Building Sustainable Employment Systems for People with Disabilities - Medicaid Infrastructure Grants

1. MEDICAID INFRASTRUCTURE GRANTS BUILDING SUSTAINABLE EMPLOYMENT SYSTEMS AND SUPPORTS FOR PEOPLE WITH DISABILITIES SARA SALLEY NATIONAL CONSORTIUM FOR HEALTH SYSTEMS DEVELOPMENT

2. What is the Medicaid Infrastructure Grant program? • Created by the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA) • First awards made in 2000, funded through FY2011 • Primary goal—competitive employment for people with disabilities through: • Medicaid Buy-In programs to reduce fear of losing health benefits due to earnings—a Medicaid category with work incentives built in, premiums • Improved Medicaid services and stronger infrastructure to support working people with disabilities • A comprehensive, coordinated approach to removing employment barriers

3. What is the Medicaid Infrastructure Grant program? • Administered by Centers for Medicare and Medicaid Services—CMS • Grants go to state Medicaid agency, or other entity in cooperation with state Medicaid • VR agencies, DD agencies, university policy and research centers, Governor’s Council on Disability • Minimum grant award • States with no Medicaid Buy-In: $500,000 to $750,000 per year • State with Medicaid Buy-In: Up to 10% of MBI expenditures

4. What is the Medicaid Infrastructure Grant program? • Forty-eight states have had MIG funding since 2000; about 40 have 2008 MIG award. • Annual awards from $500,000 to more than $5 million per year. • 6 states received more than $1 million each in 2006, 2 received more than $5 million each. • Two types of grants: “Basic Medicaid Infrastructure” and “Comprehensive Employment Systems” • States without a Medicaid Buy-In get a Basic grant

5. What do MIG projects do? Develop and enhance Medicaid Buy-In programs and Medicaid services Support benefits planning services and infrastructure Engage with businesses as employers Conduct outreach and education Evaluate state disability and workforce systems Collect and track program and outcomes data Bring state, federal and private partners together Carry out statewide strategic planning

6. What roles do MIGs play in building state infrastructure? Convener – convene stakeholders to identify systems needs and promote infrastructure development; Facilitator – facilitate discussions and relationships necessary to make sustainable changes to state’s infrastructure; Coordinator – coordinate policy development, pilot projects and initiatives to demonstrate best practices; and Leader – develop and provide leadership on workforce development for people with disabilities.

7. How are other states using their MIG dollars? Strengthening supported employment programs—ME, AR, WA Building capacity for benefits planning—OR, IN, ND, MT Integrating employment into Medicaid services and policy—WI, AZ “Marketing” employees with disabilities to businesses—CT, WA, MD

8. Why is the MIG important to Florida? Brings in federal dollars to build state infrastructure to improve employment outcomes Plays planning and coordinating role to move the employment agenda forward statewide Supports Medicaid Buy-In development Creates cross-state partnerships to share strategies, data and best practices Establishes forum for highlighting Florida’s accomplishments

9. Why is Florida important to the MIG program? • Leading the way in Business Leadership Network development • Business-to-business network to increase awareness and understanding about employment opportunities for people with disabilities • Offering promising practices in benefits planning • Florida Benefits Information Resources Network and Employment Coordinators to build benefits planning capacity • Setting the example with Employment First • Encouraging employment as the first option for people with disabilities • Sharing expertise in marketing and outreach • Collaborating with other state and federal partners to raise awareness nationally and locally about disability and employment

10. How have MIGs improved employment outcomes for people with disabilities? • MIGs helped develop and implement Medicaid Buy-In programs – roughly 98,000 MBI enrollees nationally in 2006, an increase from 30,000 in 2001. • Combined earnings of all MBI program participants nationally increased from $222 million in 2001 to more than $556 million in 2006 (contribution to tax base). • MIGs helped 20 states expand Personal Assistance Services (PAS) coverage in the workplace up to 40 hours a week. (Source: Mathematica GPRA Report, December 2007)

11. How have MIGs improved employment outcomes for people with disabilities? • MIG outreach and education efforts provide information about Medicaid Buy-In and other work incentives to millions of people with disabilities. • MIGs contribute hundreds of thousands of dollars towards work incentives planning infrastructure and services. • MIGs provide strategic leadership on disability and employment issues within each state and nationally.

