Shaping policy, sharing solutions, strengthening communities

1. Shaping policy, sharing solutions, strengthening communities

2. Driving (or Following!) Service Trends: Federal Fiscal and Policy Developments Barbara Merrill Vice President for Public Policy, ANCOR Six State Summit, August 14, 2013

3. ANCOR is…A national nonprofit trade association advocating and supporting • Over 800 private providers of services and supports to • Over 500,000 people with disabilities and their families • And employing a workforce of over 400,000 direct support professionals and other staff

4. National Advocacy Campaign DSP Recognition Week Sept. 11 • Signature ANCOR NAC Initiative – mission to elevate state and federal recognition of importance of DSPs/focus attention on need to address workforce crisis • US Senate Resolution obtained S.Res. 208 • Gubernatorial Proclamations • Confirmed or in process in each of the Six States!

5. National Advocacy Campaign DSP Recognition Week Sept. 11 • ANCOR DSP of the Year call for nominations begin • National DSP Call-in Day Sept. 13 • ANCOR Webinar: Attracting Media Attention • Wednesday, August 21, 2013 2 p.m. – 3 p.m. Eastern time

6. DSP Wage Survey • National Advocacy Campaign DSP Wage Survey – November 2013 release • New this year: surveying service categories - Deadline August 31, 2013 • To participate and receive a FREEcopy https://redcap.icts.uiowa.edu/redcap/surveys/?s=2DwWzu • CO and UT lead the Six States….(!)

7. ACA Employer Compliance • ANCOR has consistently supported the ACA; supported Obama Admin’s delay • Priority Issue for ANCOR: this gives our members more opportunity to evaluate impact • Objective is to obtain reliable cost impact data for lobbying/advocacy purposes • Data will determine advocacy position, but concern that increased costs will drive greater use of part time staff

8. ACA Employer Compliance • Preliminary results • Provider analyses vary widely, variables include current plan, state Medicaid eligibility • 93% provide insurance • 69% intend to “play” • Over half estimate increased costs from 15 to 50% • Six state participation low – SD leads • http://www.surveymonkey.com/s/VHVTZ63

9. Federal Budget Update

10. Federal Budget Status • Sequester • Automatic spending cuts and tax increases in effect due to sequester • Federal employees experiencing furloughs • Continuing resolution signed by Obama in late March keeps government funded through end of September, though cuts are still in effect

11. Federal Budget Status • White House Budget • Released in May, calls for $400 billion in health care spending reductions over 10 years • Medicaid largely exempted from cuts, as Obama administration wants to encourage Medicaid expansion under ACA • Does not include “blended rate” for FMAP or reduction/elimination of provider taxes, which had been in previous White House proposals

12. Federal Budget Status House (Ryan) Budget • House Budget Committee budget would convert Medicaid to a block grant program • Would repeal Affordable Care Act • Passed the House narrowly, was rejected by the Senate

13. Federal Budget Status • Senate Budget Proposal • Proposes $975 billion in spending cuts, including $275 billion in health care savings • Lacks specifics on details of spending reductions • Passed the Senate 50 to 49, was rejected by House • Skirmishes over de-defunding ACA

14. Despite Improving Economy, Specific Threats to Medicaid Remain • Converting the program to a block grant system –House/Ryan Budget • Implementing per-capita caps, which would provide states a set amount of funding per Medicaid enrollee – • Reducing/phasing out provider taxes • CO, MT, ND, SD, UT: ICF-ID tax

15. Upton-Hatch Per Capita Cap Proposal • Making Medicaid Work: Protect the Vulnerable, Offer Individualized Care, Reduce Costs • Based on the product of the state’s number of enrollees in each of the four population categories and the per capita amount for each population category

16. Upton-Hatch Per Capita Cap Proposal • Based on most recent year expenditures/rebased every 5 years • Maintains benefits for people with disabilities but no funding guarantees • Shared savings promise/risk corridors for disabled groups • Growth factor larger for lower spending states

17. Companionship Exemption • 12/11 DOL proposes changes – supported by President Obama • Rule forwarded to WH OMB Feb 2013 – 90 day review has passed • NCD/NAMD/NASDDDS/ANCOR call separately for further review of impact • DOL Secretary Perez listening session August 19th at DOL • Separate sessions for Industry, Disability, Labor, and State Medicaid Directors

18. LTC Commission • Established in “Fiscal Cliff” legislation that repealed the CLASS Act • Broad charge to make recommendations to Congress • Long term care/long term supports and services • To include adequacy of workforce considerations • Taking public comment through website: • http://www.ltccommission.senate.gov/

19. LTC Commission: Sampling of Recommendations from Diverse Groups • Creating a privately funded benefit • Allowing HCBS waiver services to include room and board costs • Making self-direction a right/ requiring states to set up PCA matching registries • Federal training standards for PCAs/DSPs • De-linking eligibility to institutional LOC • Increased kinship support

20. Employment Policy Trends • Accelerated pace toward competitive employment fueled by: • DOJ litigation – Oregon, Providence • State Plan Review by CMS • Employment First Policies: NGA Chair Gov. Markel Initiative • Workforce Investment Act Senate HELP bill

21. Employment Policy Trends • 26 States have Employment First official policies (AR, CA, CO, CT, DE, DC, IL, KS, LA, MA, ME, MI, MD, ND, NJ, OH, OK, OR, RI, PA, TN, TX, UT, VA ) • Another 13 efforts or initiatives underway: (FL, GA, ID, IN, IA, KY, MN, MS, NM, NY, NC and WI) • States that have or are moving to eliminate sheltered workshops include ME, NY

