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Assistive Technology and Medicaid

Assistive Technology and Medicaid. Mary Sowers NASDDDS July 14, 2014. NASDDDS National Association of State Directors of Developmental Disabilities Services 113 Oronoco Street, Alexandria, VA 22314 Tel: 703·683·4202; Fax: 703·684·1395 Web: www.nasddds.org. Topics to Cover.

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Assistive Technology and Medicaid

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  1. Assistive Technology and Medicaid Mary Sowers NASDDDS July 14, 2014 NASDDDS National Association of State Directors of Developmental Disabilities Services 113 Oronoco Street, Alexandria, VA 22314 Tel: 703·683·4202; Fax: 703·684·1395 Web: www.nasddds.org

  2. Topics to Cover • Medicaid Basics • Medicaid HCBS Basics • Medicaid Authorities: Opportunities for Assistive Technology Coverage • New HCBS Regulations • Questions NASDDDS National Association of State Directors of Developmental Disabilities Services

  3. Medicaid and Assistive Technology • Medicaid can be an important source of public financing for assistive technology • In addition to medical and rehabilitative uses, AT can also play a key role in assisting individuals return to or remain in their homes and communities and avoid institutional utilization • To understand how AT is covered in Medicaid, it is important to understand some Medicaid basics NASDDDS National Association of State Directors of Developmental Disabilities Services

  4. Medicaid BasicsTitle XIX of the Social Security Act (SSA) • Established in 1965 as a companion program to Medicare • “Grants to States for Medical Assistance Programs” – Medicaid • Federal/State entitlement partnership program • Medicaid mandates some eligibility groups and services, States may elect to include other groups and benefits NASDDDS National Association of State Directors of Developmental Disabilities Services

  5. Medicaid State Plan • Medicaid State Plan has, historically, referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute • With additions to the SSA, a state’s Medicaid State Plan can include more services and benefits than those in 1905(a). • There are now HCBS state plan benefits, described more fully below, at 1915(i) and 1915(k) of the SSA. NASDDDS National Association of State Directors of Developmental Disabilities Services

  6. Medicaid State Plan, Continued • Under the traditional Medicaid State Plan, states often cover some AT through Home Health Services and/or Durable Medical Equipment • Coverage and payment for items varies by state • Medically-necessary DME for use in the home or to function in the community. States may have a list of preapproved items with established process for modifications or exceptions. • Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid. NASDDDS National Association of State Directors of Developmental Disabilities Services

  7. Medicaid Home and Community Based Services (HCBS) • States may offer HCBS through a number of statutory authorities, as well as some time-limited grant programs • Increased demand from individuals and families, the Olmstead decision, other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade. • The two primary HCBS sources for AT include: 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option NASDDDS National Association of State Directors of Developmental Disabilities Services

  8. 1915(c) HCBS Waivers • Section 1915(c) of the Social Security Act, originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS • More than 300 waivers serving more than 1 million people • In federal fiscal year (FFY) 2011, total state and federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1 1 CMS, Truven Health Analytics, Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011, Steve Eiken, Brian Burwell, Lisa Gold, Kate Sredl, Paul Saucier, October 2013 NASDDDS National Association of State Directors of Developmental Disabilities Services

  9. 1915(c) HCBS Waivers • Title XIX permits the Secretary of Health & Human Servicesto waive certain provisions required through the regular State Plan process: • For 1915(c) HCBS waivers, the provisions that can be waived are related to: • Comparability (amount, duration, and scope) – provides ability to target benefit • Statewideness • Income and resource requirements NASDDDS National Association of State Directors of Developmental Disabilities Services

  10. 1915(c) HCBS Waivers • Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF), Intermediate Care Facilities for the Mentally Retarded (ICFs/MR), or hospital Level of Care (LOC) • Serves diverse target groups – including individuals with intellectual and developmental disabilities, individuals with physical disabilities, individual who are aging and those with mental health support needs • Services can be provided on a less than Statewide basis • Allows for participant-direction of services NASDDDS National Association of State Directors of Developmental Disabilities Services

  11. 1915(c) HCBS WaiversWaiver Requirements • Costs: HCBS must be “cost neutral” as compared to institutional services, on average for the individuals enrolled in the waiver • LOC: Institutional levels of care define waiver LOCand the populations that may be targeted • Choice: HCBS participants must have the choice of all willing and qualified providers NASDDDS National Association of State Directors of Developmental Disabilities Services

