Health and Disability Policy Briefing

1. The American Public Human Services Association July 2007 Health and Disability Policy Briefing

2. Disability: The Numbers • Approximately 50 million Americans (19.3 percent) have a disability of some type. • Many individuals have more than one type of disability. • The likelihood of disability increases with age. • Nearly 70 percent of people with disabilities are children or working age adults. Source: Access of Health and Long-Term Services for People with Disabilities, Jeffrey S. Crowley, Health Policy Institute, Georgetown University, April 2006

3. Overview: Work & Health Coverage Interaction • People who work use their health insurance less. • Employer-sponsored health insurance is declining and becoming less comprehensive. • Many people with disabilities have health-related needs that are not covered by private insurance. • Private coverage is often unavailable or unaffordable to people with disabilities.

4. Medicaid: The Basics • Medicaid provides coverage for designated groups of low-income individuals and individuals with disabilities. • Jointly financed by the federal and state governments. • States determine services covered, provider payments, and certain eligibility qualifications, within federal guidelines.

5. Mandatory Services Physician’s services Laboratory and x-ray Inpatient and outpatient hospital services Early and periodic screening, diagnostic, and treatment (EPSDT) services for individuals under 21 Nursing facility services Home health services (for those entitled to nursing home care) Optional Services Prescription drugs Dental services Physical therapy Prosthetic devices Intermediate Care Facilities for persons with Mental Retardation (ICF/MR) services Personal care services Rehabilitation services Private duty nursing Hospice services Home and community-based services Medicaid: Mandatory and Optional Services

6. Ten Things to Know About Health and Disability Policy • Disability/chronic illness can affect all aspects of someone's life: employment, education, health, housing, income, and the need for medical and support services. • Nearly half of Medicaid expenditures cover services for people with disabilities. • 17 percent of Medicaid enrollees are people with disabilities (2006) • 46 percent of Medicaid expenditures are for people with disabilities (2006)

7. Medicaid Spending on Categories of Enrollees Elderly 9% Elderly 23% Blind & Disabled 17% Blind & Disabled 46% Adults 26% Adults 13% Children 48% Children 19% 2006 U.S. Total = 59.7 million U.S. Total = $299 billion in 2006 Note: Expenditure distribution based on spending only on services. Excludes DSH, supplemental provider payments, vaccines for children, and administration. SOURCE: Health Management Associates estimates based on CBO Medicaid Baseline, March 2006.

8. Ten Things to Know About Health and Disability Policy • Medicaid provides a comprehensive set of acute and long-term care benefits to meet the needs of people with disabilities.

9. Medicaid Expenditures by Service

10. Ten Things to Know About Health and Disability Policy • Disabilities include both physical and mental impairments. Medicaid provides coverage for both, and is the single largest payer of mental health services.

11. Ten Things to Know About Health and Disability Policy • Medicaid is leading the way in supporting employment for people with disabilities. • Medicaid covers mandatory services that are essential to employment: acute care, long-term care, and inpatient and outpatient hospital services. • Medicaid Infrastructure Grants (MIG) • Another critical support is retaining health coverage through the Medicaid Buy-In, SSI sections 1619 (a) and (b), and other options.

12. Supporting Employment (Continued) • States have implemented Medicaid programs and demonstration projects to allow working people with disabilities to retain health coverage. • Medicaid Buy-In program • 1902(r)(2) • 1115 waiver • DRA Benchmark Benefits

13. Medicaid Buy-In: Overview • The Medicaid Buy-In program allows states to expand Medicaid coverage to working individuals with disabilities whose income and assets would otherwise make them ineligible. • Currently 33 states have Buy-In programs. • As of 2005, more than 161,000 people have participated in state Buy-In programs.

14. National Buy-In Enrollment by Quarter (2000-2005) Source: The Interaction of Policy and Enrollment in the Medicaid Buy-In Program, 2005: Final Report, Mathematica Policy Research, Inc., May 2007, Figure III.1 • Note: Missouri rescinded its Buy-In program in August 2005 causing a drop in total enrollment. The program has been reinstated in 2007.

