Medicaid Programs to Improve care and access Overview of Medicaid Programs & Affordable Care Act Provisions that impact care transitions

States’ community long term care (LTC) programs provide home and community based services for Medicaid eligible individuals including case management and an array of supports Most 1915c waiver programs offer transition services CMS Medicaid Programs

Medicaid Grant Programs – Recently Completed Person-Centered Planning – Completed September 2011 – assisted States in strengthening and expanding the use of person-centered planning models. Participating States/Territories: AK, AR, AZ, CT, FL, GU, ID, LA, MA, MO, NC, TN, NH, MS, VA, WA Systems Transformation – Completed September 2011 – assisted States in the reform of the community long-term support service infrastructure with the goal of achieving greater integration while also increasing access, choice and control, and improving quality. Participating States: AR, CA, IA, KS, LA, ME, MA, MI, MO, NH, NJ, NM, NY, NC, OR, RI, SC, VA

Medicaid Grant Programs – In Progress Person-Centered Hospital Discharge Planning – Active through September 2012 – assists States with the development and implementation of enhanced hospital discharge models and with increasing capacity of single entry points (including ADRCs). Participating States: AK, CA, HI, ID, KS, MD, MO, NC, OR, and SC. State Profile Tool – Active through September 2012 – assists States with assessing their long-term services and supports systems and partners with them in the development of a set of national balancing indicators. Participating States: AR, FL, IA, KY, ME, MA, MI, MN, NV, and VA.

States are able to offer health home services for individuals with multiple chronic conditions or serious mental illness effective January 1, 2011 Coordinated, person-centered care Primary, acute, behavioral, long term care, social services = whole person Enhanced FMAP (90%) is available for the health home services (first 8 quarters) Medicaid Affordable Care Act (ACA): Section 2703: Health Homes for Individuals with Chronic Conditions

Community First Choice (CFC) 1915(k) State Plan Option Goal - To provide “person-centered” home and community-based attendant services and supports as an optional service under the State Plan Effective October 1, 2011 Financial Incentive - 6% increased FMAP

CFC Eligibility & Services Must be eligible for medical assistance under the State plan. Income up to 150% of FPL, or if greater, meet an institutional level of care. Services: Attendant services and supports to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, or cueing.

Section 2401: Community First Choice Option Services (continued) Allows for the purchase of back-up systems or mechanisms (such as the use of beepers or other electronic devices) to ensure continuity of services and supports. Additional Services at the State’s Option Permissible Services & Supports –Allows for transition costs such as security deposits for an apartment or utilities, purchasing bedding, basic kitchen supplies, and other necessities required for transition from an institution. –Allows for the provision of services that increase independence or substitute for human assistance to the extent that expenditures would have been made for the human assistance.

Section 2401: Community First Choice Option Beneficiary Focus Utilizes a person-centered plan Allows for the provision of services to be self-directed under either an agency-provider model or a traditional self- directed model with a service budget that may include: – vouchers –direct cash payments –use of a financial management entity to assist in obtaining services Collaborate with a Development and Implementation Council that includes a majority of members with disabilities, elderly individuals, and their representatives.

Section 2401: Community First Choice Option Potential challenges : Community First Choice 1915(k) State Plan Option –Establish and maintain a comprehensive continuous quality assurance system specifically for this service. –Maintenance of existing programs – For the first full fiscal year in which the state plan amendment is implemented, the state must maintain or exceed the level of expenditures for services provided under the state plan, waivers or demonstrations. –Collect and report information for Federal oversight and the completion of a Federal evaluation. Opportunities for collaboration and coordination

Medicaid ACA: Section 2401: Community First Choice Option (cont’d) Implementation status Notice of Proposed Rulemaking published February 25, 2011 – Comment period closed April 26, 2011 Final regulation targeted for early Winter Community First Choice State plan Option is effective October 1, 2011 but final rule has not been published (11/2011)

Medicaid ACA : Section 2403: Money Follows the Person Now extends through 2019-transitions individuals from institutions to community based care and adds resources to balance LTC Enhanced Federal match for community services for first year following transition from facility 43 States and the District of Columbia now participating in the demonstration

Medicaid ACA : Section 2403: Money Follows the Person ADRC/MFP Supplemental funding opportunity: in 2010, (25 States) up to $400,000 for MFP and ADRC was provided for MFP Grantees to work together to expand ADRCs, build processes & partnership & utilize MDS 3.0 Section Q States eligible for the 2012 ADRC Supplemental Funding Opportunity: CO, FL, GE, HI, ID, IL, ME, MA, MISS, MN,NV, NJ, NM, OH, RI, SC, TN, VT, WV MFP States can request and submit with budget in nearly 2012, approved by April of 2012, guidance now being sent out to eligible Grantees

