Money Follows the Person (MFP) January 28, 2010 Presentation to Families USA 15th Annual Grassroots Meeting Carol Irvin Debra Lipson

2 Principal Aims Reduce reliance on institutional care Develop community- based LTC opportunities Enable people with disabilities to participate fully in their communities

Todays Presentation 3 Overview of the MFP program Early implementation experiences

MFP Demonstration Grants Awarded 4 30 grantees (29 states and DC) –17 in January 2007 –14 in May 2007 –1 state not implementing a program Size of Awards –Total awards to date: $1.44 billion –Wide range of state commitments, from $5.4 million to $142 million

Two Programs in One 5 Each state is implementing two programs –Transition program –Rebalancing program

Transition Program 6 Medicaid beneficiaries in institutional care for at least six months –Nursing homes, hospitals, intermediate care facilities for the mentally retarded, institutions for mental diseases Transition to a qualified residence –Home, apartment, or group home with four or fewer people Quality assurance –24-hour backup –Risk assessment and mitigation processes –Incidence reporting and management systems

Transition Program (contd.) 7 MFP Services –Eligible for one year – 365 days –Package of home- and community-based services (HCBS) Qualified HCBS Demonstration HCBS Supplemental services Continuity of services –After MFP eligibility ends, qualified HCBS must continue based on beneficiarys Medicaid eligibility status

Enhanced matching funds –Qualified HCBS –Demonstration HCBS Reinvest enhanced matching funds in LTC –Medicaid beneficiaries who use LTC supports and services –Overall service system Rebalancing Program 8

States are… –Transitioning beneficiaries with particularly challenging needs –Making investments in the LTC infrastructure In Summary 9

Early Implementation Experiences 10

Diversity in state MFP transition goals Current status of program implementation in states Challenges and barriers to implementation Overview 11

Number and type of populations to be transitioned vary among states: –By demonstration year –In distribution across five population groups –By percentage of MFP eligibles –By medical complexity and level of care needed Diversity in Transition Goals 12

MFP Transition Goals by Demonstration Year 13 34,066 total transitions Source: MFP 2009 Supplemental Budget Requests, December 2008.

MFP Transition Goals by State and Target Group 14 Total Transitions by Categories

October 2007–April 2008June–October 2008After January 2009 Maryland Missouri New Hampshire Oregon Texas Washington Wisconsin Arkansas California Delaware District of Columbia Georgia Hawaii Iowa Kansas Kentucky Michigan Nebraska New Jersey North Dakota Ohio Pennsylvania Virginia Connecticut Illinois Indiana Louisiana North Carolina New York Oklahoma Current Implementation Status: Start Dates 15

Elderly Phys. Disabled < 65 People with MR-DD People with Mental IllnessOtherTotal 2007 and ,482 January–June ,932* Cumulative1,0171,1411, ,414* Percentage of total transitions to date 30%33%35%<1%1%3,414* Percentage of total transitions planned 47%27%20%4%2% Transitions to Date 16 *Preliminary count based on reports submitted as of Sept. 18, Source: MFP grant progress reports.

Starting point –Previous experience transiting people from institutional to community-based care Housing, Housing, Housing Supply of HCBS –Waivers and waiver services –Providers and work force Challenges to Program Implementation 17

Experience and Capacity at Start of MFP Key Implementation Challenges SubstantialDevelop new service categories to assist people with more extensive needs Expand capacity of existing transition programs ModerateScale up transition capacity by increasing transition coordinators or agencies Develop transition services for new populations MinimalConduct outreach Hire or train transition coordinators Recruit providers to deliver new services Starting Point 18

Transition coordinationmost states wish to increase capacity Strategies to ensure affordable, accessible housing Most states planning to change Medicaid home- and community-based services (HCBS) policies to accommodate MFP participants during or after the one-year transition period Quality managementmost states need to strengthen to meet grant requirements Common MFP Design Challenges 19

Strategy Number of States (n=30) State and local government agency staff 11 Contracts with private organizations e.g., Centers for Independent Living, Area Agencies on Aging, case management agencies 10 Combined approach State staff for individuals with MR/DD* moving out of ICFs-MR** Private organizations for elderly and physically disabled individuals 9 Approaches to Transition Coordination 20 *MR/DD = Mental retardation or a developmental disability. ** ICFs-MR = Intermediate care facilities for the mentally retarded.

Lack of affordable and accessible housing –In 2008, 71 MFP candidates could not enroll or transition through MFP for this reason –Half of MFP states reported that shortages of affordable, accessible housing units, or lack of housing subsidies, led to fewer transitions The Housing Challenge 21

Strategy Number of States (n=30) Housing registries to find vacant units that are accessible to the disabled 28 Outreach and education to state and local public housing authorities, landlords, etc., to obtain preference for MFP participants 22 Housing task force or committee19 Housing-related MFP benchmarks13 Dedicated funding to pay for rental or bridge subsidies for MFP participants 10 Strategies to Find Affordable, Accessible Housing 22

Inadequate community-based services –In 12 states, shortages of HCBS or direct-care workers affected timing or number of transitions –Hawaii, New York, and other states experienced delays in implementing new HCBS waivers in which MFP participants were to enroll Achieving quality assurance requirements –24/7 back up The Service Accessibility Challenge 23

New HCBS waiver programs to serve people transitioning from institutions Increase in HCBS waiver program capacity (slots) Increase in consumer direction options –Nearly all states expanding consumer directed options in some way –Seven states have MFP benchmarks for self-direction Changes to Medicaid HCBS Policies 24

Most demonstration and supplemental services are designed to support transition to the community Some states are testing whether specialized services reduce institutionalization or re- admissions: –Telehealth services in rural areas –Special mental or behavioral health services Types of MFP Demonstration or Supplemental Services 25

Economic downturn has strained state Medicaid management resources and HCBS capacity 18 MFP state grantees report that state budget crises will affect many MFP components –e.g., fewer staff to manage program, reduced waiver slots, provider payment delays, freezes on hiring or contracting State Budget Crises Affecting Implementation Progress 26

National Evaluation of the MFP Demonstration Grant Program: Reports from the Field –No. 1: Transitioning Medicaid Enrollees from Institutions to the Community: Number of People Eligible and Number of Transitions Targeted Under MFP –No. 2: Implications of State Program Features for Attaining MFP Transition Goals –No. 3: Early Implementation Experience of State MFP Programs Available at: or For More Information 27