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Staff Updates

Staff Updates. Session I Monday, 11:00 am February 14, 2011 Employment and Affordable Care Act Review. Employment. Too many people with intellectual and developmental disabilities are underemployed, in segregated settings, and earn very little money 424,000 earning sub-minimum wages (GAO)

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Staff Updates

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  1. Staff Updates Session I Monday, 11:00 am February 14, 2011 Employment and Affordable Care Act Review Disability Policy Seminar February 14-16, 2011

  2. Employment • Too many people with intellectual and developmental disabilities are underemployed, in segregated settings, and earn very little money • 424,000 earning sub-minimum wages (GAO) • limited exposure to the workforce, reduced expectations, lack of access to jobs • Workforce Investment Act and Vocational Rehabilitation agencies under-funded and under-trained • Major changes are needed legislatively and administratively to turn the system around Disability Policy Seminar February 14-16, 2011

  3. Employment cont. • Sen. Harkin, HELP Committee Chairman, developing legislation • Recommendations: • Need recommendations to made general workforce programs accessible • Incentivize states to change Medicaid and other systems to embrace “employment first” policies • Support model transition services that ensure that youth transition to good jobs and postsecondary opportunities, not segregated settings Disability Policy Seminar February 14-16, 2011

  4. Health Care Reform: 2 Laws • Patient Protection and Affordable Care Act (P.L. 111-148) • Health Care and Education Affordability Reconciliation Act (P.L. 111-152) • “Affordable Care Act” • http://www.heathcare.gov • For health insurance information by state • Comprehensive ACA implementation Disability Policy Seminar February 14-16, 2011

  5. Groundbreaking Legislation • Expand Coverage and Access to Care • 32 million uninsured will be covered • New insurance exchange with premium sharing subsidies, and cost sharing caps • Large expansion of Medicaid eligibility • Significant insurance market reforms • Completes the ADA • Prevention, research, Medicare and others • Long term services and supports expansions Disability Policy Seminar February 14-16, 2011

  6. ACA Implementation • Phased in over next several years • Awaiting regulations and guidance on many key issues • Regulations arriving at a steady pace • States working on implementing legislation • Numerous threats to the ACA Disability Policy Seminar February 14-16, 2011

  7. Insurance Reforms In Effect Now • Means for plan years beginning on or after September 23, 2010 • Eliminates pre-existing condition exclusion for under age 19 • Lifetime limits not allowed • Phase-in of elimination of annual limits • Rescissions • Access to doctors • Emergency room • Appeals Disability Policy Seminar February 14-16, 2011

  8. Threats to ACA • Full repeal passed in the House –failed in the Senate • Lawsuits pending • Partial repeal votes expected • If politically unpopular aspects repeal has cost implications • Defunding implementation and specific programs Disability Policy Seminar February 14-16, 2011

  9. Political Climate • Highly politically charged debate • Our organizations long term supporters of health care reform and long term services and supports expansions • Not a partisan choice • Rely on credible, non-partisan sources of information Disability Policy Seminar February 14-16, 2011

  10. Premiums • Secretary can’t set premiums • Transition period until 2014 • $250 million over 5 years for states to build capacity for rate review • Medical Loss Ratio • 85% of premiums spent on benefits • Hotly debated Disability Policy Seminar February 14-16, 2011

  11. Grandfathered Plans Grandfathered plans—plans in existence on March 23, 2010 Most health insurance through large employers (100 or more workers) will not see major changes to their coverage Routine changes allowed: Keeping pace with medical inflation Adding new benefits Modest adjustments to existing benefits Voluntarily providing new consumer protections Disability Policy Seminar February 14-16, 2011

  12. Applies to Grandfathered Plans? YES Pre-existing condition exclusions (EXCEPT individuals plans) Lifetime and Annual Limits (EXCEPT individual plans) Rescissions Dependent Care extension (EXCEPT if other employer-sponsored) NO Access to Doctors Emergency room Appeals changes Disability Policy Seminar February 14-16, 2011

  13. Insurance Reforms in 2014 • Can’t consider health status when calculating premiums • Prohibit discrimination based on health status • Eliminate use of annual limits for all • Guaranteed issue and renewability Disability Policy Seminar February 14-16, 2011

  14. Individual Responsibility • Tax penalties for no coverage-administered by IRS • 2014-- $95 • 2015--$325 • 2016-- $695 • Percent of household income 1% in 2014, 2% in 2015 2.5% in 2016 and after • Exempts individuals with incomes too low to pay taxes Disability Policy Seminar February 14-16, 2011

  15. Why is this important? • Need all people to be covered by insurance • Shares the risk for insurers • Helps keep premiums lower • Guarantee issue requirements and other reforms cannot work without greater coverage Disability Policy Seminar February 14-16, 2011

  16. Expanding Coverage • Temporary Pre-Existing Conditions Plans • Now until 2014 • Coverage for Dependents (age 26) • Effective now • Medicaid Expansion • Effective 2014 but states can begin early • Health Insurance Exchanges • Effective 2014 –can be state, regional or run by the federal government Disability Policy Seminar February 14-16, 2011

