Aging & Disability Resource Centers: A Focus on Long-term Care Enrollment Counseling

1. Aging & Disability Resource Centers:A Focus on Long-term CareEnrollment Counseling June 30, 2008 1

2. During this webcast… • Introduction to Enrollment Counseling • Highlight key knowledge areas • Eligibility • Benefit Options • Enrollment Counseling Process • Technical Assistance Documents 2

3. Our presenters…. • Charles Jones, Office for Family Care Expansion • John O’Keefe, Bureau of Long Term Support • Maurine Strickland, Office for Resource Center Development, Bureau of Aging & Disability Resources 3

4. Goals of Long-Term Care Reform • Choice • Access • Quality • Cost-Effective 4

5. Aging & Disability Resource Centers Help people…. • explore their needs • access information about service options • maximize use of their personal funds to delay or prevent need for public funding • learn about the benefits and programs available to them 5

6. ADRC’s provide….… • A welcoming place • Trusted, reliable information • Core services … • Information & Assistance • Options Counseling • Enrollment Counseling • Benefits Counseling, Elder and Disability • Prevention, Information & Activities • Functional eligibility determination & coordinates enrollment into LTC programs 6

7. Enrollment Counseling assisting an individual who… • is found eligible for publicly funded long-term care • is making a choice to enroll in • a managed care organization • IRIS the Self-Directed Supports Waiver • or use only Medicaid card services 7

8. Information about eligibility… Medicaid is - Federal/State funded health care program • Pays for essential health and long-term care (LTC) services • Medicaid eligibility is required for all LTC options discussed during this webcast 8

9. Medicaid funded long-term care • Eligibility Requirements • Functional (Level of Care) • Non-Financial • Financial • People with long-term care needs receive assistance with the eligibility process • Each ADRC has an enrollment plan that describes how the ADRCtogether with their partners assist people 9

10. Functional Eligibility Long-term care functional screen collects information on: • Medical Conditions • Activities of Daily Living (ADL) • Instrumental Activities of Daily Living (IADL) • Living Situation • Supports • Behaviors • Risk factors 10

11. Nursing Home Level of Care (includes ICF-MR) Family Care all Medicaid LTC services, including waiver services primary & acute health care thru Medicaid card Family Care Partnership and PACE all Medicaid and Medicare services including primary and acute health care SDS Waiver – IRIS waiver services (planning to incorporate personal care in the future) other long term care services thru Medicaid card primary and acute health care thru Medicaid card LTC Benefit Options Based on Level of Care Results 11

12. LTC Benefit Options Based on Level of Care Results Non-Nursing Home Level of Care • Family Care • Standard Medicaid LTC card services (but not waiver) • Interdisciplinary care management • MCOs may provide other flexible services • Fee-for-service • All services from individual providers thru Medicaid card 12

13. Long-term Care Functional ScreenNursing Home Level of Care

14. Long-term Care Functional ScreenNon-Nursing Home Level of Care

15. Long-term Care Functional ScreenNo Level of Care

16. ADRCs help people through the MA application process Prepare for interview with Income Maintenance (IM) Medical remedial expenses • Items and services purchased “out of pocket” by consumers that are not paid or are not covered by Medicaid, waiver programs or other responsible third party. Cost share • For more information about cost sharing see program references or the Medicaid Handbook appendix 5.9.5 http://www.emhandbooks.wi.gov/meh/ 16

17. References • Use www.access.wisconsin.gov • Webcasts – Special topics • Introduction to Publicly Funded Long-Term Care • Spousal Impoverishment • Estate Recovery & Lien Law • Medicare Part D http://dhfs.wisconsin.gov/aging/training/index.htm 17

18. Medicaid Eligibility Fact Sheets Many single page fact sheets are available (some in multiple languages). http://dhfs.wisconsin.gov/medicaid1/publications.htm#Fact_Sheets 18

