Current Status and Policy Implications of the Money Follows the Person Demonstration

1. Disability Policy Research Forum Current Status and Policy Implications of the Money Follows the Person Demonstration On The Air September 24, 2009 12:00 to 1:30 pm

2. Money Follows the Person (MFP): Opportunities for Long-Term Care (LTC) Systems September 24, 2009 Presentation to the Disability Policy Forum Carol Irvin ● Jeffrey Ballou ● Audra Wenzlow

3. Principal Aims • Reduce reliance on institutional care • Develop community-based LTC opportunities • Enable people with disabilities to participate fully in their communities

4. Today’s Presentation • Overview of the MFP program • Starting point for states • Baseline for LTC systems • Baseline rates of transitions from institutional to community-based care • Grantee goals and early implementation experiences (Debra Lipson)

5. Overview of the MFP Program

6. MFP Demonstration Grants Awarded • 30 grantees (29 states and DC) • 17 in January 2007 • 14 in May 2007 • 1 state not implementing a program • Size of Awards • Total awards to date: $1.44 billion • Wide range of state commitments, from $5.4 million to $142 million

7. Two Programs in One • Each state is implementing two programs • Transition program • Rebalancing program

8. Transition Program • Medicaid beneficiaries in institutional care for at least six months • Nursing homes, hospitals, intermediate care facilities for the mentally retarded, institutions for mental diseases • Transition to a “qualified” residence • Home, apartment, or group home with four or fewer people • Quality assurance • 24-hour backup • Risk assessment and mitigation processes • Incidence reporting and management systems

9. Transition Program (cont’d.) • MFP Services • Eligible for one year – 365 days • Package of home- and community-based services (HCBS) • Qualified HCBS • Demonstration HCBS • Supplemental services • Continuity of services • After MFP eligibility ends, qualified HCBS must continue based on beneficiary’s Medicaid eligibility status

10. Rebalancing Program • Enhanced matching funds • Qualified HCBS • Demonstration HCBS • Reinvest enhanced matching funds in LTC • Medicaid beneficiaries who use LTC supports and services • Overall service system

11. In Summary • States are… • Transitioning beneficiaries with particularly challenging needs • Making investments in the LTC infrastructure

12. National Evaluation of MFP • State-level analyses • Trends in: • LTC use, such as increasing use of HCBS • LTC expenditures • Individual-level analyses • Increasing transition rates • Successful transitions • Low reinstitutionalization rates • Improved quality of life

13. Balance of LTC Systems at Baseline—2005

14. Balance of Use and Expenditures in 2005 While more than half of LTC users receive HCBS, institutional care accounts for most LTC expenditures. Source: MAX 2005 for 30 MFP states.

15. LTC Users • A diverse population uses LTC services and supports • 55 percent—elderly • 27 percent—people under age 65 with physical disabilities • 15 percent—people with developmental disabilities • 3 percent—people with chronic mental illness

16. HCBS Use and Expenditures The challenge will be to increase HCBS use and expenditures among the elderly and beneficiaries under age 65 with physical disabilities. Source: MAX 2005 for 30 MFP states.

17. Transition Rates at Baseline—2004

18. Size of the Population Eligible for MFP • Approximately one million people institutionalized for 6 or more months, or about 75 percent of those in institutional care in 2004 • Considerable variation across states • 3,000 in Delaware • 126,000 in New York Source: MAX 2004 for 31 MFP states.

19. Diversity of the Eligible Population • Elderly account for most of the eligible population • 77 percent—elderly • 14 percent—people under age 65 with physical disabilities • 9 percent—people with developmental disabilities • 1 percent—people with chronic mental illness Source: MAX 2004 for 31 MFP states.

20. Baseline Transition Rates MFP is an important opportunity to improve low transition rates. Source: MAX 2004 for 31 MFP states.

21. Number of Transitions in Original Plans • Number of transitions proposed (in flux) • About 37,700, or 0.9 percent of eligible population • Transition targets vary by state • 100 to 3,350 • Disproportionately targeting those under age 65 and people with developmental disabilities • 44 percent—elderly • 29 percent—people under age 65 with physical disabilities • 20 percent—people with developmental disabilities • 6 percent—people with chronic mental illness • 1 percent—people with other conditions/dual diagnoses

22. Potential Effects on Transition Rates • May increase the rate of transitions among the long-term institutionalized population by 15 to 40 percent in grantee states • Ranges from a 3 to 87 percent increase across states

23. Money Follows the Person (MFP) Demonstration: State Program Goals, Features, and Implementation Progress September 24, 2009 Presentation to the Disability Policy Forum Debra J. Lipson ● Noelle Denny-Brown ● Susan R. Williams

24. Overview • Diversity in state MFP transition goals • Key differences in state transition program characteristics • Current status of program implementation in states • Challenges and barriers to implementation • Implications for long-term care (LTC) rebalancing

25. Diversity in States’ Transition Goals • Number and type of populations to be transitioned vary among states: • By demonstration year • In distribution across five population groups • By percentage of MFP eligibles • By medical complexity and level of care needed

26. MFP Transition Goals by Demonstration Year 34,066 total transitions Source: MFP 2009 Supplemental Budget Requests, December 2008.