  17. Medicaid Expansion • Expands Medicaid eligibility to 133 % of Federal Poverty Line (2014) - • approximately $14,600/ individual; • $29,400/family of 4 (2009 FPL Guidelines) • New method of disregards brings it up to 138% of Federal Poverty Level • No asset test for eligibility Disability Policy Seminar February 14-16, 2011

  18. Medicaid Expansion, cont. • People with disabilities likely to benefit • People receiving SSDI and in the 2-year Medicare waiting period • People who do not meet Social Security disability standard and are low income • People who meet the disability standard but income or assets are too high Disability Policy Seminar February 14-16, 2011

  19. Medicaid Expansion, cont. • Federal Share (FMAP): • 100% for 2014 – 2016 (3 years) • Phases down to 90% for 2020 and subsequent years • CMS guidance--States can start earlier and phase it in • By 2019 CBO estimates 16 million new enrollees • Maintenance of effort requirements Disability Policy Seminar February 14-16, 2011

  20. Health Insurance Exchanges (2014) • Provide coverage, increase competition, lower costs to small employers and individuals without access to affordable employer coverage • “Marketplace”: Private insurance plans that meet minimum standards on benefits and cost-sharing set forth in regulations • Multi-state Exchanges run by HHS for states that choose not to operate their own Exchange • Subsidies to low income individuals Disability Policy Seminar February 14-16, 2011

  21. Essential Benefits Package for Exchange Plans • Hospitalization, emergency services, ambulatory (i.e. outpatient) services • Prescription drugs and laboratory services • Rehabilitative and habilitative services and devices • Mental health and substance abuse disorder services including behavioral health treatment • Preventative and wellness services and chronic disease management • Pediatric services including dental and vision care • Maternity and newborn care Disability Policy Seminar February 14-16, 2011

  22. Essential Benefits, cont. • LAW REQUIRES: • Appropriate balance among the categories • Cannot discriminate against individuals because of their age, disability or expected length of life • Must take into account the health care needs of diverse segments of the population including women, children, persons with disabilities and other groups Disability Policy Seminar February 14-16, 2011

  23. Challenges to the Essential Benefits • Comprehensive benefits versus costs • What do the key terms mean? • What is essential? • What is appropriate balance? • How should medical necessity be defined? • What coverage limits are allowed? • What is the scope of each benefit category • What is covered in a typical employer plan? Disability Policy Seminar February 14-16, 2011

  24. Rehabilitative and Habilitative Services and Devices • Broad category -- everything from therapies to wheelchairs • Medicaid definition of habilitation • Importance of acquiring and maintaining skills • No limitation on scope or setting • Powerful opposition to the disability position Disability Policy Seminar February 14-16, 2011

  25. Autism Services • Mental health and substance use disorder services, including behavioral health treatment • Autism Speaks –this includes autism services • Primarily concerned about Applied Behavior Analysis (ABA) • State coverage mandates for autism are often broader and include habilitation • May be an issue in states with mandates Disability Policy Seminar February 14-16, 2011

  26. Challenges to the Exchanges • Grants to states to plan the exchanges • Enforcement responsibilities • Level insurance playing field • Ensuring accessibility • Qualified plans (sufficient providers etc.) • Seamless interplay with Medicaid and CHIP • Helpful services to employers who use it • Advocates need to be involved Disability Policy Seminar February 14-16, 2011

  27. Impact on Employers • Designed to build on employer-sponsored insurance • Impact varies by the size of the employer • Pay roll tax deduction available for small employers who provide health insurance Disability Policy Seminar February 14-16, 2011

  28. Summary Slide • Grandfathered plans • Large employers • Part-time employees • Penalties for unaffordable or non-coverage • Credits and subsidies for very small employers • Free choice vouchers • Fraud provisions Disability Policy Seminar February 14-16, 2011

  29. Inclusion of Long Term Services and Supports in Health Care Reform • Disability and aging communities worked together • Goal – Ensure two-pronged inclusion of LTSS in health reform: • National LTSS insurance program – avoid impoverishment • Improve Medicaid – eliminate institutional bias Disability Policy Seminar February 14-16, 2011

  30. Long Term Services and Supports in Health Care Reform • Accomplished: • CLASS Act • Improvements to Medicaid • Community First Choice Option; • Improving existing Section 1915(i) option; • New state balancing incentives; • Spousal impoverishment protections; • Extend Money Follows the Person demonstration; • Expand Aging and Disability Resource Centers Disability Policy Seminar February 14-16, 2011

  31. Community Living Assistance Services and Supports (CLASS) Act Plan • New national LTSS insurance program • Based on voluntary payment of premiums • through employer or directly • Nominal premium for full-time students and people with income below poverty level • Vesting after 5 years of premium payments • Work requirement Disability Policy Seminar February 14-16, 2011

  32. CLASS Act Plan, cont. • No exclusions based on pre-existing conditions • Benefits eligibility is based on functional need • Need for assistance with activities of daily living or equivalent Disability Policy Seminar February 14-16, 2011

