Maryland Medicaid Advisory Committee: Balancing Incentive Program

1. Mark Leeds Director of Long Term Care and Community Support Services April 26, 2012 Maryland Medicaid Advisory Committee: Balancing Incentive Program

2. Medicaid’s Rebalancing Vision • Improving access to home and community-based services (HCBS) • Eliminate barriers to receiving HCBS • Improve collaboration between agencies • Enhance person-centered focus • Shift focus from institutional settings to HCBS • Shift spending • Increase self-direction options • Take advantage of opportunities presented through the Affordable Care Act

3. Balancing Incentive Program Offers an enhanced federal medical assistance percentage (FMAP) for all HCBS covered during the “balancing incentive period” through September 30, 2015 Maryland qualifies for a 2% enhanced payment rate All enhanced federal payments must be used to fund new and expanded Medicaid community-based LTSS By the end of the balancing incentive period Maryland must: Increase HCBS to 50% of total Medicaid LTSS spending Implement required structural changes Three required structural changes: Core Standardized Assessment Single Entry Point / No Wrong Door Conflict-Free Case Management

4. Structural Change #1 Core Standardized Assessment • BIP Assessment Requirements • Data are captured Statewide for all populations seeking community LTSS • Includes a Level I screen/Level II assessment process across populations • Level I screen is available for completion in person or over the phone • Level II assessment is completed in person by a qualified professional • Used to determine eligibility, identify support needs, and inform service planning

6. Core Standardized Assessment, cont. • Assessments must meet certain criteria • BIP Manual included a crosswalk to compare existing instruments to the new standards • DHMH conducted a review of instruments with stakeholder participation • Chose the interRAI suite of tools • interRAI assessments have been tested for reliability and validity • interRAI suite includes assessments for institutional care, home care, mental health, and intellectual disabilities

7. Core Standardized Assessment, cont. • DDA is using the Supports Intensity Scale • Community programs with Nursing Facility Level of Care will use the interRAI-HC • Older Adults Waiver, Living at Home Waiver and State Plan Personal care • Phase in for nursing facilities, Medical Day Care waiver, hospitals • Pilot of screen and interRAI-HC assessment starting in May • Main purpose is to ensure Nursing Facility Level of Care determinations are consistent with current regulations and transmittals • Phone Screen and interRAI-HC assessment will be part of the LTSS tracking system • Tracking system includes the client profile, client history, screen, assessment, and programmatic information (application status, referrals, plans of service) for community programs with nursing facility level of care 7

8. Structural Change #2Single Entry Point / No Wrong Door • Maryland Access Point (MAP) Sites • MAP initiative led by Maryland Department of Aging • Formalized partnerships between Area Agencies on Aging, Centers for Independent Living (CILs), Local Health Departments, and Departments of Social Services • BIP/MFP Expansion of MAP sites • 1-800 number and website expansion • MAP sites will be completing the assessment phone screen • Increased funding and partnership requirements 8

9. Structural Change #3 Conflict-Free Case Management • A provider agency which is financially impacted by increased or decreased service utilization cannot determine the level of services authorized under the care plan • DHMH to review all regulations for LTSS programs and ensure conflict-free case management • BIP requires separation of case management and service provision • Exceptions for rural areas, managed care, etc. • Administrative separation is acceptable

10. Balancing Incentive Program Maryland submitted an application to participate in BIP on February 10, 2012 CMS approved the application with a start date of April 1, 2012 to begin receiving the enhanced FMAP Projected award of $106 million A final work plan is due to CMS on August 10th

11. The Award • The award must be spent on services or administrative functions that increase services for people who meet institutional level of care • Award cannot fund the required structural changes • MFP Rebalancing will fund the required changes • Potential Projects • Additional Waiver Slots • Rate Increases • Expanded participation through Community First Choice • One-time spending • Staffing 11

12. Stakeholder Process • Monthly MFP / BIP workgroup meetings • Next meeting is May 1, 2012 from noon to 3 p.m. in room L3 at DHMH • Meetings are normally held the first Tuesday of each month • Dedicated email address: LTCReform@dhmh.state.md.us 12