27. MFP Transition Goals by State and Target Group Total Transitions by Categories

28. Common MFP Program Design Features • Transition coordination—most states wish to increase capacity • Strategies to ensure affordable, accessible housing • 26 of 30 MFP grantee states offering MFP Demonstration and supplemental services • Most states planning to change Medicaid home- and community-based services (HCBS) policies to accommodate MFP participants during or after the one-year transition period

29. Approaches to Transition Coordination *MR/DD = Mental retardation or a developmental disability. **ICFs-MR = Intermediate care facilities for the mentally retarded.

30. Strategies to Find Affordable, Accessible Housing

31. Types of MFP Demonstration or Supplemental Services • Most demonstration and supplemental services are designed to support transition to the community • Some states are testing whether specialized services reduce institutionalization or re-admissions: • Telehealth services in rural areas • Special mental or behavioral health services

32. Changes to Medicaid HCBS Policies • New HCBS waiver programs to serve people transitioning from institutions • Increase in HCBS waiver program capacity (“slots”) • Increase in consumer direction options • Nearly all states expanding consumer directed options in some way • Seven states have MFP benchmarks for self-direction

33. Current Implementation Status: Start Dates

34. Transitions to Date *Preliminary count based on reports submitted as of Sept. 18, 2009. Source: MFP grant progress reports.

35. Drop in Total Transition Goals Over Time * Centers for Medicare & Medicaid Services.

36. Implementation Challenges Common to All MFP States • Extensive reporting requirements • Involves programming changes to Medicaid Management Information Systems • Qualified residences limited to homes, apartments, and small-group homes • Limits assisted living options in most cases • Eligibility limited to residents with institutional stays of at least six months • Hardest group to transition

37. Some Challenges Are State-Specific

38. Housing and HCBS Barriers in Many States • Lack of affordable and accessible housing • In 2008, 71 MFP candidates could not enroll or transition through MFP for this reason • Half of MFP states reported that shortages of affordable, accessible housing units, or lack of housing subsidies, led to fewer transitions

39. Housing and HCBS Barriers in Many States (cont’d) • Inadequate community-based services • In 12 states, shortages of HCBS or direct-care workers affected timing or number of transitions • New York and Hawaii experienced delays in implementing new HCBS waivers in which MFP participants were to enroll

40. State Budget Crises Affecting Implementation Progress • Economic downturn has strained state Medicaid management resources and HCBS capacity • 18 MFP state grantees report that state budget crises will affect many MFP components • E.g., fewer staff to manage program, reduced waiver slots, provider payment delays, freezes on hiring or contracting

41. Implications for LTC Rebalancing

42. MFP: Not the Next Era of Deinstitutionalization • There have been few MFP transitions relative to those eligible to transition • But if most planned MFP transitions occur, the rate of transitions among long-term residents would rise significantly • There have been fewer transitions than expected • In the initial years • Over the entire demonstration period, depending on how long it is extended

43. MFP: Not the Next Era of Deinstitutionalization (cont’d) • As a consequence, extra revenue to states from enhanced federal matching assistance percentage (FMAP) will decline • Drop in revenue will reduce funds for system rebalancing

44. Broader View of MFP Role in LTC Rebalancing • Best case • Critical to ensuring individual rights under Olmstead • Show how Medicaid HCBS systems can serve people with greater levels of need • Risks/unintended consequences • Could reduce resources available to divert unnecessary institutional admissions or reduce lengths of stay • MFP participants displace HCBS waiver participants

45. For More Information • National Evaluation of the MFP Demonstration Grant Program: Reports from the Field • No. 1: Transitioning Medicaid Enrollees from Institutions to the Community: Number of People Eligible and Number of Transitions Targeted Under MFP • No. 2: Implications of State Program Features for Attaining MFP Transition Goals • No. 3: Early Implementation Experience of State MFP Programs (forthcoming) Available at: http://www.mathematica-mpr.com/ or http://www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp

46. Ruth Katz, Discussant