Medicaid ACA : Section 10202: Balancing Incentive Payments Program Designed to help states balance their system of long- term services and supports (LTSS) $3B awarded through increased Federal matching payments of 2% or 5% to States that: –Currently spend less than 50% or less than 25% of long-term care budgets on home and community-based services (HCBS)

Balancing Incentive Program Goal – increase access to non-institutionally based Medicaid Services and implement key structural reforms States must reach benchmarks of either 2 or 5% by the end of the program CMS is accepting applications from States immediately through August 1, 2014 Enhanced FMAP available until September 30, 2015 or until total program funding of $3 billion dollars is expended State Medicaid Agencies must apply

Medicaid ACA: Section 10202: Balancing Incentive Payments Program Participating States must commit to three structural changes: –Implement a No Wrong Door/Single Entry Point system –Use a Core Standardized Assessment Instrument –Implement Conflict Free Case Management standards –Agree to Data reporting requirements

Balancing Incentive Program Eligibility – States who submit an application and spend less than 50 % on HCBS States may submit expenditure data on total Medicaid expenditures on LTSS as of FY 2009 to be reviewed on case by case basis States may not apply based on expenditures by target population(s) Funding available for community-based LTSS

Balancing Incentive Program Financial Incentives – 2 or 5 % on eligible HCBS provided under the following Medicaid program authorities: HCBS under 1915 (c) or (d) or under an 1115 Waiver; State plan home health; State plan personal care services; The Program of All-Inclusive Care for the Elderly (PACE); Home and community care services defined under Section 1929(a); and Self-directed personal assistance services in 1915 (j), services provided under 1915(i), private duty nursing authorized under Section 1905 (a)(8) (provided in home and community-based settings only) Affordable Care Act, Section 2703, State Option to Provide Health Homes for Enrollees with Chronic Conditions Affordable Care Act, Section 2401, 1915(k) - Community First Choice (CFC) Option.

Balancing Incentive Payments Program Implementation Status Released 10/2011 Enhanced FMAP begins effective October 1, 2011 User manual available

Resources Balancing Incentive Program Guidance: ByDID=1&sortOrder=descending&itemID=CMS &intNumPerPage=10 Questions or comments:

Affordable Care Act: Section 2701: Adult Health Quality Measures Development of core set of quality measures for adults eligible for Medicaid-voluntary submission by SMA, most are claims based to start and medically oriented Establishment of a Medicaid Quality Measurement Program NPRM published in 2011, comments received and reviewed by AHRQ and Technical Panel Final rule for 1st core set to be published in January 2012

Subtitle H – Improved Coordination for Medicare-Medicaid Enrollees Section 2601 – 5-year period for Medicaid waivers for Medicare- Medicaid enrollees Section 2602 –Establishes Federal Coordinated Health Care Office to: –Ensure Medicare-Medicaid enrollees have full access to the services to which they are entitled. –Improve the coordination between the federal government and states. –Develop innovative care coordination and integration models. –Eliminate financial misalignments that lead to poor quality and cost shifting. Provisions of The Affordable Care Act: Provisions to Improve Care Coordination for Medicare-Medicaid Enrollees

ACA Provisions to Improve Care Coordination for Medicare-Medicaid Enrollees Federal Coordinated Health Care Office established, known as the Medicare-Medicaid Coordination Office. The Medicare-Medicaid Coordination Office is working on a variety of initiatives to improve access, coordination and cost of care for Medicare- Medicaid enrollees in the following areas: Program Alignment (29 misalignments Federal Register-public notice for comments closed 7/11/11) Data and Analytics Models and Demonstrations (through partnership with the Innovation Center) More information at:

ACA Provisions to Improve Care Coordination for Medicare-Medicaid Enrollees Implementation Status 15 states-Planning Grants designing new integrated care models for serving Medicare-Medicaid enrollees. Each received up to $1 million (related to State Plan- Health Homes CMS will facilitate coordination). Providing all State Medicare data for care coordination, including timely availability of Parts A, B, and D data (announced in May-2 State, historical and going forward). Implementing initiative to align financing of Medicare and Medicaid (announced in State Medicaid Director letter on July 8, 2011) either 3 way agreement blended capitated rate (acute and community care) or managed fee for service (reimbursement method). Developing a demonstration (contract RFP will be released-in Fall) to reduce potentially avoidable hospitalizations and improve quality of life among nursing home residents-focus on NH residents-entities-additional clinical staff to avoid hospitalizations announced Friday July 8. ( use evidence based model and test).

Additional Information CMS: Community Services and Long-Term Supports  State Medicaid Director Letters  MFP Technical Assistance Website 