Maureen M. Corcoran President

1. Rebalancing Long-Term Services and Supports:Money Follows the Person and theBalancing Incentive Program The New York State Association of Community and Residential AgenciesNovember 2013 Maureen M. Corcoran President Daphne Kackloudis Saneholtz Senior Advisor Vorys Health Care Advisors, LLC

2. Topics to Discuss • New York State’s System Transformation • Money Follows the Person • Balancing Incentive Program • See NYSACRA’s synopsis of MFP and BIP 2

3. New York State’s System Transformation • Dynamic health care environment nationally and at state level • New York State is undertaking a system transformation for individuals with intellectual and developmental disabilities (IDD) • Transformation plan included in Appendix H of Partnership Plan waiver • NYSACRA committed to working with OPWDD to implement transformation in a way that ensures the stability of services for consumers and providers 3

4. OPWDD Priority Elements of Transformation • Expanding opportunities and supports for employment • Expanding community service options, including supportive housing and community-based services • Expanding self-direction options • Creating opportunities for people to move from institutions to integrated settings by adhering to the Olmstead Plan 4

5. Components of Transformation • Amending existing, approved Money Follows the Person (MFP) protocol to include the IDD population • Seeking federal approval for a balancing incentive program (BIP) • A combined §1915(b)/(c) waiver to implement a managed care structure for delivering home- and community-based services and supports • Residential transitions and supportive housing • Supported employment services and competitive employment • Consumer self-direction 5

6. MFP: Background • Enacted as part of the Deficit Reduction Act of 2005. • Part of a comprehensive strategy to assist states in reducing reliance on institutional care while developing HCBS opportunities. • Enhanced federal funding to move individuals to the community. • The Affordable Care Act extends MFP through September 2016, and adjusts the amount of time an individual must be institutionalized in order to take advantage of the program from 6 months to 90 consecutive days.

7. MFP: Background (contd.) • Five population groups that are eligible to participate: • Individuals over age 65 • Individuals with disabilities under age 65 • Individuals with intellectual disabilities • Individuals with serious mental illness • Others, such as individuals with two or more primary diagnoses and those who do not fit into one of the other four groups

8. MFP By the Numbers • As of 2007, 75% of MFP-eligible were classified as age 65 or older and living in a nursing home • Another 15% were individuals younger than age 65 living in a nursing home • Almost 9% were living in an ICF-DD • Less than 1% each were individuals younger than age 22 residing in an inpatient psychiatric hospital and individuals age 65 or older living in a mental hospital Source: Lipson D. and Williams S. (January 2011.) Mathematica Policy Research, Inc. The National Evaluation of the Money Follows the Person (MFP) Demonstration Grant Program. Reports from the Field #5

9. MFP By the Numbers (contd.) • As of 2007, individuals with IDD were a target population in 28 of the 31 states/jurisdictions involved in the MFP program.* • More than 31,000 people with chronic conditions and disabilities transitioned from institutions back into the community through MFP programs between 2007 and 2012.** *Source: Money Follows the Person: Population, Functional, and Quality Indicators for People With Developmental Disabilities. September 2007. Prepared for Center for Medicaid and State Operations, Centers for Medicare & Medicaid Services, United States Department of Health & Human Services. Prepared by Nancy Kirchner, Charles Moseley, EdD. National Association of State Directors of Developmental Disabilities Services. **Source: Medicaid.gov. Money Follows the Person (MFP).

10. Requirements for States Participating in MFP • States must maintain: • A transition program that identifies Medicaid beneficiaries in institutional care who want to live in the community and helps them do so, and • A rebalancing initiative that invests enhanced MFP federal matching funds into programs and services that increase, relative to institutional care, the proportion of Medicaid long-term care expenditures flowing to community services and supports.

11. What is the value of participating in MFP? • Significant flexibility in determining populations to transition out of institutional settings, services to offer in the community, and how they want to use their grant money to accomplish set goals. • Examples of how states can use their MFP funds • To pay the first month’s rent and security deposit for an individual transitioning from an institution to an apartment. • To pay a transitioning individual’s unpaid utility bill that would otherwise prevent him or her from receiving a necessary utility service in his or her new apartment.

12. NY’s MFP Program • Approved in 2007 • Since then, has been transitioning individuals out of nursing homes and into the Traumatic Brain Injury or Nursing Home Transition and Diversion waivers

13. Including the IDD Population in NY’s MFP • Effective April 1, 2013 and running through 2016, OPWDD will use MFP to transition individuals from developmental centers, community-based ICF-DDs, and skilled nursing facilities into community settings. • “Acceptable community settings” include the individual’s private home, his or her family’s home or a community residence that is home to four or fewer unrelated individuals.

14. Including the IDD Population in NY’s MFP (contd.) • Previous institutional funding will not be directly available to meet the individual’s support needs in the new community setting, but HCBS funding will be available for their community supports and services. • As a result of the expansion of MFP, OPWDD will transition roughly 875 individuals into community settings.

