Minnesota’s Medicaid Buy-In

1. Minnesota’s Medicaid Buy-In Medical Assistance for Employed Persons with Disabilities (MA-EPD)

2. Medical Assistance for Employed Persons with Disabilities MA-EPD Goals • The goal of the program is to encourage people with disabilities to work and enjoy the benefits of being employed, and • Promote competitive employment and the economic self-sufficiency of people with disabilities

3. Medical Assistance for Employed Persons with Disabilities Background • Grassroots effort by advocacy groups led to Minnesota legislature’s adoption of Medicaid Buy-In program • Efforts began in the early ’90s to demonstrate the need for allowing workers with disabilities to retain their Medicaid eligibility

4. Medical Assistance for Employed Persons with Disabilities • “It’s a great program. I don’t know what I would do without it.” Bill • “I want to make sure my premium is there on time. I don’t want to lose this great coverage.” Kathy

5. Medical Assistance for Employed Persons with Disabilities General Enrollment Data Data Source: MMIS

6. Medical Assistance for Employed Persons with Disabilities Changes in MA-EPD Policy

7. Medical Assistance for Employed Persons with Disabilities “There really is a program that doesn’t make you be poor before you can use it? Wow!”Nancy

8. Medical Assistance for Employed Persons with Disabilities Changes in MA-EPD Policy

9. Medical Assistance for Employed Persons with Disabilities MA-EPD Safety Net With today’s economy and job market, we’ve seen many people lose their jobs, through no fault of their own. Like Ed, who is a software developer. Ed had worked for the company for 13 years when he was laid off due to down-sizing. Without the 4-month job loss leave he would have been without medical coverage. He was able to find another job before his 4 months expired and had continuous medical coverage.

10. Medical Assistance for Employed Persons with Disabilities Compare: MA and MA-EPD

11. Medical Assistance for Employed Persons with Disabilities “I could work more but I make sure I don’t work more than 18 hours each week so I don’t lose my SSDI.”Doug

12. Medical Assistance for Employed Persons with Disabilities Challenges Manual Billing System Lack of clear definition of “work” SSDI Cash Cliff

13. Medical Assistance for Employed Persons with Disabilities “I started working to get on MA-EPD but now I’m working because I like it. It gives me something to do and I work with some really fun people.” Laura

14. Stay Well, Stay WorkingBenefit Package Health Care Services (modeled on Medicaid State Plan) – Medica / UBH Wellness Employment Navigator Services – MN Resource Center Employee Assistance Program – Optum Intensive Employment Assistance Services as needed –MN Resource Center Peer-Facilitated WRAP Services – Consumer Survivor Network

15. Stay Well, Stay WorkingOutcomes to be Studied • Employment stability & job performance • Health management • Quality of life • Frequency of symptoms of mental illness • Access to employer-sponsored health benefits • Benefits of person-centered supports • How employees access support services

16. Medical Assistance for Employed Persons with Disabilities For further information contact: Beth Grube, Policy Consultant Beth.grube@state.mn.us 651- 431-2412 Or MaryAlice Mowry, Director, Pathways to Employment & Stay Well, Stay Working Maryalice.mowry@state.mn.us 651- 431-2384

17. WORK (Work Opportunities Reward Kansans) Mary Ellen O’Brien Wright Kansas Health Policy Authority

18. Work Opportunities Reward Kansans WORK • Approved under the Deficit Reduction Act – State Flexibility in Benefit Packages (Section 6044) • A Secretary Approved Benchmark Benefit package • A “package” of benefits designed for adults with disabilities who are employed and enrolled in the Kansas Medicaid Buy-In program, Working Healthy

19. “Cash and Counseling” Model • Goes a step beyond consumer self-direction • Allows consumers to directly manage their funds • Offers flexibility in terms of what services are purchased, and how they are purchased

20. Working Healthy Eligibility Two Optional Medicaid Categories: “Basic” and “Medically Improved” • Federal Requirements • 16-64 years of age • Determined disabled by SSA • State Requirements • Verified earned income subject to FICA/SECA • Kansas resident

