1. Elderly Waiver and Alternative Care – Programs Supporting Older Adults at Home 2013 Age and Disabilities Odyssey Libby Rossett-Brown - Elderly Waiver/Alternative Care Program Administrator Gail Carlson – Alternative Care Operations June 18, 2013

2. Session Goals  Understand the basic concepts and policies of the Elderly Waiver (EW) and Alternative Care (AC) programs  Comparison of EW and AC Service sets  Become knowledgeable of each programs financial eligibility  AC fees and cost sharing

3. Acronyms  CMS Centers for Medicare and Medicaid Services  SRU Special Recovery Unit  MA Medical Assistance  EW Elderly Waiver  MCO Managed Care Organization  MSHO Minnesota Senior Health Option  MSC+ Minnesota Senior Care Plus  SIS-EW Special Income Standard-Elderly Waiver  LTCC Long Term Care Consultation  NF Nursing Facility  MNA Maintenance Needs Allowance

4. Acronyms  DHS Department of Human Services  LOC Level of Care  CL Customized Living  AC Alternative Care  CDCS Consumer Directed Community Supports  FFP Federal Financial Participation  HCBS Home and Community Based Services  PNA Personal Needs Allowance  PCA Personal Care Attendant

5. Purpose of Elderly Waiver (EW) and Alternative Care (AC)  Maintain people in their own homes – person chooses to live in the community  Connect people with services that they need  Support Caregivers  Support choice and informed decision making  Prevent or delay NF admissions  Move people out of institutions

6. Elderly Waiver  The Elderly Waiver program funds home and community based services for people age 65 and older who are eligible for Medical Assistance and require the level of care provided in a nursing home, but choose to reside in the community.  Authority found in MN Statute, Section 256B.0915  Federal and State funding

7. Alternative Care  Contain MA expenditures by funding care in the home and community  Prevent impoverishment of older adults by assisting them to access services at an earlier point of need and prevent more costly levels of care  Authority found in MN Statute, Section 256B.0913  State funded only

8. EW – Who is Eligible?  Age 65 or older  Eligible for Medical Assistance  A Minnesota Resident  Need nursing home level of care as determined by the Long term care consultation process (LTCC)  Requires a waiver service to remain in the community

9. EW-Who is Eligible?  The EW service cost for an individual cannot be greater than the estimated nursing home cost for that individual and is limited by the case mix classification  The person’s plan of care assures health and safety

10. AC-Who is Eligible?  Age 65 and older  Have chronic care needs  Chooses to reside in the community  Have financial resources to meet their own health related needs and independent living needs  At risk of NF placement as determined by the LTCC  May be eligible for Medicare Savings Programs

11. EW and AC Program Models  Voluntary Enrollment  Payer of Last Resort  Cost sharing by participants  Program and service is appropriate to need  Most cost effective way to meet the need  Enhance self sufficiency  Support and extend informal caregiving

12. EW client Characteristics FY13 Average Age: 80 years old 198 are 100+ years Oldest is 107 Total Eligible EW Clients FY13 27,798 Gender: 73% female 27% male Marital Status: 48% are widowed 19%married Case Mix: 17% A; 17% B; 22% L; 12% D, 13% E, 2%K Living Arrangements: 2/3 live alone Ave Cost (State): $10,675 per client/per yr or $890/month EW Total Cost: Approx. $266 million (FY2013) Managed Care FFS 1,664 6% MSHO-EW 19,554 70% MSC+ -EW 6,580 24%

13. Minnesota Elderly Waiver Clients by County FY2013 Total EW Clients 27,798

14. AC client Characteristics FY13 Average Age: 82 years old 27 are 100+ years Oldest is 103 Total Eligible AC Clients FY13 4,037 Gender: 76% female 24% male Marital Status: Nearly 2/3 are widowed Case Mix: 29% A; 24% B; 20% L;9% D, 8% E Living Arrangements: 2/3 live alone Service Months: 30 months average Ave Cost (State): $6,096 per client/per yr or $797/month AC Total Cost: Approx. $28.2 million (FY2013)

15. Minnesota Alternative Care Clients by County FY2013 Total Eligible AC Recipients FY13 4,037

16. Enrollment Process for EW/AC  Community Assessment determines service needs – County Social Service Department Tribal Entity Public Health Nurse/Social Worker Managed Care Organization (EW)  Medical Assistance Eligibility (EW) – county financial worker  AC financial eligibility determined by the Case Manager

17. EW Financial Eligibility  Special Income Standard (SIS-EW) – income is equal to or below $2,130/month (300% SSI)  Clients can keep $971(as of 7/1/13) – Maintenance Needs Allowance (MNA)  If income exceeds $971 the client must pay for part all waiver service costs – Waiver Obligation.

