Medicaid LTC in Home/Community April 29, 2008 Mystic Lake, MN

1. Medicaid LTC in Home/Community April 29, 2008Mystic Lake, MN Cyndi Gillaspie Native American Contact Centers for Medicare & Medicaid Services cynthia.gillaspie@cms.hhs.gov 303-844-4725

2. Indian Health Service Budget CMS Programs Other TPL IHS Funding

3. Administration of CMS Programs • Medicare • Medicaid • SCHIP Federal Administration Federal & State Administration Federal & State Administration

4. Medicaid Administration • States Determine: • Who is covered. • How providers are paid. • What services are covered. (within Federal Guidelines • CMS Provides: • Oversight of Program. • Technical Assistance. • Federal Matching Funds.

5. Medicaid - Who is Covered? • Mandatory Categorically Needy Groups - Required by Statute • Children and Families • Pregnant Women • Disabled and Aged Individuals • Optional Categorically Needy Groups – States Select • Medically Needy – States Select

6. Medicaid - Who Can Determine Eligibility? • State Medicaid Agency Staff • TANF Agencies (State Agencies or County Agencies) • Tribes Who Administer TANF • The State must enter into interagency agree-ments with other State Agencies, County Agencies or TANF Tribes, if they are going to do eligibility determinations.

7. What Does Medicaid Cover? • Mandatory Services • Optional Services • States also must assure Transportation to Medicaid covered appointments.

8. Payment for Medicaid Services • States design payment methodology, within Federal upper limit and other regulatory requirements. • Medicaid is the payer of last resort, except • Indian Health Service is the payer of last resort after all CMS programs.

9. Cost Sharing in Medicaid • Nominal cost sharing for Medicaid services can be charged. • IHS/Tribal/Urban Centers (I/T/Us) can waive cost sharing requirements. • For Long Term Care Programs, a calculation of Post Eligibility Treatment of Income (PETI) may be used. • For Medically Needy eligibility, there may be a spend down.

10. Special Medicaid Provisions • 100% Federal Financial Participation for services provided through IHS or Tribal 638 Clinics. • Tribal Consultation Required for Waivers • Tribes/IHS can waive cost sharing

11. Special Provisions in Medicaid, continued • Certain income exemptions for eligibility • Assets located on the reservation or held in certain trusts can not be accessed for estate recovery in the Medicaid program

12. Special Provisions in Medicaid, continued • Urban & Tribal Indian Health Clinics can bill as FQHCs—cost based reimbursement. • Tribes and Tribal Organizations can enter agreements with States to provide Medicaid Administrative Match to draw federal funds. • Any federal funds drawn by states based upon Tribal matching costs must be given to the Tribe or Tribal Organization.

13. Special Provisions in Medicaid continued • Tribes who operate their own TANF program can, with State agreement, determine eligibility for Medicaid.

14. Long Term Care Options

15. Changing from Institutions to Community Source: Based on CMS/HCFA 64 data provided by The Medstat Group, Inc Institutional services are nursing facilities and ICF/MR. Community services are state plan home health and personal care and HCBS waivers (the latter two starting in 1985). Expenditures were adjusted for price increases based on the Skilled Nursing Facility Input Price Index developed by CMS, Office of the Actuary. dupree, yuskauskus, helweg 05/07

16. Key CMS LTC Community Based Programs • 1915(c) Waivers (Home and Community Based Waivers) • Deficit Reduction Act State Plan Options • 1915(i) HCBS state plan option • 1915(j) Self-directed personal care option • Money Follows the Person (MFP) demo grants • Program for All Inclusive Care for the Elderly - PACE dupree, yuskauskus, helweg 05/07

17. HCBS Covered Services - both 1915(c) and 1915(i) • Case Management • Homemaker/chore • Home health aide services • Personal care • Adult day health • Habilitation • Respite care dupree, yuskauskus, helweg 05/07

18. HCBS Waivers (1915c) • Provide community based long-term care and support as an alternative to institutional placement. • Allow a State to waive certain provisions of the Social Security Act. • Statewideness • Comparability of services • Income and resource requirements dupree, yuskauskus, helweg 05/07

19. Considerations for HCBS Waivers for AI/AN communities • Waiver of statewideness • 100% FMAP possible – case by case basis • Full range of LTC like services • Consultation Between State and tribes • Case Management dupree, yuskauskus, helweg 05/07

20. Eligibility for Waiver • Income Limits and Covered Groups set by State—may be as low as the Medically Needy Income or as high as 300% of the SSI Standard. • Personal Needs Allowance set by State—may be as low as $30 or as high as 300% of the SSI Standard • Must meet Level of Care Assessment—without waiver services would be in NF

21. HCBS Waivers National Overview • 284 Waiver Programs • More than 1 million participants • $21.2 Billion • 7.5% of total Medicaid spending • 24% of all Medicaid long-term services spending • 67% of all Medicaid community service spending dupree, yuskauskus, helweg 05/07