22. WIA – Workforce Investment Act • Reauthorization long overdue; championed by Senator Harkin (D-IA) • ANCOR-supported bi-partisan bill passed in Senate HELP Committee • Extensive ANCOR analysis available • Strong focus on transition age /presumption of competitive/non sheltered work • Continues 14C Special Wage Certificates but layers in more frequent reviews of appropriateness

23. WIA/14C – Cautionary Note • As a founding AFP member, ANCOR brings both passion and experience to the table, representing providers across the spectrum who agree that as a nation we must do better to improve employment outcomes for people. • ANCOR believes it imperative that it is critical to • NOT pull rug out from people/avoid unintended consequences of increasing unemployment • Provide Congress with a balanced, objective statement of the issue – aided through distribution of • ANCOR/Chimes initiated George Washington University Graduate School Research Paper

24. Managed Care/Integrated Service Delivery Trends • 26 states are projected to have MLTSS by 2014 • Dual Eligible Demonstrations • 20 states are pursuing – 6 have approved CMS MOUs

25. Early States with MLTSS for Individuals with IDD • Arizona since late 1980s ALTCS 1115 • Michigan since 1998 – 1915 b & c with network of pre-paid capitated MCOs with strong values and person centered planning in regulations • Wisconsin since 1999 – 1915 b & c Family Care for LTSS only with self directed option

26. New States Including or Planning To Include IDD Washington Vermont Minnesota North Dakota Maine Montana New York Michegan (upper penisula) Wisconsin Michegan New Hampshire Oregon South Dakota Idaho Massachutes Pennsylvania Rhode Islad Wyoming Connecticut Delaware Iowa Ohio Maryland Nebraska New Jersey Illinois Nevada Utah West Virginia Colorado Indiana Kentucky Kansas Missouri Virginia North Carolina Tennessee California South Carolina Oklahoma Arkansas New Mexico Arizona Mississippi Georgia Alabama Texas Louisiana Florida Alaska Hawaii

27. Managed Care/Integrated Service Delivery Trends • Provider driven integrated MLTSS • Growing interest in Health Home ACA option (see ANCOR brief) • Keystone Autism Program in PA • Providers partnering with MCOs

28. MLTSS: What to expect • Traditional opponents of managed care now view as critical cost containment – particularly as states expand Medicaid eligibility • Well financed, politically sophisticated Medicaid MCOs competing for state contracts • Difficult state legislative battles

29. MLTSS: What to expect • Focus on Outcomes • Need for Electronic Health Records • Push to serve more people at home, increased family support, shared living/host

30. ANCOR’s Funding Reform Checklist • Available on ANCOR Connected Community website • Stakeholder Engagement • Mission And Vision, Core Values/Guiding Principles • Assessment And Rate Setting Methodology • Performance Measures And Metrics • State Responsibility And State Regulations • Financial Risk Between The State And The MCOs • Requirements For The MCOs • Health Information Technology (HIT) And Electronic Health Records(HER)

31. Sustainable Medicaid Project

32. Drivers: Daunting Demographics • Demand for Medicaid funded services for frail elders • People with ID are living much longer • Demand for DSPs will mushroom by 2020 • Waiting list for residential services: 123,000 • Aggregate approximately 300,000 • Aggressive DOJ Activity • VA, GA, IL • Wait list specific litigation

33. Drivers: Impact of Great Recession • Astronomical State Budget Gaps • States cut rates, services, optional services • Implementation of SIS/other standardized assessment tools for resource allocation

34. SMP Goals • Put ideas on the table… • Ideas that include saving taxpayer dollars, without compromising quality • Identify a package of Medicaid sustainability proposals that can be advanced in DC & that ANCOR members can advance in their state capitals

35. Priorities Priorities Established • Recognize current initiatives: leverage federal incentives to encourage states to expand HCBS services • Incentives for I/DD providers to develop Health Homes, inc. EHR funding • Payment for Outcomes – under development • Streamlining regulations that impact business environment/Scope of Practice – under development • More to come • Technology, Workforce

36. Priorities Development of Fact Sheets • First two released this summer – • Provider Driven Integrated Service Delivery (Health Homes) • Leveraging Federal Incentives • Object is for ANCOR members to use at the state/federal level • http://www.ancor.org/advocacy/advocacy-toolkit

37. Priorities Leveraging Federal Incentives • Balancing Incentive Program (BIP) • Enhanced FMAP linked to % of HCBS expenditures • Requires standardized assessment, conflict free case management, no wrong door • Approved applications: NH, MD, IA, MS, MO, GA TX, IN, CT, AR, NY, NJ, LA, OH, ME, IL • Example: IN has planned to convert all ICFs to waiver • Money Follows the Person • Can be used in conjunction with BIP • Value cited in Hatch/Upton proposal

38. Priorities Leveraging Federal Incentives Health Home Option • Integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole • Have 2 or more chronic conditions, have one chronic condition and are at risk for a second, have one serious and persistent mental health condition • Includes IDD • Value cited in Upton/Hatch proposal

39. Priorities Leveraging Federal Incentives Health Home Option • 90% FMAP for 8 quarters • Comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, patient & family support, referral to community & social support services • OH, MO, RI, IN

41. NYS: In the News • Closing sheltered workshops • Transitioning ICF residents to Waiver placements • Increasing self direction • Adopting CQL guidelines for care coordinators for personal outcome measures

42. Another not so subtle plug: • 2013 ANCOR Technology Summit and Showcase -October 2 & 3 • Omni Interlocken Resort, Broomfield, CO • 2013 ANCOR Leadership Summit: Workforce Matters- November 19 & 20, Liason Hotel, Washington, DC

43. Further resources available on the ANCOR website: • Facts about Medicaid • Advocacy Toolkit • ANCOR’s Action Center • ANCOR’s National Advocacy Campaign • ANCOR 2009 Wage Study