18. EW Financial Eligibility  Clients do not have to meet the waiver obligation in full each month to remain eligible.  Waiver obligations cannot be collected until services are delivered

19. SIS-EW Example  Mr Is it summer – not married and income is $1000/month  Special income standard is 2130 – He is below the standard Maintenance needs allowance (MNA) is $971 Calculation: Income minus the MNA = difference of $29 He will have a $29 waiver obligation This amount is paid towards waiver services used in a month

20. Financial Eligibility non SIS-EW  Income is greater than $2130/month  Keep $719/month income (medically needy income standard 7/1/13)  Will have a medical spenddown – must pay a portion of medical costs and waiver costs.

21. Non SIS-EW example  Mrs Flowers has income of $3000/month  Special income standard is $2130 She will need to spend down to 75%FPG ($719) because she is already over 100%FPG ($958) There are other disregards and deductions  Client will need to meet a medical spendown of $2281 and will pay a portion of medical costs and waiver costs

22. EW Asset Limit  MA method B: $3000 for a household of 1  Married couples: The community spouse is entitled to an asset allowance and an asset assessment needs to be completed  An asset assessment protects a specified amount of assets for the community spouse.  Asset assessments are completed by the financial worker

23. AC Financial Eligibility  Financial resources are within 4.5 months of Medical Assistance Eligibility ($25,881 7/1/13) and  Capable of meeting own remaining health needs and  Capable of meeting a monthly fee requirement  Spousal Impoverishment rules apply

24. AC Financial Eligibility  Monthly income is >$1149 (7/1/13) or  Assets are >$3000 (MA Asset limit) and  Total combined adjusted monthly income and assets are less than the projected nursing facility care cost for 135 days (+MA asset limit of $3000)  7/1/13 this is $25,881

25. AC Financial Eligibility  Income is ≤$1149 and assets are ≤$3000 applicant is ineligible for AC  Can be temporary served under AC up to 60 days during their application to Medical Assistance/Elderly Waiver  If income and assets available are greater than the projected nursing facility care cost for 135 days(+MA asset limit of 3000) client is ineligible for AC and cannot be temporarily served

26. AC Financial Worksheets Alternative Care Program Eligibility Worksheets: DHS 2630A Married person with a community spouse DHS 2630 Unmarried individuals, or Married couples when both may choose AC or a married person whose spouse is an EW recipient or is living in a nursing facility Case Manager determines financial eligibility

27. Estate Claim Recovery  Effective 7/1/2003, DHS and the county pursue estate claims for people that use the AC program  An estate claim is a method of recovering AC payments from the estate of a deceased person  It is only payable from the assets in the estate of the recipient of AC services.  The estate will pay a portion of the claim before it will give heirs any inheritance  The estate may include a life estate or any joint tenancy interests in real estate that is owned at the time of death.  Lead agency role to inform clients concerning estate recovery - Use form 5186

28. Estate Claims  Estate claims are imposed for recipients over the age of 55 who receive Medical Assistance. The law has changed recently concerning QMB, SLMB, QI1.  Dates of service before 1/1/2010 » subject to recovery  Dates of service after 1/1/2010 » Exempt from recovery  Liens are only imposed if stay in a nursing facility or hospital is greater than 30 days (paid for by MA)

29. AC Monthly Fees – Cost Sharing Fees are used to help fund the program Fees are based on income and assets; sliding fee scale-0%, 5%,15% or 30% of the cost of AC services Dollar amounts and effective date of fees are entered into the service agreement MMIS screen when a client enters the AC Program, even if the amount due is $0; All Alternative Care services shall be included in the estimated costs for the purpose of determining the fee. See Bulletin 12-25-05 for detailed information on AC Fees

30. Payment Options Include  DHS Form 4639 describes payment options  Personal checks, money orders, or cashiers checks made out to DHS-AC Fees and mailed to:  DHS-AC Premiums  PO Box 64835  St. Paul, MN 55164-0835  Credit card payments and bank withdrawals (including recurring payments) made at:  http://payments.dhs.state.mn.us http://payments.dhs.state.mn.us  Payment plan (including partial payments)  Representative Payee or greater family involvement  Automatic withdrawal of AC fees from a checking or savings account is no longer a payment option  Do not send cash