  12. 1915(c) HCBS WaiversPermissible Services • Home Health Aide • Personal Care • Case Management • Adult Day Health • Habilitation • Homemaker • Respite Care For chronic mental illness: • Day Treatment/Partial Hospitalization • Psychosocial Rehabilitation • Clinic Services • AND, Other Services – can be State-proposed service specifications NASDDDS National Association of State Directors of Developmental Disabilities Services

  13. 1915(c) HCBS WaiversPermissible Services, Continued • AT is commonly covered in 1915(c) waivers • States cover a wide array of technology, including commercially available technology when it is addressing an identified need in an individual’s plan of care. • States frequently include annual, multi-year and/or lifetime dollar limits on AT • Prior authorization is also common for technology costing over certain amounts. NASDDDS National Association of State Directors of Developmental Disabilities Services

  14. 1915(c) HCBS WaiversPermissible Services, Continued CMS offers the following Core Service Definition for Assistive Technology, but states may amend/change as needed: Assistive technology device means an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants. Assistive technology service means a service that directly assists a participant in the selection, acquisition, or use of an assistive technology device. Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant; (B) services consisting of purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices for participants; (C) services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (D) coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the service plan; (E) training or technical assistance for the participant, or, where appropriate, the family members, guardians, advocates, or authorized representatives of the participant; and (F) training or technical assistance for professionals or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of participants. NASDDDS National Association of State Directors of Developmental Disabilities Services

  15. 1915(c) HCBS WaiversWaiver Cycle • CMS Review/Approval Process: • CMS approves a new waiver for a period of 3 years (possible 5 years for programs serving Medicare/Medicaid eligible individuals) • States may request amendments at any time • States may request that waivers be renewed; CMS considers whether the State has met statutory/regulatory assurances in determining whether to renew • Renewals are granted for a period of 5 years Each of these opportunities for change or renewal offers an opportunity to add or improve AT coverage NASDDDS National Association of State Directors of Developmental Disabilities Services

  16. 1915(i) HCBS as a State Plan Option • Originally authorized under the Deficit Reduction Act of 2005 (effective 2007), 1915(i) permits states to offer HCBS as a state plan option. • The Affordable Care Act of 2010 amended 1915(i), providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c) NASDDDS National Association of State Directors of Developmental Disabilities Services

  17. 1915(i) HCBS State Plan OptionSimilarities Between 1915(c) and 1915(i) • May target services to specific groups (waives comparability) • Evaluation to determine program eligibility • Assessment of need for services • Plan of care • Health and Welfare and Quality Requirements • Self Direction • Same allowable services • Both use a preprinted application format NASDDDS National Association of State Directors of Developmental Disabilities Services

  18. Differences Between 1915(c) and 1915(i) • Financial Eligibility Criteria • Program Eligibility • Institutional care requirements • Length of time for operation • Financial estimates • Waiver of statewideness NASDDDS National Association of State Directors of Developmental Disabilities Services

  19. Institutional Care Requirements …or not! 1915(c) • Must have eligibility criteria at least as stringent as the institutions. • LOC must be: equal to or greater than institution but not less than institution 1915(i) • Needs based, not tied to institutional criteria • But, institutional criteria must be more stringent than 1915(i) needs-based criteria, therefore: • Needs-based eligibility criteria must be: less than institution NASDDDS National Association of State Directors of Developmental Disabilities Services

  20. Program Eligibility1915(i) 1915(c) • Can cap the numbers served • May have a waiting list • Can cap individual expenditures 1915(i) • Cannot cap the numbers served or individual expenditure • All eligibles are entitled to the program • May NOT have a waiting list • Eligibility assessment must be independent NASDDDS National Association of State Directors of Developmental Disabilities Services

  21. 1915(i) If state targets, 5 years until renewal Indefinite if state does not target Length of Time for Operation 1915(i) 1915(c) • 3 years initial • 5 years upon renewal NASDDDS National Association of State Directors of Developmental Disabilities Services

  22. Financial Estimates1915(i) 1915(c) • Reasonable estimates of cost and utilization. • Program must be cost neutral compared to institutional care 1915(i) • Reveal payment methodology on Attachment 4.19-B of the State Plan. NASDDDS National Association of State Directors of Developmental Disabilities Services

  23. Services1915(i) and 1915(i) are the same • 1915(i) permits all statutory and “other” 1915(c) services • Under 1915(i) and (c) states can “target” services to specific populations • Example: autism services, recovery services • May have multiple iSPAs or HCBS waivers • Same prohibitions on covering services that otherwise would be covered through IDEA or the Rehabilitation Act NASDDDS National Association of State Directors of Developmental Disabilities Services