19. Systems ADRC uses the LTC Functional Screen (LTCFS) to: • Determine level of care • Calculate individual’s budget amount for the SDS Waiver Income Maintenance uses Client Assistance for Re-employment and Economic Support (CARES) to: • Determine Medicaid Eligibility • Generate notices to applicants and people who are enrolled in long-term care program • Enroll people in long-term care programs • Send information to Medicaid Management Information System (MMIS) 19

20. Systems continued… The Department and its partners use Medicaid Management Information System (MMIS) to: • Store eligibility and enrollment information • Issue payments to Managed Care Organizations • Generate federally required reports The Department and its partners use Program Participation System (PPS) to • Document information regarding centralized enrollment for Managed Care • Track participation in IRIS (SDS Waiver) • Communicate between the ADRC and the Independent Consultant Agency 20

21. Let’s describe the long-term care options? Managed Care • Family Care (FC) • Family Care Partnership/PACE IRIS (Self-Directed Supports Waiver) Medicaid Card Services - only 21

22. Family Care Partnership Managed Long-Term Care

23. Managed Care Organizations…. Help each person…. • Identify the results they want • Participate in building a plan for services focused around their outcomes • Provide directly or purchase services and supports in the service plan • Coordinate LTC services with the member’s physician and other medical care • Make sure services meet expectations for quality and timeliness 23

24. Key Differences….Managed Care Programs • Family Care and Partnership offer the same long-term care benefit package… • In addition, Partnership includes: • Health and medical care (acute and primary care) • Medical personnel on the care team • Drug coverage • Integration of Medicare benefits 24

25. Full range of Medicaid LTC services including home and community based waiver, nursing facility care, medical equipment and supplies, therapies and transportation Interdisciplinary care management (member, nurse and social worker/care manager) LTC services managed by the team Choose services from a LTC provider network Assist with the coordination of health care Managed Care Benefits & ServicesFamily Care 25

26. Managed Care Benefits & Services Family Care, continued • Members select their own physician (paid for with Medicare and/or Medicaid) • People with both Medicare and Medicaid receive prescription drug benefits through the Medicare Part D plan they choose 26

27. Family Care Partnership Managed Care Benefits & ServicesPartnership • Full range of long-term care services AND health and medical care in one benefit. Covers…. • Medicaid primary, acute and long-term care services, • prescription drugs, • plus home and community based waiver services (includes Medicare services if eligible) 27

28. Managed Care Benefits & ServicesPartnership continued Family Care Partnership • Interdisciplinary Care Management (nurse practitioner, RN, SW, Partnership doctor). LTC, acute, primary care managed by the team. • Members use providers and physicians who are in the provider network (if a person’s physician is not in the network, the MCOs may be able to add physicians) 28

29. Family Care Partnership Managed Care Benefits & ServicesPartnership continued Individuals who are eligible for Medicare must: • Be enrolled in Medicare Part B • Enroll in the MCO’s Medicare special needs plan 29

30. Family Care Partnership Managed Care Benefits & ServicesPartnership continued Individuals who are eligible for Medicare must enroll in the MCO’s Part D prescription drug plan. • Drug coverage is integrated • Members cannot use Senior Care or any other Medicare Part D Plan • Members get their drugs from the MCO • MCO must assure members can get drugs prescribed for them • Person may want to check the formulary before enrolling to see if his/her drugs are covered

31. Managed Care Benefits & ServicesProgram of All-Inclusive Care for the Elderly PACE is… • Very similar to Partnership (in Wisconsin) • PACE-run day care centers – where people may get some services, e.g., bathing • Smaller network of primary care physicians 31

32. Family Care Partnership Self-Directed Supports inManaged Care SDS in managed care: • Background • Care management for all members incorporates consumer participation and respect for choice • Self-Directed Supports is a new way for people to direct their LTC goods, services and supports • Available to all Family Care/Partnership members • Each member can choose which supports to direct 32

33. Family Care Partnership Self-Directed Supports inManaged Care Members play a more active role • Deciding how resources are allocated for services and supports to meet personal outcomes - “SDS Plan” – even to buy services or supports that are not part of the MCO’s benefit package • Selecting their own workers, including family, friends, neighbors • Directing workers 33

