What is The “Money Follows the Person” Initiative, Anyway?

1. What is The “Money Follows the Person” Initiative, Anyway? Jason Rachel, Money Follows the Person Project Director, DMAS Julie Stanley, Director, Community Integration for People with Disabilities Governor’s Housing Conference November 13, 2008

2. Overview: Money Follows the Person Demonstration Project • Four-year Medicaid Demonstration Project to assist seniors and people with disabilities who currently live in institutions to move to the community if they choose to • Person-centered: Over 1,000 individuals in Virginia to move to the community, each with an individual plan, supports they need, and someone to work with them before and after they move • Community-based: Partnerships among human services and housing agencies (local government and private) are key • State-planned and administered: Department of Medical Assistance Services (DMAS) (Virginia’s Medicaid agency) working with many other agencies, including state housing agencies • Federally-sponsored: Centers for Medicare and Medicaid Services (CMS) (federal Medicaid agency) • State- and federally-funded: 25% state/75% federal for 1st year living in community; 50%/50% thereafter

3. Community Supports for Individuals Who Transition • Each individual will enroll in a Medicaid home and community-based “waiver” or a Medicaid program called “PACE” • All Medicaid waivers and PACE pay for a variety of services available to people enrolled, based on their individual needs for each service • Non-Medicaid services will also be available

4. Housing for IndividualsWho Transition • Each individual must move to a “qualified residence” in the community • Home owned or leased by the individual/family member • Apartment leased by the individual/family member • Setting in which no more than four unrelated individuals reside • Group homes (4 or fewer beds) • Sponsored residential settings • 4-bed Assisted Living Facilities • Adult Foster Care

5. Medicaid and Housing* • HUD-subsidized housing programs are largely Federally-driven by Congress and HUD. Medicaid is a Federal/State partnership. Some aspects are determined by the Federal government, others by the State. • HUD Housing Choices Vouchers (Section 8), 202, 811 and Hope VI programs are standardized programs that operate consistently across States. Medicaid programs can (and do) vary from state to state. • Medicaid and HUD housing programs use very different methods to determine financial eligibility. Aperson can be eligible for a HUD housing program, but may not be eligible for the Medicaid program. • Medicaid funds cannot be used to pay for room or board. * The information on this and several subsequent slides is excerpted largely from A Medicaid Primer for Housing Officials, Rutgers Center for State Policy/National Academy for State Health Policy, September 2007. A copy has been included in your conference bag.

6. To Understand How Money Follows the Person Relates to Housing, It Helps to Understand the Basics of the Medicaid Program

7. The Medicaid Basics • Provides primary, acute, and long-term support services to individuals who meet income, resource and other categorical requirements (e.g., residency, citizenship) • States have considerable flexibility to determine who is eligible and what services will be covered • Medicaid costs are shared between the Federal government and States • Medicaid pays for a significant amount of the long-term support services provided to low-income individuals

8. Medicaid Eligibility • Medicaid eligibility is very complicated • Eligible individuals are “entitled” to all “mandatory” and “optional” services the State covers under the regular Medicaid program (called the “State plan”) if they meet the “medical necessity” criteria to receive the service • Some people are “dually eligible” for both Medicaid and Medicare

9. Medicaid’s “Institutional Bias” • Institutional placement is an entitlement. • Home and community-based “waiver” services are not an entitlement. States may create waiting lists when they reach the maximum amount that has been approved for the waiver program. • The Money Follows the Person Demonstration Project is designed to reverse the institutional bias.

10. Who is Eligible for Medicaid? Primary eligibility categories: • Mandatory eligibility groups, e.g., people who receive benefits under the Supplemental Security Income (SSI) program • Optional categorically needy group, e.g., people who receive payments under a State Supplement to SSI • In Virginia, the state supplement is called an “auxiliary grant.” Auxiliary grants are available in assisted living facilities and adult foster care programs in Virginia. • Medically needy group. States may extend Medicaid eligibility to additional qualified persons who may have too much income to qualify under mandatory or optional categorically needy groups • Virginia has a Medically Needy program that covers seniors and people with disabilities.

11. How Do People Get Long-Term Medicaid Services in the Community? • Services that support people to live independently in their home or apartment are primarily covered by States under home and community-based waiver service programs. • The major exception is services for persons with mental illness, who rely heavily on mandatory and optional State Plan services. • The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program that features a comprehensive service delivery system to address the long-term needs of individuals who are eligible for nursing home care. The service package permits individuals over 55 to continue living at home while receiving services rather than be institutionalized.