22. Number of Active Waivers Per State WA - 7 VT - 4 ME 3 MT - 3 ND - 3 MN 5 OR- 5 ID 4 NH - 4 WI 8 NY 8 SD - 4 MI 3 MA - 3 WY - 5 IA 6 RI - 7 PA - 11 NE - 7 NV 4 OH 7 CT - 7 IL 7 UT 5 IN 8 NJ - 8 CA 7 WV 3 CO - 10 VA 8 MO 7 DE - 6 KS - 6 KY - 4 MD - 7 NC - 7 TN - 6 NM 4 OK - 5 AR 6 DC - 3 SC - 6 AL 7 GA 5 MS 5 TX 11 LA 5 FL 12 AK 4 HI -5 dupree, yuskauskus, helweg 05/07

23. The HCBS State Plan Option: DRA Section 1915(i) • States can amend their state plans to offer HCBS as a state plan optional benefit. • Breaks the “eligibility link” between HCBS and institutional care • Individualized care plans • Other program attributes dupree, yuskauskus, helweg 05/07

24. State Plan Option for Self-Directed Personal Care DRA Section 1915 (j) • New, simplified application • States may opt to offer self-directed personal care services, including those offered by family members • Provide items that increase independence or substitute for human assistance • Individualized budgets • Incorporate participant direction into existing or new HCBS waivers. dupree, yuskauskus, helweg 05/07

25. State Plan Option for HCBS Services • Available to individuals eligible for Medicaid under the State Plan • No Special Income Group eligibility (300% SSI Standard) because that group is based on institutional eligibility.

26. State Plan Option for Self-Directed Personal Care DRA Section 1915 (j) • Does not Have to Meet Statewideness & Comparability: • target populations, limit numbers and limit by geographic areas. • Requirements for • Evaluating consumer’s need for personal care • Safeguards for health, welfare and financial accountability • Annual reports and periodic evaluations dupree, yuskauskus, helweg 05/07

27. Planning Budgeting Spending Service Delivery …Are individualized and directed by the person and those closest to him or her HCBS Self-Direction dupree, yuskauskus, helweg 05/07

28. HCBS + Self-Direction Means: • Services can be sensitive to culture, traditions & community • Families stay intact; people can hire family members • Supports separate from housing • Individuals & their families determine what is best, not the funder dupree, yuskauskus, helweg 05/07

29. PACEProgram of All-Inclusive Care for the Elderly Key Components • Focus on Frail, Nursing Home Eligible Population • Comprehensive Medical and LTC Services • Integrated Team Management Care • Integrated Medicare and Medicaid Financing • Provider Assumption of Financial Risk • http://www.cms.hhs.gov/pace/ dupree, yuskauskus, helweg 05/07

30. Waivers and AI/AN • Medicaid money must flow through the state; • Tribe(s) may explore an agreement with State agency • Can waive statewideness and designate geographic area, ex., a Reservation • Tribe(s) may tailor services and provider qualifications (can be specific to a tribe) • 100% FMAP for some HCBS services under compacting - 638 Authority dupree, yuskauskus, helweg 05/07

31. Accessing HCBS Long Term Care Services • Eligible Tribal Memberscan apply to be consumers for benefits in their area. • Qualified Tribal Providerscan contract with the State or administering agency as a waiver provider or to perform certain administrative functions. • Tribal Governmentscan perform a wide range of administrative functions re HCBS program operations on behalf of the State Medicaid Agency. dupree, yuskauskus, helweg 05/07

32. Tribal Management of HCBS in Minnesota - Elderly Waiver…A Promising Practice The State of Minnesota contracts with the White Earth Nation to provide eligibility determination for and case management of Medicaid and state-funded home and community-based services to persons aged 65 and older who live on their reservation. • http://www.cms.hhs.gov/PromisingPractices/Downloads/mnltctribal.pdf dupree, yuskauskus, helweg 05/07

33. Additional Information? • Contact the CMS Native American Contact (NAC) in your Region. • www.cms.hhs.gov

34. CMS Native American Contacts • Region Iirvin.rich@cms.hhs.gov Irv Rich 617-565-1247 • Region IIjulie.rand@cms.hhs.gov Julie Rand 212-616-2433 • Region IIItamara.mccloy@cms.hhs.gov Tamara McCloy 215-861-4220 • Region IVdianne.thornton@cms.hhs.gov Dianne Thornton 404-562-7464 • Region Vpamela.carson@cms.hhs.gov Pam Carson 312-353-0108

35. CMS Native American Contacts • Region VIeudora.sadongei@cms.hhs.gov Dorsey Sadongei 214-767-3570 • Region VIInancy.rios@cms.hhs.gov Nancy Rios 816-426-6460 • Region VIIIcynthia.gillaspie@cms.hhs.gov Cyndi Gillaspie 303-844-4725 • Region IXrosella.norris@cms.hhs.gov Rosie Norris 415-744-3611 • Region Xcecile.greenway@cms.hhs.gov Cecile Greenway 206-615-2428