34. Family Care Partnership Self-Directed Supports inManaged Care Overview of how it works: • Wish to self direct identified in assessment • MCO can provide help if the member needs assistance with learning self direction • Can be just selecting and directing workers 34

35. Family Care Partnership Self-Directed Supports inManaged Care MCO makes budget available to member to direct the supports the member has selected • Member creates an “SDS Plan” for how the resources will be used • Care management team approves plan • Member carries out the plan

36. Family Care Partnership Self-Directed Supports inManaged Care MCO makes assistance with self direction available thru: • Fiscal intermediary - provides strictly payroll support – checks, withholding, tax filing, etc. • Co-employment agency - offers help with recruiting, screening, interviewing, hiring, training, firing workers 36

37. Family Care Partnership Self-Directed Supports inManaged Care Interdisciplinary Team Role: • IDT continues to support members • Manage supports not directed by member • Authorize resources available to member • Secure training/TA for members or workers • Monitor member’s use of resources • Monitor member’s health and safety

38. Family Care Partnership Self-Directed Supports inManaged Care About 15% of Family Care members participate in the Self-Directed Supports option • Commonly self-directed services include: • Personal care • Supportive home care • Respite care • Transportation • Vocational supports 91% 38

39. Family Care Partnership Managed Care Summary • MCOs maintain a network of quality providers to meet members needs • Person-centered interdisciplinary care management with the member at the core of the team identifies and authorizes services and supports • Managed Care Options • Family Care • Partnership • PACE 39

40. IRIS – Self-Directed Supports Waiver

41. IRIS: Include, Respect, I Self-Direct Include –participants are supported to be active members of their communities Respect – participants’ preferences are honored; participants direct their own lives and long term supports. I – (the participant) am in charge of my own plan. Self-Direct – includes me managing my own services and life. 41

42. IRIS New option in how persons receive LTC goods, services and supports Alternative to Managed Care Begins July 1, 2008 Participant access is synchronized with Family Care expansion in each county 42

43. IRIS Items to know… • Like other publicly funded long-term care options, IRIS is offered to all persons including individuals who have guardians. • As part of the functional screen, an individual budget is calculated, based on an individual’s needs. • The ADRC advises participant of the projected budget before making the choice to participate. • Individuals who choose IRIS are expected to coordinate and direct all of their services. Family, friends, or others are may help.

44. IRIS Regarding individual budgets: Each person will receive an individual budget allocation : may be reviewed/adjusted updated annually to reflect the cost of living adjustment (COLA) Includes ongoing waiver long-term care costs The person also has access to services through Medicaid and/or Medicare. 44

45. IRIS Within program parameters, IRIS participants: • Make their own decisions within their allocated budget about the goods, supports and services they will receive. • Make their own decisions about who provides these supports and services. • Make their own decisions about when and where supports and services are received.

46. IRIS IRIS participants select: Their own physician and other health care providers who accept Medicaid as payment just like in Family Care. Persons eligible for Medicare receive prescription drug benefits through the Medicare Part D plan they choose. DHS is working on allowing IRIS participants to self-direct their Medicaid Personal Care Card services. 46

47. IRIS Infrequent supports (e.g. housing modification, short-term residential setting or adaptive equipment) are funded through a separate exceptional expense fund on an as-needed basis. For those needing workers/attendants, both co- employment and employer authority are available. Persons may use their budget to purchase the services of a broker, if they wish. 47

48. IRIS Allowable Supports and Services include: Goods and services include all community-based, long-term care waiver services; and A new option: Participant Customized Goods and Services (details at:http://dhfs.wisconsin.gov/bdds/sds/). 48

49. IRIS • People may live in any community setting they choose, including Adult Family Home, CBRF and RCAC, and still select IRIS. • Regardless of where people chose to live, they must manage within their individual budget.

50. IRIS Role of the ADRCs • Provide information and counseling about the individual’s publicly funded long-term care choices • Provide key information to individuals about IRIS, which includes the individual’s budget (generated from the Long-Term Care Functional Screen)