility revolve around which doors your state has selected What the Card buys... ! Most but not necessarily all conventional "health care" benefits ! May or may not buy personal assistance ! May or may not come with restrictions Coverage ! Usually, there's more covered than first meets the eye (or anyone will readily admit) ! More can be covered than most states do ! Strategy: You need to go explore to find out January 1999 - Modify October 1999 New guidelines under personal assistance - allows supports in and out of the home Talks about consumer directed personal assistance services, revision includes people with cognitive disabilities Coverage ! If the state can't or won't cover a service in the Medicaid state plan, it can still be offered through HCB waiver program ! As in dental services, services over and above limits in state plan, therapies (including acupuncture and massage therapy!) Medicaid home and community-based (HCB) waiver program ! Enormous flexibility ! Wide range of services and supports can be offered ! Services and supports can be family and consumer directed ! The waiver program is the main way states are getting money to pay for services and supports in the community ! It's changing quickly Quick Facts... ! HCB waiver programs served 45,000 DD people in 1990; served 240,000 people in 1992, 622,000 in 1999 ! 33% of waiver participants live with their families ! 15% live in their own home ! Every state has a DD waiver program (some have 14) ! States can serve as many people in waiver programs as they want (and can afford) There are no longer any restrictions on how many people can be in a waiver. HCB Waiver 101 ! HCB waiver program allows states to use money for community services and supports instead of institutional services ! States decide how many people to serve ! States decide what types of services and supports to offer ! December, 2000 / 244 approved waivers throughout the country HCB Waiver 102 ! Not a cash assistance program ! Services can't duplicate what's offered in the Medicaid state plan (waivers are constructed to take into account what's available) ! Services offered must meet a disability-related "need" or help the caregiver support the person ! Waiver eligibility based on person not the family* Medicaid is a program that buys things - it is not a cash assistance program. One of the oldest waiver services is respite. Supports Waiver Programs Can Buy ! Respite ! Caregiver training ! Vehicle modification ! Private duty nursing ! Extra health care and therapy benefits ! Day programs or SEP ! Summer camp ! Case Management ! Emergency Home Response ! Personal assistance ! Home modifications ! Adaptive equipment ! Communications aids ! Dental care ! Crisis supports ! Other professional services ! A Medicaid card Waivers Allow For: ! Cultural Diversity ! Flexibility ! Creativity ! Individual Services -- Supports vs. Buildings --Choice --Natural Settings --Expectations But ! If it isn't "officially covered" in the waiver program, individuals can't get it ! If there are no "slots", individuals can't get into the supports even if covered ! Advocacy re: HCB waivers: --What's offered --Making the program bigger ! Bigger waiver programs are how states are "Unlocking the Waiting List" Model Waiver = Capacity of 200 The only difference between a waiver and a model waiver is you check one box Live Examples of Approved HCB Waiver Programs for Families ! PA Person/Family Directed Waiver Program ! OK: 2 HCB Waiver Programs for children and adults who live with their families ! IL: "Supported Living Option" ! UT: Distinct "Family Support and Assistance" benefit Waiver 201 ! Individuals with disabilities can direct their own services ! Individuals can be in the payment loop ! Individuals by law have the right to choose service providers (waivers are "voucher-like" ! If I live in ICF/MR, I have the right to choose a waiver vendor. (Olmstead) Waiver 202 ! Yes, a neighbor can provide waiver services ! Yes, individuals can recruit and train workers ! No, the waiver will not buy a house Waiver 303 ! Yes, there can be a fiscal intermediary ! Yes, support brokers/personal/family agents can be paid for with waiver dollars ! No, waivers won't buy a horse (but they can by hippo therapy) At the end of the day... ! A waiver can be "flexible", "creative", "innovative" ! The waiver program is the central financing strategies for getting supports into a person's home Parting words... ! Especially with respect to Medicaid, we need partnerships. ! Truth: It isn't rocket science, just weird ! Truth: You need your own experts, "gurus" ! Truth: Medicaid "policy" is in its best shape ever for supporting individuals States Can Simplify the Medicaid Application Process The following states have taken steps to simplify their Medicaid application processes, either by allowing mail-in applications, by eliminating the assets test for children, by shortening the Medicaid application form or by using a combination of these techniques. Mail-In ! Alabama ! Alaska ! Connecticut ! Delaware ! Hawaii ! Illinois ! Maine ! Massachusetts ! Michigan (local decision) ! Minnesota ! Mississippi ! Missouri ! New Mexico ! North Dakota ! Ohio ! Oregon ! Pennsylvania ! Utah ! Vermont ! Virginia ! Washington ! Wyoming No Assets Test ! Alabama ! Alaska ! Arizona ! Connecticut ! Delaware ! DC ! Florida ! Georgia ! Illinois ! Indiana ! Kansas ! Kentucky ! Louisiana ! Maine ! Maryland ! Massachusetts ! Michigan ! Minnesota ! Mississippi ! Missouri ! Nebraska ! New Hampshire ! New Jersey ! New Mexico ! New York ! North Carolina ! Ohio ! Pennsylvania ! South Carolina ! South Dakota ! Tennessee ! Vermont ! Virginia ! Washington ! West Virginia ! Wisconsin Short Application ! Alabama ! Alaska ! Arkansas ! Colorado ! Georgia ! Hawaii ! Illinois ! Indiana ! Iowa ! Kentucky ! Michigan ! Mississippi ! Missouri ! New Hampshire ! New Mexico ! New York ! Ohio ! Oregon ! South Carolina ! South Dakota ! Tennessee ! Texas ! Utah ! Vermont ! Virginia ! Washington ! West Virginia ! Wyoming A state with HCFA approval can waive ! Statewideness ! Income and resource standards ! Comparability of services ! Equal provision of services --As long as the average per capita cost of providing these services will not exceed the cost of institutional care States may select ! Services ! Service definition ! Target population ! Number of individuals to be included Waivers Highly Targeted Waivers 3.2% Participants Individuals with DD = 39.7% waiver participants Individuals with other Disabilities = 57.1% THE END Page 121