31. AC Monthly Fees - Contacts MAXIS email at DHS.MADE@state.mn.us –For current or past month fee changes –Refunds Special Recovery Unit at (651-431-3205) or 1-800-657-3762 –For client billing questions

32. AC Monthly Fees – Cost Sharing Case Managers can change fees on the service agreement for the following month: If there is a change in condition which results in a change in the cost of services; If there is a change in the adjusted income or assets; A client enters a nursing facility as an admission for more than 30 days

33. AC Monthly Fees *Income minus recurring and predictable medical expenses Client Income*Gross Assets Monthly Fee Income<100% FPG ($958) and <$10,000$0 Income>=100% ($958) and <150% FPG ($1437) and <$10,0005% cost of AC Services Income>=150%($1437) and <200% FPG ($1915) and <$10,00015% cost of AC Services Income >=200% FPG ($1915) OR >=$10,00030% cost of AC Services 20

34. Over Due Fees Case managers are responsible for notifying AC clients if they are behind in paying their fees. This information can be found on Infopac report RN190. This report is organized by county of service. Clients are identified as open (O), closed (C) or deceased (D). Clients continue to receive overdue fee notices until they are current in payment of their fees, or for one year after they have been closed or deceased.

35. Over Due Fees Case managers need to work with clients and their families to make arrangements to pay overdue fees (including a partial payment plan); however clients be ineligible for the AC Program after 60 days of nonpayment of fees. Eligibility may be extended while making arrangements to pay outstanding fees 256B.0913 Subdivision 4

36. Overdue Fees  When clients move to a new county, the new lead agency is responsible for collecting the fees, including past due fees incurred prior to the move. The current county of service must update the county fields on the screening document before the client will show up on the RI90 report under the new county.  Clients who are dis-enrolled for non payment of fees are not eligible to re-open to AC for 30 days  The client must be mailed the Notice of Action Home and Community-Based Waiver Programs and AC (DHS-2828) form and be closed to the AC Program with 10 day notice per instructions in bulletin #12- 25-05

37. AC Infopac Reports RN-190 and RN-193 are available AC RN-190 is a bi-monthly report that provides information on AC clients with over due fees by county of service and case manager. It provides the clients name, due date, balance due by due date, PMI and Swift ID and status (O-open, C- closed or D-Deceased). RN-193 provides client name, address, pmi, swift Id and case manager name by county of service.

38. Fees may be waived if: A person is residing in a NF and receiving case management only A married couple is requesting an asset assessment under the spousal impoverishment provision A person is eligible for AC but has not received any services A person has chosen CDCS for which the cost of services is not greater than the cost of services minus the monthly fee that would otherwise be assessed Income and assets determine that the fee can be waived The client is on temporary AC The AC waiver reason is identified on the screening document

39. EW/AC Benefit Set  AC services are generally the same as those offered under the EW program  AC is a state funded program so it has some unique differences from EW which is a federally funded program  AC does not have residential services such as: Foster Care or Customized Living  Both programs are payers of last resort

41. EW/AC Benefit Set  Services on both programs: Adult Day Service/ADS bath Caregiver Training/Education Case Management Chore Services Companion Services Home Delivered Meals Home Health Aide

42. EW/AC Benefit Set  Homemaker services  Environmental Accessibility Adaptations  Personal Care Assistant  Respite Care  Nursing  Specialized Supplies and Equipment  Transportation  Consumer Directed Community Supports

43. EW Only Services Foster Care Residential Care Customized Living/24 hour Customized Living Transitional Supports

44. AC Only Services  Conversion Case management  Nutritional Service  Discretionary Services

45. Specialized Supplies and Equipment  Includes durable and non durable medical supplies and equipment which are provided as necessary to the direct treatment of the recipients condition and which medical assistance does not fund.  Medical Assistance equipment and supplies are defined in Minnesota Rules, parts 9505.0310. Also a section of the MHCP Provider Manual

46. Specialized Supplies and Equipment Devices, controls or medical appliances or supplies specified in the community support plan that enable a person to increase their ability to:  Perform activities of daily living  Perceive, control or interact with their environment or communicate with others  The most cost effective way

47. Specialized Supplies and Equipment  Items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items  Once an item is purchased it becomes the property of the person it was purchased for