12. What is a Home and Community-Based Waiver? • Home and community-based waiver services help individuals who are eligible for Medicaid, and who otherwise qualify for admission to an institution, to live independently in the community • To be approved by CMS, the cost of waiver services cannot exceed what the State would have spent in the absence of the waiver • Services can be targeted to certain groups or regions of the state • Virginia’s waivers are targeted to certain groups, but all are available statewide.

13. Waiver Eligibility • Individuals must meet the State’s medical (functional level) criteria for admission to an institution: • Intermediate Care Facility for Persons with Mental Retardation (now known as “Intellectual Disabilities”) • Nursing Home • Hospital • Individuals must meet the financial requirements for Medicaid

14. Virginia’s Home and Community Based Waivers • Elderly or Disabled with Consumer Direction (largest, with over 12,000; no waiting list) • Mental Retardation/Intellectual Disability (waiting list for “slots”) • Developmental Disabilities (waiting list for “slots”) • Day Support (no waiting list) • Alzheimersand Dementia Assisted Living (no waiting list) • Technology-Assisted (no waiting list) • HIV/AIDS (no waiting list)

15. Who Provides Waiver Services? • Qualified public and private human services agencies who enter into a ”provider agreement” with DMAS provide the bulk of waiver services. These are called “agency-directed” services. • Some services can be “consumer-directed,” meaning that the individual using the waiver is the “employer” and therefore hires, supervises and fires his or her service provider. Depending on the waiver, the following services can be consumer-directed: • Personal Assistance • Respite • Companion • Individual Supported Employment Individuals who consumer direct are assisted by “Services Facilitators”

16. Can Waivers be “Project-Based”? • No. Waiver services are available to eligible individuals and cannot be assigned to providers. • Medicaid waiver services stay with the individual when the individual moves. • CMS requires that people who use waiver services have a choice of all qualified providers of the services covered under a waiver. • DMAS determines what providers are qualified.

17. New Medicaid Services Under Money Follows the Person • Transition Services • Up-front household expenses when setting up a household • Being added to five waivers • $5,000 lifetime maximum per person • Transition Coordination • 2 months before and 12 months after the individual moves • Being added to Elderly or Disabled with Consumer Direction Waiver • Consumer-Directed Individual Supported Employment • Being added to three waivers • 24-Hour Emergency Back-up Through 2-1-1 VIRGINIA for the first 12 months following transition to the community

18. Existing and New Services To Be Added to Waivers • Elderly and Disabled with Consumer Direction (EDCD) • Environmental Modifications • Assistive Technology • Transition Coordination • Transition Services • Technology Assisted (TECH) • Personal Emergency Response System (PERS) • Transition Services • HIV/AIDS (AIDS) • Environmental Modifications • Personal Emergency Response System (PERS) • Assistive Technology • Transition Services

19. Existing and New Services To Be Added to Waivers, cont’d • Individual and Family Developmental Disabilities Services (DD) • Consumer Directed Individual Supported Employment • Transition Services • Mental Retardation (MR) • Consumer Directed Individual Supported Employment • Transition Services • Day Support (DS) • Consumer Directed Individual Supported Employment

20. Non-Medicaid Services UnderMoney Follows the Person • Supplemental home modification funding if amount needed exceeds Medicaid $5,000 maximum • “Bridge rent” for up to 90 days after signing a lease if needed for home modifications to be completed before the individual moves • Funding for each provided by the Virginia Department of Housing and Community Development

21. Waiver Services That Help People Find Community Housing • Depending on the waiver, one of the following providers is available to assist individuals moving to the community from institutions: • Case Managers (MR, DD and AIDs Waivers) • Transition Coordinators (EDCD Waiver) • Health Care Coordinators (TECH Waiver) • These are the people who will be contacting housing agencies when rental assistance is needed

22. The Housing Challenges • Lack of accessible housing stock • Housing and human services plan in different systems • Inability to afford housing • People living in institutions often have no, or extremely low, income. • Sole income of many will be SSI, currently $638 per month. • Some gave up homes to receive services in institutions because they could not access the services and supports they needed to stay in the community. • While some may obtain employment, they will not have sufficient income at the time of transition to afford rent. • Medicaid program cannot pay • No state-funded programs exist • Federal housing rental vouchers are scarce, and those available are not dedicated to individuals transitioning