12. What is the Medicaid Buy-In program? A Medicaid eligibility category for working people with disabilities whose income or assets would otherwise disqualify them from Medicaid coverage • Individuals “buy into” coverage by paying premiums. • States have flexibility to set eligibility criteria (income and asset limits), premium structures and other features.

13. Why is the Medicaid Buy-In important? Allows people with disabilities to work and earn more without fear of losing health coverage and vital services Creates incentive for people receiving Social Security benefits to return to work, increase earnings Offers chance for greater financial independence through earnings and savings

14. How are Medicaid Buy-In programs different from “regular” Medicaid? Employment requirement, verification procedures (proving you’re employed) Income disregards (retirement funds, Independence Accounts) Treatment of earned versus unearned income (different limits, spousal income, premium calculations) Grace periods for temporary loss of work Premium structures

15. How many people are using the Medicaid Buy-In? (Source: CMS presentation, NCHSD 2007 Fall Conference) 2006 total enrollment in 32 states = 98,264

16. Who is enrolling in Medicaid Buy-In programs? • (Source: Mathematica enrollment report, April 2008) • About 70% of MBI enrollees had SSDI just before they enrolled, over half had Medicare. • “Primary disabling condition” (diagnosis data) • Mental health disabilities for about 32% • Intellectual disabilities for almost 12% • Musculoskeletal conditions for almost 10% • All other diagnoses – 21% • Unknown – 25% Everything varies by state!

17. Who is enrolling in Medicaid Buy-In programs? • (Source: Mathematica enrollment report, April 2008) Gender split is roughly even About three-quarters of enrollees are white Age distribution:

18. What do states charge for premiums? (Source: CMS presentation, NCHSD 2007 Fall Conference) • Most states charge premiums for MBI coverage; $22 million collected in 2006 • 25 states collected premiums, 7 states did not • Two-thirds of states charged $50/month or less, 10% charged $100/month or more

19. Is the Medicaid Buy-In “working”? (Source: Mathematica GPRA Report, December 2007) Average earnings for MBI enrollees were slightly higher in 2006 than 2005, from $7,876 to $8,237 (roughly 4% increase) Total combined earnings of MBI enrollees (contribution to the tax base) rose from $222 million in 2001 to $556 million in 2006 (enrollment growth + earnings growth) Improving employment rates? Nationally, too hard to tell

20. What does CMS expect of MIG states going forward? Sustainability Build in the ability to sustain what has been identified as important infrastructure that promotes competitive employment. Leadership Demonstrate that leadership is engaged at all levels and will sustain itself beyond the life of the grant. Stakeholder engagement Show that wide range of stakeholders are involved in building infrastructure and creating sustainability plans for new infrastructure. Measurable outcomesActivities must be measurable; include a thorough evaluation component; collect and analyze data to document program success.

21. How can you—Task Force members—help the MIG achieve shared goals? Lend expertise on workforce development and employment related supports for people with disabilities; Advise and consult with MIG staff on grant activities & objectives; Serve as “ambassadors” by providing important connections for MIG staff and stakeholders to key decision makers to move strategic priorities forward; and Represent MIG goalsand objectives in other venues to spread the word about how to get involved.

22. What is the National Consortium for Health Systems Development? A technical assistance center for MIGs developed by states for states to promote the development of sustainable workforce and employment supports infrastructure by: • Promoting state-to-state information sharing and disseminating promising practices through teleconferences, policy briefs and individual state consultation • Offering work incentives training and education • Facilitating communication and collaboration with federal partners agencies (CMS, DOL/ODEP, SSA, etc.) • Providing forums for national and regional MIG meetings and workshops • Hosting a comprehensive web-based resource exchange atwww.nchsd.org A project of Health & Disability Advocates, Chicago, Illinois