  24. Waiver of Statewideness 1915(c) • May waive statewideness  1915(i) • May not waive statewideness  NASDDDS National Association of State Directors of Developmental Disabilities Services

  25. 1915(i) – Current Status • As of June 2014, 14 states have approved 1915(i) SPAs: • California • Colorado • Connecticut • Florida • Idaho • Indiana • Iowa • Louisiana • Michigan • Mississippi • Montana • Nevada • Oregon • Wisconsin NASDDDS National Association of State Directors of Developmental Disabilities Services

  26. Assistive Technology and Managed Care • Many states are considering moving HCBS and other LTSS into a managed care environment • Assistive technology may be included in services covered by managed care entities • States may also allow managed care entities to provide cost effective alternatives to covered services – Assistive technology may play a key role in those alternatives

  27. Assistive Technology and Self-Direction • States may have a set array of technology they will pay for in their standard fee-for-service arrangements • In some states, self-direction, through the management of an individual budget may afford even greater opportunity for individualized AT. • Self-direction is an option in both 1915(c) and 1915(i) HCBS programs.

  28. New HCBS Regulations: Effective March 17, 2014 • To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c)*, 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate • To enhance the quality of HCBS and provide protections to participants NASDDDS National Association of State Directors of Developmental Disabilities Services

  29. Overview of the rule • States can now combine multiple target populations within one 1915(c) waiver • Gives CMS with new compliance options for 1915(c) waiver programs, not just approve/deny • Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible • Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example) NASDDDS National Association of State Directors of Developmental Disabilities Services

  30. Overview of the rule • Conflict-free case management • Was just in guidance, now it is in rule • Implements the final rule for 1915(i) State plan HCBS—same requirements on HCB settings character, person-centered planning • Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option • Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements NASDDDS National Association of State Directors of Developmental Disabilities Services

  31. And the “big deal” items….. • HCB Settings Character • What is NOT community • What is likely not community • What is community • Person-centered planning • Codifies requirements • Transition planning-coming into compliance with the HCB settings requirements NASDDDS 4/17/14

  32. HCBS setting requirements 42CFR441.310(c)(4) • Is integrated in and supports access to the greater community • Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources • Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services NASDDDS National Association of State Directors of Developmental Disabilities Services

  33. Assistive Technology: New Role in HCBS • As states identify strategies to meet the obligations of the new regulations, they may look to technology to assist individuals to more effectively engage in their community, get and maintain employment, develop social networks, and communicate with friends, family and co-workers. NASDDDS National Association of State Directors of Developmental Disabilities Services

  34. How to Get Involved • Determining whether, what and how your state covers AT can be daunting • Building relationships, becoming informed and educating others are key to having a voice in future AT coverage strategies NASDDDS National Association of State Directors of Developmental Disabilities Services

  35. How to Get Involved, Continued • A key message to policy-makers….AT may be the necessary difference for individuals to live, work and meaningfully engage in community NASDDDS National Association of State Directors of Developmental Disabilities Services

  36. Good resources… • A number of states, such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation. • To learn more about state activity and options: • www.medicaid.gov • Coleman Institute http://www.colemaninstitute.org/

  37. 2014: State of Aging and Disabilities Assistive Technology and Medicaid July 14, 2014

  38. NASUAD Overview • Founded in 1964 to represent state agencies on aging. • In 2010, changed name in recognition of the fact that most state agencies served aging and disability populations. • 56 members Represents State and Territorial Agencies on Aging and Disabilities. • Board of Directors – Executive Officers, 10 regional representatives and 10 regional alternate reps.

  39. Our mission To design, improve, and sustain state systems delivering home and community based services and supports for the elderly and individuals with disabilities and their caregivers

  40. Key Resources • NASUAD.org • HCBS.org • NASUADiQ.org • Friday Update • Integration Tracker • Expansion Tracker

  41. Join us at the 30th annual HCBS conference • September 15-18, 2014, Crystal City, VA • 5 pre-conference intensives • 130 sessions covering all populations receiving LTSS • 1,000 attendees representing state policymakers, federal officials, staff, academics, businesses, etc. • For more information: www.nasuad.org

  42. State Aging & Disability Agencies

  43. Managing relationships identified as key job responsibility

  44. State Medicaid HCBS Options

  45. State Assistive Technology Coverage

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