  33. CLASS Act Plan, cont. • Cash benefits for maximum consumer and family control • No impact on federal benefits eligibility • SSI and Medicaid • No “means-testing” – income is not considered • No need for lifetime impoverishment • Individual can continue to work • Advocacy and advice/assistance available Disability Policy Seminar February 14-16, 2011

  34. CLASS Act Plan, cont. • Separate CLASS Independence Trust Fund • Secretary of HHS to develop the Plan • Plan can pay for itself AND take pressure off the Medicaid program • Important for future of Medicaid program Disability Policy Seminar February 14-16, 2011

  35. Improving Long Term Services and Supports in Medicaid • The need for change: • Institutional Bias within Medicaid • Nursing homes mandatory • Community-based services optional or waiver • People with disabilities and their families do not have an equal choice • Long waiting lists for community-based services and supports Disability Policy Seminar February 14-16, 2011

  36. Improving LTSS in Medicaid, cont. Disability Community Long Term Goal: Enact the Community Choice Act Would mandate Medicaid community-based attendant services and supports Too costly and politically impossible to enact a mandate to states Worked with White House and Congressional Sponsors on a first step in that direction – Community First Choice Option Disability Policy Seminar February 14-16, 2011

  37. Community First Choice (CFC) Option • New state Medicaid plan option included in health reform law • Comprehensive home and community based services for people eligible for an institutional level of care (nursing home, intermediate care facility (ICF), or IMD) • States receive 6 percent additional federal match for CFC services • Permanent provision in Medicaid program – does not “sunset” Disability Policy Seminar February 14-16, 2011

  38. CFC Option, cont. • Included services and supports: • Assistance with activities of daily living (ADLs) • Assistance with instrumental activities of daily living • Assistance with health-related tasks • Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish the above • Back-up systems or mechanisms (such as beepers, electronic devices) • Voluntary training on how to select, manage, and dismiss attendants Disability Policy Seminar February 14-16, 2011

  39. CFC Option, cont. • Manner of service provision: • Hands-on assistance • Supervision • Cueing • Other permissible services • transition costs (first month’s rent and utility deposits, bedding, kitchen supplies, etc.) • needs identified in person-centered plan that would increase independence or substitute for human assistance Disability Policy Seminar February 14-16, 2011

  40. CFC Option, cont. • Eligibility is based on functional need (not age, diagnosis, etc.) • Allows people with incomes up to 300 percent of the SSI level to be eligible (depending on state rules) Disability Policy Seminar February 14-16, 2011

  41. CFC Option, cont. States must: • provide services in a home or community setting • provide consumer-controlled services, statewide, in the most integrated setting appropriate • create a Development and Implementation Council – majority of members must be people with disabilities, elderly individuals, and their representatives • establish a comprehensive quality assurance system using feedback from consumers, families, providers Disability Policy Seminar February 14-16, 2011

  42. CFC Option, cont. • Available beginning October 1, 2011 • Advocates should be working with states now Disability Policy Seminar February 14-16, 2011

  43. Home and Community Based Services (HCBS) State Plan Option (Section 1915(i)) Medicaid 1915(i) Option States can provide services without a waiver States must establish eligibility that is less strict than for institutional and HCBS waiver services – states serve people who are not eligible for the state’s HCBS waiver Very few states took up this option to expand community-based services Disability Policy Seminar February 14-16, 2011

  44. Amendments to HCBS Option(Section 1915(i)) ACA improved it to: • Allow states to provide full range of services allowed in HCBS waiver –including “other services approved by the Secretary” • Remove the authority for states to cap services, limit services to certain sections of the state, and maintain waiting lists • Align income eligibility criteria with other HCBS programs – allows people with incomes up to 300 percent of the SSI level to be eligible Disability Policy Seminar February 14-16, 2011

  45. Amendments to HCBS Option(Section 1915(i)), cont. States may target certain populations in need for 5 years CMS letter to State Medicaid Directors: August 6, 2010 http://www.cms.gov/smdl/downloads/SMD10015.pdf Effective Date: October1, 2010 Disability Policy Seminar February 14-16, 2011

  46. Federal Implementation • Department of Health and Human Services • CLASS Act Plan • Design/implementation of programs/public education • Centers for Medicare and Medicaid Services (CMS) • Community First Choice Option; Section 1915(i); State Rebalancing; Money Follows the Person • Guidance to states • Funding decisions • Will need your input and responses to alerts on regulations, etc. Disability Policy Seminar February 14-16, 2011

  47. State Implementation • Implementation of Medicaid Long Term Services and Supports changes • States have many choices • Community First Choice Option • Section 1915(i) option • Other new provisions • Work with Governor, State Legislature Disability Policy Seminar February 14-16, 2011

  48. Message to Congress • Full Implementation – No Repeal • Support the CLASS program • Oppose repeal • Support full implementation of the Communty First Choice Option and other Medicaid long term services improvements Disability Policy Seminar February 14-16, 2011

  49. Q & A Disability Policy Seminar February 14-16, 2011

  50. Staff Updates Session Ii tUESday, 9:00 am February 15, 2011 Budget Overview, Social Security, Medicaid, Housing and Autism Disability Policy Seminar February 14-16, 2011

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