48. Specialized Supplies and Equipment  Items, equipment and supplies that exceed the scope or limits in the state plan may be covered.  May cover evaluation of the need for equipment and/or device and, if appropriate, subsequent selection and acquisition.  The service includes equipment rental during a trial period, customization, training and technical assistance to enrollees  Maintenance and repair of devices  EW/AC Section of MHCP EW/AC Section of MHCP

49. Oral and Enteral Nutritional Products  MA may pay for nutritional products whether or not they are oral or tube fed  EW/AC may pay for nutritional products with the following requirements: - There is a physicians orders, medical documentation and a physical reason why the person cannot obtain their caloric intake without the supplements - The Doctor has established that the person needs the product to maintain body weight and strength in the community

50. Personal Emergency Response Services (PERS)  Includes more traditional systems which require the individual to press an alert or panic button worn on a pendant or bracelet in the event of a fall or an emergency.  Payment can include installation and testing, the monthly service fee and the system/equipment purchase.

51. Environmental Accessibility Adaptations  Minor physical adaptations to the home, required by the individuals care plan that are : - Necessary to ensure the health, welfare and safety of the individual with mobility problems, sensory deficits or behavior problems. - Enabling the individual to function with greater independence in the home, and without which, the individual would require institutionalization. - The annual limit is $10,000 – per waiver year - May be funded in any setting which can be defined as the person’s primary place of residence and the modification is of direct and specific benefit to the recipient. EW should be the payer of last resort

52. Environmental Accessibility Adaptations  Can include: installation of grab bars and ramps, widening of bathroom facilities, widening of doorways, installation of specialized electrical or plumbing systems which are necessary to the medical equipment and supplies which are necessary for the welfare of the individual.  Environmental modifications also include modifications to vehicles  Environmental modifications also include modifications to adaptive equipment –such as furniture or utensils required by an individual.  Excluded Modifications: general utility and that do not have a direct medical or remedial benefit to the individual such as carpeting, roof repair, central AC or adaptations that add to the square footage of the home

53. Tribal EW and AC  Legislation allows tribes to behave as a county and administers EW and AC – perform screenings, approve payment for services including PCA  White Earth and Leech Lake tribes currently participating  Expansion to other tribes

54. Service Delivery Systems for EW Recipients  Fee for Service: The provider bills MN Dept of Human Services for each service  Minnesota Senior Care Plus (MSC+): 2003 State Legislation adds LTC to basic Medicaid Managed Care package. Includes basic services plus LTC services (EW and 180 days NF) It is now being implemented in 87 counties.  This is mandatory for all clients 65+ Who are not excluded from Managed care.

55. Service Delivery Systems for EW Recipients

56. EW/Managed Care All MSHO/MSC+ seniors get initial risk assessment and follow up regardless of setting of care or eligibility for waiver services. 98% of enrolled seniors get primary and preventive physician visits All seniors are reviewed for need for PCA and LTC services Coordinates with Medicare Adds a focus on improvement of management for chronic conditions

57.  The project creates and implements a single comprehensive, and integrated assessment and support planning application for long term care services and supports in Minnesota.  Person centered approach to ensure services are tailored to the individual’s strengths, goals, preferences, and assessed needs.

58. HCBS Waiver Provider Standards  Uniform, statewide standards for HCBS providers and - Statewide mechanisms for enrolling and licensing HCBS providers and - enhanced provider enrollment standards with an emphasis on services that will remain unlicensed - define Lead Agency quality assurance functions for waiver services.

59. HCBS Waiver Provider Standards  All currently enrolled waiver service providers have begun a provider record review with DHS  Minnesota Statute Chapter 245D establishes foundation licensing standards to be effective 1/1/2014. These standards apply regardless of the funding source for the service.  DHS will provide training to lead agencies and providers

60. NF Level Of Care Changes  In 2009, the MN Legislature passed legislation that changes nursing facility level of care (NF LOC) criteria for public payment of long term care.  The change was important to:  - Provide more consistent access to services  - Address MN aging demographics and manage growth in public spending for long term care  - Support service sustainability  - Improve the ability of lead agencies to assess individuals, monitor programs, evaluate outcomes and assess the impact of public spending  Will be implemented 1/1/14

61. Resources Libby Rossett-Brown Elderly Waiver/Alternative Care Program Administrator 651-431-2569 Libby.Rossett-Brown@state.mn.us County’s Social Service Department County’s Income Maintenance Department AC Operations Questions: Gail Carlson 651-431-2586 Gail.V.Carlson@state.mn.us