Health Care Reform and Implications for Persons with Disabilities Equip for Equality May 27, 2010 Stephanie F. Altman, Health & Disability Advocates

Prepared & presented by Health & Disability Advocates, April For more info: COMPONENTS OF PATIENT PROTECTION & AFFORDABLE CARE ACT Community Living Assistance Services & Support Act (CLASS) National High Risk Pool (HRPs) Community First Choice Option Changes in Medicaid Medicaid Maintenance of Effort Requirements Extending Money Follows the Person grants Additional $ for Aging & Disability Resource Centers Demonstrations & Pilots

Prepared & presented by Health & Disability Advocates, April For more info: C OMMUNITY L IVING A SSISTANCE S ERVICES & S UPPORT A CT (CLASS) Monthly premium: $120-$150/month 5 years before individual is vested and can draw down a benefit Benefit is $50/day (at a minimum); $75/day is estimated at this point Qualifying services: for ADLs or IADLs Services in home, or residential Considerations for Illinois: 1. How do we encourage people to participate? 2. Do we know who would use the program? 3. Does it change the way we currently deliver services?

Prepared & presented by Health & Disability Advocates, April For more info: H IGH R ISK P OOLS : B ACKGROUND Approximately 200,000 people are enrolled in 35 state high risk pools nationally Individuals are uninsurable in the private market due to pre-existing conditions Health care reform legislation creates a national transitional high risk pool to begin in June 2010 (unless a state opts to expand their own high risk pool) and operate until the Exchange is implemented in 2014

Prepared & presented by Health & Disability Advocates, April For more info: C URRENT H IGH R ISK P OOL P LANS Nationally, steep premiums that increase with age; range from 125 to 200% of individual market rates for the state High levels of deductibles and co-insurance; similar to other individual policies Limits on some benefits, such as preventive services, prescriptions, and mental health In Illinois the Comprehensive Health Insurance Program (I-CHIP) premium is 143% of the individual market rates 16,000 enrollees Source: Jean P. Hall & Janice Moore, University of Kansas

Prepared & presented by Health & Disability Advocates, April For more info: T EMPORARY H IGH R ISK P OOLS IL has opted to run its own pool (SB 240) National pool will be managed by Health & Human Services National and new state pools will require being uninsured for 6 months prior to enrollment – there will be no wiggle room on definition of “uninsured” Both will cap premiums at 100% of individual market rates, and guidance on package and deductibles is forthcoming; however, plans must cover at least 65% of health care costs.

Prepared & presented by Health & Disability Advocates, April For more info: H IGH R ISK P OOL C ONSIDERATIONS FOR I LLINOIS I-CHIP premium is higher (143%) than the temporary high risk pool (100%) New funding -- $5 billion – must be used for new enrollees; and cannot be used for existing enrollees IL estimated share to be $200 million total but it can’t be used for premium parity between programs Will IL try to use GRF for Section 7 Pool and Insurance Assessment for HIPPA CHIP pool to create premium parity? Temporary High Risk Pool enrollees must be uninsured for at least six months and HHS has not issued guidance on definition of pre-existing condition I-CHIP uses 31 presumptive conditions and has a catchall category for people without presumptive conditions but rejected on two insurance applications.

Prepared & presented by Health & Disability Advocates, April For more info: C OMMUNITY F IRST C HOICE O PTION Medicaid State Plan Option –1915 (k) to provide attendant care services & supports Must be categorically eligible for Medicaid Income under 150% fpl or have income that does not exceed income thresholds for institutional level care Services: health related tasks with ADLs, IADLs, hands on supervision or cueing; acquisition of skills to accomplish ADLs, IADLs, and voluntary training for managing attendants Optional Services: transition costs (rent, utility deposits, first month’s rent and utilities, bedding, basic kitchen supplies and other “necessities”), and services that increase independence or substitute for human assistance. Reimbursement rate for Optional Services is an additional 6% points above FFP – i.e. 56%