21. WORK Eligibility Consumers must meet the Working Healthy eligibility requirements, plus: • Eligible for the Physical Disability, Developmental Disability, or Traumatic Brain Injury Waivers, or • On the waiting lists for these waivers, or • Meet the same level of care as individuals on these waivers, and • Competitively employed in an integrated setting, and • Residing in a home or property that is not owned, operated, or controlled by a provider of services not related by blood or marriage

22. Working Healthy/WORK Benefits • Full Medicaid coverage • Personal and other services for those who need them • Countable earned income up to 300% Federal Poverty Level • Cash assets up to $15,000 • Retirement accounts (no limit) • Individual Development Accounts (no limit) • Elimination of spend down (Premiums for those >100% of FPL) • Medicare coverage paid by Medicaid (sometimes employer premiums paid) • Benefits planning

23. WORK Services Package • Assessment • Personal Services • Assistive Services • Independent Living Counseling

24. Assessment Determination of a consumer’s need for personal assistance services based on his/her functional limitations

25. Personal Services • One or more persons assisting, or cuing/prompting, consumers with activities of daily living they would typically perform themselves in the absence of a disability • Alternative and cost-effective methods of obtaining assistance to the extent that expenditures would otherwise be used for human assistance, e.g., meal or laundry service, purchase of equipment that decreases the need for human assistance

26. Personal Services • Work related services include assisting, or cuing and prompting, consumers to understand job responsibilities, in interacting appropriately with other employees and the general public, in appropriate work behavior, in practicing safety measures, in symptoms management

27. Monthly Allocation • Personal Services are paid directly by the consumer with a monthly allocation that is determined during the assessment. • Flexibility in spending the allocation: • Wages for assistants can vary based on required tasks, time of day, etc • Funds can be used to pay for assistant’s vacations or health insurance • Unspent allocation funds can be rolled over into a designated savings account to be used the next month or for approved savings • Consumers can be creative!

28. Assistive Services • Assistive Technology not covered under the Kansas Medicaid State Plan • Services that assist consumers to use assistive technology • Home modifications

29. Independent Living Counseling Assisting consumers to: • develop, and obtain approval for, their Individualized Budgets and Emergency Back-Up Plans • access training • locate service providers • coordinate their services • report problems • etc…

30. Benefits Specialists • Collect data on individual’s current benefits status • Provide a critical analysis of work, earning, and resources on a consumer’s benefits in order to help him/her make an informed choice about employment • Provide options to the individual and their support network if appropriate about the impact of employment or increased employment on benefits • Provide information about Working Healthy and WORK

31. Temporary Unemployment Working Healthy has a six months “grace” period. Consumers may remain in the program for six months while they seek employment or recover

32. Reasons for WORK • The DRA Benchmark Benefits provision, under which WORK was authorized, provided the most flexibility for designing an innovative program that meets the needs of a working population requiring personal assistance services to work and live in the community. • The Kansas Health Policy Authority (KHPA), which administers Medicaid in Kansas, believes that Working Healthy, combined with the WORK services necessary to support employment, will increase the number of Kansans with disabilities who are employed. • Unlike most waivers, WORK allows consumers with various disabilities, including developmental disabilities, to be served within the same program. KHPA believes this will promote competitive, integrated employment for adults with developmental disabilities.

33. Reasons for WORK • WORK provides consumers with the ability to “control” their services, rather than to just “direct” them, potentially increasing consumer satisfaction. • WORK permits direct cash payments to consumers to pay for their services, which may facilitate more cost-effective decision-making regarding services and service providers. • Kansas received a Medicaid Infrastructure Grant to Support the Competitive Employment of People with Disabilities, and believes that WORK will contribute to success in meeting employment goals.

34. Cash & Counseling: An Innovative State Program Congressional Briefing on Health and Disability Policy July 12th, 2007 United States Senate Finance Committee William A. B. Ditto, Director Division of Disability Services New Jersey Department of Human Services

35. Cash & Counseling: Program Overview • Funders • The Robert Wood Johnson Foundation • US DHHS/ASPE • Administration on Aging • Waiver and Program Oversight • Centers for Medicare and Medicaid Services • National Program Office • Boston College Graduate School of Social Work • Evaluator • Mathematica Policy Research, Inc.

