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The Affordable Care Act & Home and Community Based Service Options

The Affordable Care Act & Home and Community Based Service Options. Mitchell LaPlante, Ph.D . Charlene Harrington, Ph.D. Terence Ng J.D., M.A H. Stephen Kaye, Ph.D. University of California, San Francisco . The Institutional Bias in Medicaid LTC, 2007. Expenditures: $101 billion.

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The Affordable Care Act & Home and Community Based Service Options

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  1. The Affordable Care Act & Home and Community Based Service Options • Mitchell LaPlante, Ph.D. • Charlene Harrington, Ph.D. • Terence Ng J.D., M.A • H. Stephen Kaye, Ph.D. • University of California, San Francisco

  2. The Institutional Bias in Medicaid LTC, 2007 Expenditures: $101 billion Participants: 4.6 million Source: HCBS (Ng and Harrington, 2010) , Institutional (CMS Form 64 Data, Thompson Reuters 2009; MSIS 2007 Data)

  3. Percentage of LTSS expenditures on Community LTSS for Aged and Disabled and IDD Populations, 1995–2009

  4. Medicaid Home and Community Based Services Now • HCBS 1915(c) waivers - Must be institutional eligible, selective recipient groups - Slots, geography & expenditures can be limited - Waiting lists can be established • Personal Care optional benefit - Available in 35 states (2010) [CA/NY 50% partic.; 66% $] • Home health - The only mandatory HCBS program • 1115 Research and Demonstration Waivers - Managed Care in AZ, VT and RI • 1915(i) HCBS State Plan Option - HCBS as state plan (6 states) • 1915 (j) - Consumer Directed Personal Care (7 states) • Money Follows the Person

  5. ACA & Medicaid HCBS • Establishes Medicaid HCBS Options • Modifications to the Section 1915(i) state plan option • Community First Choice Option—state option to cover attendant services and supports • State Balancing Incentive Payments Program • Extends Mandatory Spousal Impoverishment Protections to Community-Based Population • Increases Funding for ADRCs • Extends Money Follows the Person Demo

  6. 1915(i) State Plan Option • DRA 2005 established 1915(i) • Severed institutional eligibility of 1915(c) waivers • Restricted eligibility not more than 150% FPL • No targeting to specific populations (elderly or SCI) • Allowed geographic limits and enrollment caps • Allows consumer direction • No cost neutrality • ACA modified 1915(i) and DMD letter of Aug 2010 • No geographic limits, no slots, no wait lists • Targeted specific groups & benefits (New features) • May be up to 300% SSI, same as 1915(c) & institutions • May include “other services” that used to be limited by the DRA

  7. 1915(i) State Plan Option Comments • Increase to 300% SSI removes DRA barrier to state enrollment. • Increased enrollment from 1 state to 6 and more • No renewals unless targeted populations • Ability to consolidate multiple waivers • Reduces administrative costs compared to waivers • No cost neutrality requirements • Populations may not want existing waivers eliminated if services not comparable

  8. Community First Choice Act 1915(k) • Offers states 6% extra FMAP for PAS • States required to maintain effort for 1 year based on their prior year PAS expenditures • <= 150% FPL or > 150% & meet institutional criteria • Must be statewide • Allows Consumer Direction; family members can be paid • Transition costs out of inst. • Developmental & Implementation Council must be established

  9. Community First Choice ActComments • 35 states already provide PAS through PAS state plan, but CA/NY 50% participants; 66% $ • Many other provide PAS through 1915(c) waivers • Would shifting PAS from existing state plan or waivers allow for increased FMAP under CFC? • PAS waiver states may not limit persons and costs if shift to CFC • No wait lists like waivers – increased costs • Increased admin requirements such as D&I Council, evaluations, reports etc

  10. State Balancing Incentive Program • Starts Oct 2011 • States with HCBS spending < 25% of LTC in FY 2009 • Extra 5% FMAP on HCBS • HCBS spending must reach 25% or more by FY 2015 • States with HCBS spending between 25% & 50% of LTC • Extra 2% FMAP on HCBS • HCBS spending must reach 50% or more by FY 2015 • HCBS eligibility must not be tightened during this period

  11. State Balancing Incentive ProgramHCBS/LTC Map 2009

  12. State Balancing Incentive ProgramAdmin/Structural Requirements • No Wrong Door-Single Entry Point System • Single Agency or Portal to coordinate LTC • Conflict Free Case Management Services • Single Case Manager for each LTC Recipient • No financial or other conflict of interest between assessment and service provision • Standardized HCBS Assessment Instruments • States must collect quality & outcome measures

  13. State Balancing Incentive ProgramComments • Only 1 state (MS) qualifies for full incentive, 35 states qualify for 2% • Better to base on Aged/Disabled than overall % comm. • Although states may want the money for the 5 year period & satisfy Olmstead; fear of increased admin costs & woodwork • Recipient groups may oppose changes to admin, benefits or assessments • States closer to 25% or 50% goal benefit more  increased costs and reluctance from “lesser” states

  14. Other ACA Extensions & HCBS Provisions • Extends Medicaid Money Follows the Person (MFP) through 2016 with $2.25 billion - Allows individuals who have been in institutions for “not less than 90 consecutive days” to be transitioned out, rather than the previous 6 months requirement Transition, not diversion - In 2011, 43 states and DC had MFP grants • ACA allocates $10m/year for 5 years to continue funding Aging and Disability Resource Centers (ADRC)

  15. Other ACA Extensions & HCBS Provisions • Current spousal impoverishment protections extended to persons whose spouses’ qualify for Medicaid HCBS, in addition to those who qualify for Medicaid nursing home benefits - but is not effective until 2014 and then is limited to a five year period. - States are already able to use the spousal impoverishment provisions under the current 1915(c) waiver program regulations as an option, but not mandatory.

  16. Discussion • State budget deficits threaten progress - 2010, 46 states reported $130 billion shortfall; 2012, 40 states are projecting shortfalls - AARP (2011) survey of states  31 states cut non-Medicaid aging & disability services in 2010 and 28 states want to cut in 2011. Most states cut Medicaid provider rates and some cut services, particularly personal care services. CA looking to cut 20%. - Period of increased demand due to recession, aging & HCBS demand  35 states report increases in HCBS waiver programs from 2009-2011 and 22 states expect nursing home residents to decline.

  17. Discussion • What should state rebalancing targets be? - NM spent 83% of LTC $ on HCBS in 2009. OR spent 73% of LTC $ on HCBS but 99% of DD LTC $ on HCBS, 56% of Aged/Disabled LTC $ on HCBS - States spent average 66% on DD HCBS HCBS but 34% of LTC $ on Aged/Disabled - States need to target a higher % of the Aged/Disabled populations for HCBS especially as population ages

  18. Discussion • Expansion of HCBS are voluntary with (weak and ill-designed) federal incentives to encourage change • Institutions remain mandatory. - Wide inter-state variations in community LTSS will continue • Adds to existing complexity; benefits boutique

  19. Where will the trend lines go?

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