Health Care Reform and Implications for Persons with Disabilities

1. Health Care Reform and Implications for Persons with Disabilities Equip for Equality May 27, 2010 Stephanie F. Altman, Health & Disability Advocates

2. COMPONENTS OF PATIENT PROTECTION & AFFORDABLE CARE ACT • Community Living Assistance Services & Support Act (CLASS) • National High Risk Pool (HRPs) • Community First Choice Option • Changes in Medicaid • Medicaid Maintenance of Effort Requirements • Extending Money Follows the Person grants • Additional $ for Aging & Disability Resource Centers • Demonstrations & Pilots

3. Community Living Assistance Services & Support Act (CLASS) • Monthly premium: $120-$150/month • 5 years before individual is vested and can draw down a benefit • Benefit is $50/day (at a minimum); $75/day is estimated at this point • Qualifying services: for ADLs or IADLs • Services in home, or residential Considerations for Illinois: • How do we encourage people to participate? • Do we know who would use the program? • Does it change the way we currently deliver services?

4. High Risk Pools: Background • Approximately 200,000 people are enrolled in 35 state high risk pools nationally • Individuals are uninsurable in the private market due to pre-existing conditions • Health care reform legislation creates a national transitional high risk pool to begin in June 2010 (unless a state opts to expand their own high risk pool) and operate until the Exchange is implemented in 2014

5. Current High Risk Pool Plans • Nationally, steep premiums that increase with age; range from 125 to 200% of individual market rates for the state • High levels of deductibles and co-insurance; similar to other individual policies • Limits on some benefits, such as preventive services, prescriptions, and mental health • In Illinois the Comprehensive Health Insurance Program (I-CHIP) premium is 143% of the individual market rates • 16,000 enrollees Source: Jean P. Hall & Janice Moore, University of Kansas

6. Temporary High Risk Pools • IL has opted to run its own pool (SB 240) • National pool will be managed by Health & Human Services • National and new state pools will require being uninsured for 6 months prior to enrollment – there will be no wiggle room on definition of “uninsured” • Both will cap premiums at 100% of individual market rates, and guidance on package and deductibles is forthcoming; however, plans must cover at least 65% of health care costs.

7. High Risk Pool Considerations for Illinois • I-CHIP premium is higher (143%) than the temporary high risk pool (100%) • New funding -- $5 billion – must be used for new enrollees; and cannot be used for existing enrollees • IL estimated share to be $200 million total but it can’t be used for premium parity between programs • Will IL try to use GRF for Section 7 Pool and Insurance Assessment for HIPPA CHIP pool to create premium parity? • Temporary High Risk Pool enrollees must be uninsured for at least six months and HHS has not issued guidance on definition of pre-existing condition • I-CHIP uses 31 presumptive conditions and has a catchall category for people without presumptive conditions but rejected on two insurance applications.

8. Community First Choice Option • Medicaid State Plan Option –1915 (k) to provide attendant care services & supports • Must be categorically eligible for Medicaid • Income under 150% fpl or have income that does not exceed income thresholds for institutional level care • Services: health related tasks with ADLs, IADLs, hands on supervision or cueing; acquisition of skills to accomplish ADLs, IADLs, and voluntary training for managing attendants • Optional Services: transition costs (rent, utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies and other “necessities”), and services that increase independence or substitute for human assistance. • Reimbursement rate for Optional Services is an additional 6% points above FFP – i.e. 56%

9. Community First Choice Option: Implications in Illinois • Will Illinois determine a 1915 (k) State Plan Amendment is more efficient than the 1915(c) waivers we currently operate for attendant care and health related services? • Given the budget situation, can IL opt for the Optional Services and will the cost of the expansion without a cap on enrollment be higher than the increase in federal funding through the FFP enhancement? • How does the Community Choice First Option fit within the Money Follows the Person re-balancing effort? • Consideration: MFP has changed its focus to include individuals living in a facility for 3 months or more and has a new emphasis on employment

10. Overview of HCR & Medicaid: Implications for State Medicaid Programs • Potentially Four Medicaid Vehicles • “Regular Medicaid”: Medicaid programs for “categorically eligible” populations not changed by PPAC • “New Medicaid”: New eligibility category for adults under 133% of FPL Begins 2014 unless Early Implementation • “Optional Medicaid” category for those over 133% FPL • “Benchmark” Plan under Insurance Exchange Different from current Medicaid structure in Categorical Eligibility, Coverage Packages, Reimbursement to Providers and Delivery System.

11. Medicaid & Maintenance of Effort • PPACA extends the MOE requirement of the American Recovery & Reinvestment Act (ARRA) prohibition on reducing eligibility for Medicaid until December 31, 2013 • States are prohibited from altering eligibility for any existing Medicaid program even though enhanced match may not be extended beyond December 31, 2010 (possibly expanded to June 30, 2011.) • CMS verbal interpretation is that states can improve programs without penalty, but not reduce eligibility • The MOE requirement does not apply to the “new” Medicaid expansion population

12. Delivery System and Access Reforms • Medicaid Physician Primary Care • Reimbursement Increases to Medicare Level: what will the definition of primary care codes be especially for people with special needs and can state afford to keep rates up after 100% FFP ends? • New Patient Care Models • Center for Medicare & Medicaid Innovation • Varies pilots • Demonstrations: Independence at Home Demo; Hospitals Readmissions Reduction Program; Community-based Care Transitions Program

13. What does this mean for Medicaid in Illinois?

14. Key Considerations for Illinois • What happens to people with disabilities who are not working and are above 133% of FPL? • With 100% match rate through 2017, is there more of an incentive to move more people into expansion group or exchange which may have weaker benefits packages? • Will the Exchange connect with 1915 (c ) or (k) services like the HBWD program currently does for working people who earn out of HBWD but still need long-term care services & supports?

15. Key Considerations for Illinois • What happens to people who have chronic conditions, self-insured with astronomical premiums? If they’re not in the I-CHIP, do they need to go “bare” in order to get affordable coverage? • What about assets? New expansion populations don’t have asset limits – is this something we should consider for other Medicaid populations to increase state FFP opportunities?

16. New “Seamless” Delivery System by 2014 With a Single Application