23. What are We Doing to Addressthe Housing Challenges? • Operational Protocol (Project Manual) contains extensive section and Appendices on housing: • Transition services, environmental and supplemental home modifications, and bridge rent • Qualified residences • Owning your own home • Renting a home or apartment (including HUD subsidies) • Living in adult foster care, assisted living facilities, sponsored residential programs, and group homes • Transportation information also included

24. What Else Are We Doing to Address the Housing Challenges? • Housing Task Force created by Secretaries of Health and Human Resources and Commerce and Trade • Centers for Independent Living (CILS) working in each locality with housing agencies • Combined strategies comprise Annual Housing and Transportation Action Plan, delivered to Secretaries October 15.

25. Housing and Transportation Task Force • Federal, state, local and private housing and human services partners • Developed detailed recommendations designed to: • Increase affordability and availability of community housing • Increase availability of accessible transportation • Recognize importance of housing and transportation link • Education, awareness, and partnership building among housing and human service agencies and the individuals they serve

26. Increase affordability and availability of housing • Develop a community living supplement • Increase availability of sponsored residential and adult foster care providers through marketing and provider fairs • Make the auxiliary grant portable for all populations • Produce new housing units through QAP LIHTC and non-LIHTC initiatives, and low-interest loan programs • VHDA to form Housing Solutions Work Group • Assess local housing capacity and assure that needs are included in local planning • Direct federal housing trust fund monies, when they become available, to these populations

27. Recognize importance of housing and transportation link • Develop interactive housing and transportation website • Use the existing Transportation and Housing Alliance Toolkit as a resource • Create incentives to develop housing on public transportation routes

28. Educate housing community; awareness, partnership building • Offer assistance in follow up to HUD and Governor’s letters to PHAs • Provide technical assistance to local housing offices, planning authorities and HUD offices on understanding the needs of persons transitioning, on www.accessva.org, and on laws that govern housing services, options and choice Encourage use of Virginia Easy Access. • Distribute Rutgers Medicaid Services Primer at Governor’s Housing Conference • Encourage PHAs to list accessible housing units on www.accessva.org • Through speaking engagements, e-distribution list, HUD Lines and tele-tutorials, educate housing-related groups, including: • VAHCDO, PHAS, Housing Counselors • COSCDA • Housing Commission • Local planners and contract administrators

29. Educate disability/aging communities;awareness, partnership building • Orient individuals, advocates, local agencies to housing/transportation planning • Disseminate Annual Action Plan • Ensure input of disability/aging communities is considered in housing planning activities; create a mechanism to track local changes in policy and relate ongoing needs/solutions to statewide and national housing funding agents and authorities • Develop HOME, CDBG, and HCV contact lists; disseminate to organizations to encourage participation in needs statements and priorities for resource allocation • Document changes in housing policy; work with the SILC to interface with multiple policy makers/funding agents to foster and sustain increased housing options • Assure that service agencies and advocates have information about housing agencies and a description of the services they offer through: • Virginia Easy Access • A housing resource bank on www.olmsteadva.com/mfp/ • Dissemination of information on HUD-Assisted Apartments • Training of Transition Coordinators • Developing a Housing Primer for services agencies and advocates

30. Centers for Independent Living (CILS) • CILS are contacting PHAs to ask them to partner with local agencies to support individuals transitioning under the Demonstration. They are: • offering assistance in understanding community living needs and preferences of people with disabilities and seniors • assessing local housing capacity needs and working with PHAs to develop strategies to address the needs identified in future plans and planning processes • documenting local changes in public housing policy, and work with PHAs to foster and sustain increased housing options • A human services directory and the Medicaid primer will be available to all housing agencies

31. How Will This Project Benefit the Housing Community? • Existing communication and policy gaps between some service providers and some housing agencies can be bridged • Practical information on housing needs and preferences of seniors and people with disabilities will be provided • Medicaid services will be offered not only to individuals in institutions, but also to individuals currently using Medicaid “waiver” services in the community • Individuals currently using Medicaid Waivers and public housing can get more services they need

32. For Further Information Visit the Money Follows the Person Website http://www.olmsteadva.com/mfp/ E-mail MFP@dmas.virginia.gov