Prepared & presented by Health & Disability Advocates, April For more info: C OMMUNITY F IRST C HOICE O PTION : I MPLICATIONS IN I LLINOIS Will Illinois determine a 1915 (k) State Plan Amendment is more efficient than the 1915(c) waivers we currently operate for attendant care and health related services? Given the budget situation, can IL opt for the Optional Services and will the cost of the expansion without a cap on enrollment be higher than the increase in federal funding through the FFP enhancement? How does the Community Choice First Option fit within the Money Follows the Person re-balancing effort? Consideration: MFP has changed its focus to include individuals living in a facility for 3 months or more and has a new emphasis on employment

Prepared & presented by Health & Disability Advocates, April For more info: O VERVIEW OF HCR & M EDICAID : I MPLICATIONS FOR S TATE M EDICAID P ROGRAMS Potentially Four Medicaid Vehicles “Regular Medicaid”: Medicaid programs for “categorically eligible” populations not changed by PPAC “New Medicaid”: New eligibility category for adults under 133% of FPL Begins 2014 unless Early Implementation “Optional Medicaid” category for those over 133% FPL “Benchmark” Plan under Insurance Exchange Different from current Medicaid structure in Categorical Eligibility, Coverage Packages, Reimbursement to Providers and Delivery System.

Prepared & presented by Health & Disability Advocates, April For more info: M EDICAID & M AINTENANCE OF E FFORT PPACA extends the MOE requirement of the American Recovery & Reinvestment Act (ARRA) prohibition on reducing eligibility for Medicaid until December 31, 2013 States are prohibited from altering eligibility for any existing Medicaid program even though enhanced match may not be extended beyond December 31, 2010 (possibly expanded to June 30, 2011.) CMS verbal interpretation is that states can improve programs without penalty, but not reduce eligibility The MOE requirement does not apply to the “new” Medicaid expansion population

Prepared & presented by Health & Disability Advocates, April For more info: D ELIVERY S YSTEM AND A CCESS R EFORMS Medicaid Physician Primary Care Reimbursement Increases to Medicare Level: what will the definition of primary care codes be especially for people with special needs and can state afford to keep rates up after 100% FFP ends? New Patient Care Models Center for Medicare & Medicaid Innovation Varies pilots Demonstrations: Independence at Home Demo; Hospitals Readmissions Reduction Program; Community-based Care Transitions Program

W HAT DOES THIS MEAN FOR M EDICAID IN I LLINOIS ? “Regular Medicaid”– Covered Services Defined “New Medicaid” – Covered Services NOT Defined Insurance Exchange– Covered Services NOT Defined AABD – 100% of FPL Eligible Population: people with disabilities who meet or equal disability standard; people over 65 Federal Match Rate: 50% 133% of FPL Eligible population: any adult who is not otherwise categorically eligible Federal Match Rate: 100% until 2017 Benchmark Plan (could be Medicaid Service Package) Eligible Population: Adults above133% of FPL Federal Match Rate: 100% until 2017 HBWD– 350% of FPL Eligible Population: must meet a disability standard; must be working & paying FICA Federal Match Rate: 50% State Option for Medicaid for over 133% FPL (50% Federal Match Rate) until 2017 Spend-down -- ?% Eligible population: must meet or equal a disability standard or otherwise categorically eligible Federal Match Rate: 50%

Prepared & presented by Health & Disability Advocates, April For more info: K EY C ONSIDERATIONS FOR I LLINOIS 1. What happens to people with disabilities who are not working and are above 133% of FPL? 2. With 100% match rate through 2017, is there more of an incentive to move more people into expansion group or exchange which may have weaker benefits packages? 3. Will the Exchange connect with 1915 (c ) or (k) services like the HBWD program currently does for working people who earn out of HBWD but still need long-term care services & supports?

Prepared & presented by Health & Disability Advocates, April For more info: K EY C ONSIDERATIONS FOR I LLINOIS 4. What happens to people who have chronic conditions, self-insured with astronomical premiums? If they’re not in the I-CHIP, do they need to go “bare” in order to get affordable coverage? 5. What about assets? New expansion populations don’t have asset limits – is this something we should consider for other Medicaid populations to increase state FFP opportunities?

Prepared & presented by Health & Disability Advocates, April For more info: N EW “S EAMLESS ” D ELIVERY S YSTEM BY 2014 W ITH A S INGLE A PPLICATION Health Care Coverage Insurance Exchange Expansion Medicaid Regular Medicaid