36. Original Cash & Counseling Demonstration Overview • Original Demonstration States • Arkansas, Florida, New Jersey • Study Populations • Adults with disabilities (Ages 18-64) • Elders (Ages 65+) • Florida: Both groups above & children with developmental disabilities • Feeder Programs • Arkansas and New Jersey: Medicaid personal care option programs • Florida: Medicaid 1915c Home and Community-Based long-term care waiver programs

37. Original (3) and Expansion(12) Cash & Counseling States

38. Consumer Directed Services Definition: • A philosophy and orientation to the delivery of services whereby informed consumers assess their needs, determine how these needs should be met, determine who can best meet them and monitor the quality of services received. The consumer exercises substantial control over the resources available to meet their needs.

39. Basic Model for Cash & Counseling • Step 1: Consumers receive traditional assessment and care plan • Step 2: A dollar value is assigned to that care plan • Step 3: Consumers receive enough information to make unbiased personal choice between managing individualized budget or receiving traditional agency-delivered services.

40. Basic Model for Cash & Counseling • Step 4: Consumer and counselor develop spending plan to meet consumer’s personal assistance needs • Step 5: Individual provided with financial management and counseling services (supports brokerage) • Note: Can make use of a representative or surrogate decision maker, if desired.

41. New JerseyPersonal Preference Program Reasons New Jersey Implemented Program • Demographics • Prudent Purchasing/Effective Use of Resources • Consumer Empowerment • Increase Personal Responsibility • Address Consumer Complaints & Lack of Flexibility • Support of Family Caregivers

42. New JerseyPersonal Preference Program Details of Program Design • Utilizes a Section 1115 Research & Demonstration Waiver • Cashes out NJ Medicaid Personal Care Benefit (Optional State Plan Service) • Individual Budget Based on Standard Clinical Assessment • Rates are $15.50 weekdays, $16.00 holidays & weekends • 10% Deduction to Cover Cost of Fiscal Employer Agent and Counseling Services (Maintains Cost Neutrality)

43. New Jersey Personal Preference Program Details of Program Design • Participant Designs Cash Management Plan (CMP) with assistance from Counselor • Can Select & Use Unpaid Representative to help • Participant Serves as “Employer of Record” • Participant Recruits, Hires, Determines Pay & Benefits for Workers • Workers can be Family, Friends or Others • Individual Budget can also be Used for Purchasing Services, Equipment and Home Modifications related to meeting Personal Care Needs

44. New Jersey Personal Preference Program Details of Program Design • Fiscal Employer Agent/FEA (also known as Fiscal Intermediary Service Organization) handles all payroll and other payments • FEA claims Medicaid Funds each Month and Maintains Individual Account for Participant • Counselor visits Participant Quarterly to Monitor • Nurse Reassesses Participant Every Six Months

45. Policy Implications For Workers with Disabilities • Provides opportunities to hire co-workers and friends to provide workplace PAS • Enables participants to control when and how services are delivered • Budget can be used to purchase equipment or devices to increase independence in the workplace • May reduce employer concerns about job accommodations

46. General Policy Implications • Can increase access to care • Greatly improves quality of life (all ages) • Family caregivers also benefit greatly • Community integration is enhanced • Consumers are prudent purchasers • It Works !!!!!

47. Deficit Reduction Act (PL 109-171) February 8, 2006 • States traditionally needed to use Section 1115 (Research & Demonstration Waivers) or Section 1915(c) (Home & Community Based Waivers) to offer Cash & Counseling • Section 6087 of the Deficit Reduction Act (DRA) is entitled: • Optional Choice of Self Directed Personal Assistant Services • (Cash and Counseling) • This provision became effective 1/1/07

48. Deficit Reduction Act (PL 109-171) February 8, 2006 One potential impediment for States: • Section 6087 (j)(6) • “. . . Payment for the activities of the financial management entity shall be at the administrative rate established in Section 1903(a).”

49. www.cashandcounseling.org or William A. B. Ditto, Director NJ Personal Preference Program New Jersey Division of Disability Services William.Ditto@dhs.state.nj.us For more information:

50. Personal Choices Offering Consumers Choice and Flexibility