1. A Strong Foundation for System Transformation Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid, CHIP and Survey & Certification Centers for Medicare & Medicaid Services February 16, 2011

2. DEHPG Vision A sustainable healthcare system that supports independence, health and quality of life through person-driven services and supports 2

3. DEHPG Goals  Encourage balanced systems of LTSS  Promote effective service integration  Primary, acute, LTSS  Physical and behavioral health  Medicare/Medicaid  Focus on quality of care

4. DEHPG 2.0 Disabled and Elderly Health Programs Group Barbara C. Edwards, Director Suzie Bosstick, Deputy Director Benefits & Coverage Linda Peltz, Director Coverage SPAS 1915 SPAs - (j) and (k) Benchmark Benefits Benefit Policy Long Term Services & Supports Mary Sowers, Acting Director 1915(c) Waivers 1915(i) SPAs Institutional Coverage PASRR Policy Community Systems Transformation Melissa Hulbert, Acting Director Balancing Incentives Money Follows the Person Ticket to Work Demos Medicaid Infrastructure Grants Pharmacy Larry Reed, Director Pharmacy SPAs Pharmacy Policy Drug Pricing Rebate Operations Integrated Health Systems Suzie Bosstick, Acting Director 1915(b) Waivers 1932(a) SPAs PACE Managed Care Policy Dual Eligibles Policy Health Homes COB/TPL Policy

5. The Current Landscape: Medicaid LTC LTC = 32% of total Medicaid spending, $115 b 2009 Institutional LTC (NFs) still the entitlement HCBS spending was $51.1 b (2009) –66% in section 1915 waivers Not all populations have equal access to HCBS Systems often fragmented and complex to navigate Source: Thomson Reuters, Medicaid Long-Term Expenditures in FY 2009

6. 2010 Progress Housing – 4300 HUD vouchers for people with disabilities Diversion – $12 m to 10 states for person centered hospital discharge planning models Transition - $10 m to 25 states to integrate ADRCs in Section Q response Employment -150,000 workers receiving Medicaid under buy-in; $67 m to 43 states over 10 years

7. Growth in Medicaid HCBS, 1999-2007

9. Provisions of The Affordable Care Act Supports most integrated setting appropriate –Offers new or improved HCBS State Plan options –Offers new option for integrating and linking services –Offers enhanced FMAP to help states modify delivery systems

10. Adds Section 1915(k) Optional State Plan benefit to offer Attendant Care and related supports in community settings, providing opportunities for self- direction Does not require institutional LOC under 150% FPL Includes 6% enhanced FMAP Provisions of The Affordable Care Act: Section 2401: Community First Choice Option

11. Provisions of The Affordable Care Act: Section 2402: Removing Barriers to HCBS 2402(a) directs the Secretary to promulgate rules on HCBS Ensure that systems are in place related to allocation of resources, providers, maximum choice and control. CMS is working in a cross-HHS workgroup on this provision.

12. 12 Section 1915(i) established by DRA of 2005 State option to amend the state plan to offer HCBS as a state plan benefit; does not require institutional LOC Modified under ACA effective October 1, 2010 to allow comparability waivers, add “other services” States cannot waive statewideness or cap enrollment Provisions of The Affordable Care Act: Section 2402: Removing Barriers to HCBS, Cont’d

13. Offers States substantial resources and additional program flexibilities to remove barriers 29 states plus D.C. participate Since its inception, more than 12,000 transitioned from institutional settings to home and community-based settings Provisions of The Affordable Care Act: Section 2403: Money Follows the Person

14. The Affordable Care Act (ACA) opens MFP to more States Extends and expands MFP through 2016 Planning grants (September 2010) up to $200,000 to help additional States develop and submit an Operational Protocol By April 2011, CMS expects to have at least 42 States and the District of Columbia participating in the demonstration 14

15. Development of core set of quality measures for adults eligible for Medicaid. Establishment of a Medicaid Quality Measurement Program Requirement that any federally conducted or supported health care or public health program, activity or survey collects and reports, to the extent practicable data on race, ethnicity, sex, primary language, and disability status Provisions of The Affordable Care Act: Section 2701: Adult Health Quality Measures & Section 4302: Implications for Data Collection

16. Option 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) Provisions of The Affordable Care Act: Section 2703: Health Homes for Individuals with Chronic Conditions

17. Effective October 1, 2011 Enhanced FMAP to increase diversions and access to HCBS –2% if less than 50% LTSS spending in non-institutional settings –5% if less than 25% LTSS spending in non-institutional settings CMS Guidance and Application targeted for mid-2011 Provisions of The Affordable Care Act: Section 10202: Balancing Incentive Program

18. Requires face to face encounter by a physician before certification of need for Home Health services Applies to both Medicare and Medicaid Effective 1/1/2010 Medicare home health regulation finalized Medicaid NPRM (including DME) will be issued early 2011 Provisions of The Affordable Care Act: Section 6407: Home Health

19. The Foundation for a Redesigned Service System for Individuals with Chronic Conditions Person Centered Individual Control Integration Quality

20. CMCS Assistance to States Continuing serious budget concerns for States Secretary Sebelius’ letter to Governors - committed to help States implement effective cost control –Modify benefits –Manage care for high cost enrollees –Purchase drugs more effectively –Assure program integrity

21. LTSS System Transformation A key element of effective cost management Key to State compliance with obligations under Olmstead/ADA CMCS will offer TA to leverage ACA and other available tools of transformation Sec. 1115 waiver template to put HCBS first Guidance on managed care for persons living with chronic and disabling conditions

22. Better Care, Better Health, Lower Costs Lower Per Capita Costs Higher Health Care Quality Better Population Health

23. SMDs and Regulations Medicaid Prescription Drug Rebates SMD 10006,SMD 10019 Community Living Initiative (Olmstead Tool Kit) SMD 10008 Money Follows The Person Extension SMD 10012 1915(i) SMD 10015 Concurrent Hospice Care for Children SMD 10018 5yr Approval or Renewal Period for Certain Medicaid Waivers SMD 10022 Health Homes for Enrollees with Chronic Conditions SMD 10024 Code of Regulations Rx AMP Withdrawal Reg CMS-2238-P2

24. Additional Information CMS: Community Services and Long-Term Supports  http://www.cms.gov/CommunityServices/01_Overview.asp#TopOfPage http://www.cms.gov/CommunityServices/01_Overview.asp#TopOfPage State Medicaid Director Letters  http://www.cms.gov/SMDL/SMD/list.asp#TopOfPage http://www.cms.gov/SMDL/SMD/list.asp#TopOfPage MFP Technical Assistance Website  http://mfp-tac.com/ http://mfp-tac.com/