15. MFP Transition Goals

16. MFP and Deinstitutionalization Plan: MFP Transition Goals (Four Years)

17. Accomplishing MFP Transitions • Some of the MFP transitions will be accomplished by converting ICFs into four-person Individualized Residential Alternatives (IRAs). • OPWDD is analyzing the ICFs by size in each region and examining Individual Services Planning Model scores in order to plan yearly regional MFP goals. • Additionally, OPWDD is analyzing historical data to determine how many individuals each year leave ICFs and move into private homes. • Development of non-certified housing opportunities will also play a critical role in the transition plan.

18. Two New MFP Functions • OPWDD and DOH are collaborating to develop two MFP functions: • Peer-based outreach to individuals residing in institutional settings • Individuals with IDD will promote a general awareness of community opportunities and provide information on opportunities to move into community settings.

19. Two New MFP Functions (contd.) • Regional Transition Resource Centers to support transition planning and reporting of data. • The main purpose will be to assist with transition planning, coordination, follow-up, and data collection for all New York state MFP participations – both those with and without developmental disabilities. • Spring of 2014 is time frame during which outreach and transition functions will begin.

20. BIP: Background • Like MFP, an incentive for states to rebalance their LTSS systems • Increases the Federal Medical Assistance Percentage (FMAP) to states that make structural reforms to increase access to non-institutional LTSS. • Enhanced funding is tied to the percentage of a state’s LTSS spending, with lower FMAP increases going to states that need to make fewer reforms.

21. BIP: Background (contd.) • To participate, a state must have spent less than 50% of total Medicaid medical assistance expenditures on non-institutionally based LTSS for fiscal year 2009. • States that spent 25-50% on non-institutionally-based LTSS are eligible for a 2% enhanced FMAP • States that spent less than 25% on non-institutionally based LTSS are eligible for a 5% enhanced FMAP.

22. Requirements for Participating States • State agrees to make the following structural changes: • A No Wrong Door–Single Entry Point system; • Conflict-free case management services; and • A core standardized assessment instrument.

23. OPWDD Participation in BIP • State submitted its BIP application to CMS in February 2013; CMS approved it. • New York’s BIP participation period is April 1, 2013 – September 30, 2105 • State committed to using enhanced FMAP to work toward streamlined eligibility processes, improved access, and expanded LTSS for those in need. • Requested $600+ million to implement these changes.

24. What the State Has Pledged to Do • No Wrong Door/Single Entry Point: Enhance existing NY Connects Network, which is currently operational in 54 counties and serves as an information and assistance system for LTSS. • Conflict-Free Case Management Services: Remediate any case management arrangements that do not align with the principles of BIP. • Core Standardized Assessment Instrument: Continue implementation of the Uniform Assessment System and align with other agencies to ensure compliance with the core data set.

25. Conflict-Free Case Management Source: Redesign Medicaid in New York State. Balancing Incentive Program and Money Follows the Person. New York Association on Independent Living. September 10, 2013. Presented by Mark Kissinger, DOH Director of the Division of Long-Term Care.

26. Conflict-Free Case Management As Biggest Challenge Source: Redesign Medicaid in New York State. Balancing Incentive Program and Money Follows the Person. New York Association on Independent Living. September 10, 2013. Presented by Mark Kissinger, DOH Director of the Division of Long-Term Care.

27. What the State Has Pledged to Do (contd.) • The state is working with CMS on a detailed work plan related to its transformative agenda regarding deinstitutionalization, employment, and self direction for individuals with IDD. • In its application, the state specifically indicated that its participation in BIP and other transformation initiatives will assist in the following activities:

28. What the State Has Pledged to Do (contd.) • Develop community-based capacity for an effective crisis prevention and response system utilizing the Systemic, Therapeutic, Assessment, Respite and Treatment (START) model • Develop and implement a uniform specialized assessment system, based on the interRAI intellectual disability tool • Develop and implement a statewide training and supports program for persons with IDD who are interested in self-direction

29. What the State Has Pledged to Do (contd.) • Adopt practice guidelines for care coordinators serving individuals with IDD based on the Council on Quality and Leadership (CQL) personal outcome measures and annually assess managed care care coordination using personal outcome data. • Reorganize OPWDD’s regional office structure to better meet the needs of the system

30. What the State Has Pledged to Do (contd.) • Close most campus-based institutions serving individuals with IDD and provide person-centered planning for those individuals • Reinvest approximately $166 million and expand community living for people with IDD through the development of community-based services for individuals now living in DCs in accordance with the state’s transition plan

31. About Vorys Health Care Advisors Vorys Health Care Advisors, LLC helps health care providers, business decision makers and professional associations to achieve their objectives in a constantly changing governmental and business health care environment and to assist them in making well informed, strategic and tactical decisions tailored to their individual goals, needs and aspirations. Contact Information: Maureen Corcoran, MSN, MBA 614.464.5461 mmcorcoran@VorysHCAdvisors.com Daphne K. Saneholtz, JD 614.545.6680 dksaneholtz@VorysHCAdvisors.com Vorys Health Care Advisors 52 E. Gay Street, Columbus, OH 614.464.5461 www.Vorys.HCAdvisors.com