Medicaid Long-Term Services and Supports

1. Medicaid Long-Term Services and Supports Eric Saber, Health Policy Analyst Long Term Care and Community Support Services Maryland Department of Health and Mental Hygiene December 19, 2011

2. Agenda • National Context for Rebalancing Efforts • Affordable Care Act • Money Follows the Person Extension • Balancing Incentive Payments Program (BIPP) • Community First Choice (CFC) • Status Updates

3. Nationally, rebalancing efforts have reduced the proportion of LTSS spending on nursing facilities from 73.4% to 66.6% between 2004 and 2009. Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.

4. Maryland is behind these national trends and in 2009, ranked among the poorest in home and community-based services (HCBS) financing. . . Percentage of Medicaid Long-Term Services and Supports Spending for HCBS: Older Adults and Persons with Physical Disabilities 2009 Maryland = 14.9% Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.

5. . . . indeed, Maryland was nearly alone among the states in going backwards between 2004 and 2009. Change in the Percentage of Medicaid Long-Term Services and Supports Spending for HCBS: Older Adults and Persons with Physical Disabilities 2004-2009 Maryland = -5.0% States Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.

6. While Maryland Medicaid’s payment rates to nursing facilities are higher than average. . . Maryland = $193.21 National Average: $154.13 States Source: Harrington, et al. (2008). State Data Book on Long Term Care, 2007. US Dept of Housing and Urban Development.

7. . . . payments to nursing facilities haven’t kept up with medical inflation (and things are much worse for home- and community-based service providers). Average Annual Increase: +5.9% Average Annual Increase: +4.6% Average Annual Increase: +1.4% Sources: Maryland Medicaid Long Term Care Rate Changes. (2011). Department of Health and Mental Hygiene and U.S. Bureau of Labor Statistics, Occupational Archives. 1999-2010 and www.cms.gov.

8. Affordable Care Act Supports most integrated setting, person-centered planning, and individual control. Includes increased focus on quality and accountability. Offers new or improved home and community-based services (HCBS) State Plan options. Offers enhanced Federal funding to help states modify delivery systems. Key Provisions Money Follows the Person Extension Balancing Incentive Payment Program Community First Choice: 1915(k)

9. MFP Overview • Federal demonstration created by the Deficit Reduction Act of 2005, offered through the Centers for Medicare and Medicaid Services (CMS) and designed to: • Assist states in rebalancing long-term care systems • Increase the use of Home- and Community-Based Services (HCBS) • Remove barriers to receiving services in the community • Maryland is one of 30 jurisdictions currently participating in the demonstration • Affordable Care Act extended the demonstration and offered grants to additional states • Transitions through December 31, 2016 • Spending through 2019

10. MFP Overview • To access MFP funds, states must transition individuals receiving Medicaid services from “qualified institutions” to “qualified residences” • MFP Eligibility • 90 days in institution • 1 day of Medicaid eligibility in the institution • The State receives enhanced federal matching funds for services provided to demonstration participants for 365 days • Enhanced matching funds result in “savings” to the State • States are required to spend savings on approved rebalancing initiatives • Savings can not: • Pay for services • Off-set ongoing state costs

11. Federal Requirements • Qualified Institutions • Nursing Facilities (NFs) • State Residential Centers (SRCs) • Institutions for Mental Disease (IMDs) • Chronic Hospitals • Exploring expansion to include Psychiatric Residential Treatment Facilities (PRTFs) • Qualified Residences • A home owned or leased by the individual or the individual's family member; • An apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control; • A residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside.

12. Existing Waivers Maryland will serve MFP participants using five home- and community-based waiver programs • The Traumatic Brain Injury (TBI) waiver • Serves adults in chronic hospitals and State-owned nursing facilities • The Community Pathways (CP) waiver • Serves adults with developmental disabilities • The New Directions (ND) waiver • Self-directed waiver for adults with developmental disabilities • The Living at Home (LAH) waiver • serves people with physical disabilities between 18 and 65 • The Older Adults Waiver (OAW) • serves adults with disabilities over the age of 50

13. Rebalancing Initiatives • Increase outreach to institutional residents • Peer Outreach Contracts • Program Education • Application Assistance • Improve the transition process • Enhance Transitional Case Management • Housing Assistance • Enhance existing community-based services • Peer Mentoring • New Waiver Services • Improve Systems • Statewide ADRC sites

14. Balancing Incentive Payments Program (BIPP) 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. Within six months, states must initiate “structural changes” to their LTSS systems that include: Creation of a Single Point of Entry system for LTSS Development of a Standardized Assessment Instrument Implementation of Conflict Free Case Management By the end of the BIPP period states must: Increase HCBS to 50% of total Medicaid LTSS spending Implement required structural changes

15. BIPP Updates – Financial • Received CMS assurance that Maryland is eligible to apply for a 2% enhanced match based on the Federal Fiscal Year (FFY) 2009 LTSS spending percentages included in BIPP Application • Maryland’s calculated percentage in the BIPP Application was 36.8% • Services included in this percentage are waiver programs (including DD waivers), home health and personal care expenditures.

16. Community First Choice (CFC) Optional State Plan benefit to offer Attendant Care and related supports to individuals, providing opportunities for self-direction. Includes 6% enhanced FMAP. CMS is still discussing policy decisions. Specifically, CMS is discussing whether all CFC participants must meet the State’s institutional level of care, or whether CFC also is available for people who require attendant care but are not at institutional level of care. Final Federal regulations may not be available until 2012.

17. Community First Choice (CFC) We propose to offer all required and optional services allowed under CFC regulations. Specifically, CFC would offer: Personal / Attendant Care; Personal Emergency Response Systems (PERS); Voluntary training for participants; Transition Services; and Services that increase independence or substitute for human assistance. Services offered under CFC would no longer be covered as a waiver service, but rather covered as a State Plan service. Waiver participants are eligible to receive all State Plan services. The State will: Refine this concept as federal guidance emerges, especially regarding the potential institutional level of care qualifying criteria Seek technical assistance from CMS on policy decisions; Establish an Implementation Council; and Analyze further policy decisions and implementation plan for CFC.

18. Community First Choice (CFC) • CFC is not creating a new eligibility standard. • CFC is a consolidation of current State Plan eligible participants who receive personal care into one robust program offering additional services and self-direction. • The program is expected to grow based on increased utilization due to: • Increased services to certain current participants, • Participation of currently eligible participants not receiving services, and • Improved reimbursement to most providers.

19. Improvements possible under CFC In addition to services offered under CFC, with the enhanced match the State would be able to also provide the following: Enhanced quality assurance. A provider registry. Trainings to providers. Coordinated rates across programs. An option to develop a back-up system. 19

20. Status Updates • Long Term Care Reform Workgroup is submitting a report to the legislature in December 2011. • Long Term Care Reform Workgroup will transition to the Money Follows the Person Workgroup and the Community First Choice Implementation Council in January. • MFP-BIPP stakeholder meeting on January 10, 2012 • Community First Choice Implementation Council will meet in January after council selection is complete. • Core Standardized Assessment stakeholder meetings were held on December 12 and 15 for stakeholder input.