15. Medicaid Buy-In Program: Basic Guidelines & Requirements • The Medicaid Buy-In program was created in the Balanced Budget Act of 1997 (BBA). • Must be below 250 percent of FPL. • Cannot exceed Supplemental Security Income (SSI) resource standard. • Section 1902(r)(2) • Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA) expanded the Medicaid Buy-In program. • Added two new optional eligibility groups. • States can establish their own income and resource standards. • Do not have to be below 250 percent of FPL. • Participants must be between the ages of 16 and 64.

16. Other Work Incentive Programs • Social Security Disability Insurance (SSDI): trial work period of 9 months • Supplemental Security Income (SSI): • gradual reduction in benefits • 1619 (a) • 1619 (b) • Disability Program Navigators (DPNs): assist individuals with disabilities in accessing services at One-Stop Career Centers

17. Medicaid Infrastructure Grants • Medicaid Infrastructure Grants (MIGs) were authorized by TWWIIA to provide funding for states to facilitate the employment of people with disabilities through: • Medicaid Buy-In programs • Improvements to Medicaid services that support employment • Coordinated, cross-programmatic approaches to remove barriers to employment • 40 states, plus the District of Columbia, currently have a MIG. • Most MIG states also have a Medicaid Buy-In program.

18. Ten Things to Know About Health and Disability Policy • Medicaid facilitates independent living in the community for people with disabilities. • Medicaid support services include: • Home and Community-Based Services (HCBS) • Rehabilitation services • Personal care services • Durable medical equipment • Home and Community-Based Services (HCBS) are on the rise. • In 1994, represented 19 percent of Medicaid LTC spending • In 2004, represented 36 percent of Medicaid LTC spending

19. Ten Things to Know About Health and Disability Policy • The Deficit Reduction Act of 2005 (DRA) provides opportunities to expand new services to people with disabilities. • Benchmark Benefit packages • Self-Directed Personal Assistance Services • New options to provide HCBS • Cash and Counseling • Money Follows the Person

20. Ten Things to Know About Health and Disability Policy • Medicaid fills in the gaps in Medicare coverage. • 7 million “dual eligibles” – low-income seniors and people with disabilities who qualify for Medicaid and Medicare. • A person with a disability must wait 24 months to become eligible for Medicare. Medicaid provides coverage when Medicare is not immediately available. • Medicaid provides long-term care services and “wrap-around” coverage for services not covered by Medicare.

21. Ten Things to Know About Health and Disability Policy • Medicaid provides comprehensive services for youth with disabilities. • Half of the 1 million children with severe disabilities age 4 and under receive Medicaid benefits. • 30 percent of the 5.3 million children ages 5 to 17 with disabilities receive Medicaid benefits. • “Katie Beckett” option (TEFRA option) • States also cover children in foster care.

22. Ten Things to Know About Health and Disability Policy • Fluctuations in state fiscal conditions impact the ability of Medicaid to provide services for individuals with disabilities. • Rate of growth in Medicaid spending slowed since 2000 and hit record lows in Fiscal Year 2006. • States are improving program efficiency and investing in new services, innovations, and provider payment rates. • Medicaid also must respond to rising health care costs, erosion of employer-sponsored health coverage, enrollment growth, and pressure to increase provider rates.

23. Ten Things to Know About Health and Disability Policy • Demographic and enrollment trends are impacting Medicaid programs. • Aging population • Growth in disability rolls

24. Trend: Aging Population

25. Trend: SSDI Enrollment, 1970-2005 Source: Annual Statistical Report on the Social Security Disability Insurance Program, 2005 Social Security Administration, September 2006, Chart 2

26. Challenges and Issues • Some health services can only be obtained in the home and not in the workplace. • Complexity of work incentive programs. • Barriers posed by asset limits. • Number and scope of definitions of “work” and “disability.” • Sustainability of initiatives such as Money Follows the Person and Demonstration to Maintain Independence and Employment. • Pressures on state budgets. • Age of transition for youth with disabilities. • Impending restrictions on targeted case management and the rehabilitation option.

27. For More Information • APHSA web sites: • Center for Workers with Disabilities: http://cwd.aphsa.org • National Association of State Medicaid Directors: http://www.nasmd.org • Contact: • Martha Roherty, Director (202) 682-0100 ext. 229 mroherty@aphsa.org