1. Understanding Medicaid Options for Accessing Services NCSHA 2014 Conference Boston MA Martha Knisley Technical Assistance Collaborative www.tacinc.org

2. NCSHA Medicaid Session Objectives Discuss Medicaid’s role in funding community- based services and how it relates to supportive housing. Learn about Medicaid’s Home and Community- Based Services final rule and Medicaid waiver options. 2

3. Medicaid Facts and Trends Medicaid is the country’s main public health insurance program; Over 66 million, nearly one out of every five Americans gets their health care through Medicaid; 32 million children, 18 million adults and 16 million elderly/disabled; 9 million are dual-eligibles (Medicare-Medicaid); Medicaid accounts for 23.7% of total state spending; 28 states (incl. DC) implementing expansion already. 3

4. Medicaid Facts and Trends 17 million poor non elderly single adults are now eligible for Medicaid in expansion states; Compared to approximately 4.8 million who fall into coverage gap because they live in non expansion states The federal government covers the cost of Medicaid expenditures (FMAP) between 50% and 73.6% based on a formula set in the Social Security Act which is based on a state’s average personal income relative to the national average. Poorer states have higher FMAP percentages. 4

5. Medicaid Facts and Trends Program growth factors: the economy and policy decisions (state and federal) determining who is covered, for what services and payment methods; Medicaid is an insurance program utilizing many of the same tools private insurers use to control costs, promote health and meet health care funder requirements; Medicaid covers a diverse array of services, some mandatory, some optional (state determines type and extent of coverage). 5

6. Medicaid Facts and Trends Medicaid is insurance for “persons”—in most situations not program funding, not specific to a project; States choose eligibility groups, services, payment levels and providers; Categorical rules apply (statewideness, any willing and qualified provider, freedom of choice), some may be waived; Covers “medically necessary” services. 6

7. Medicaid Facts and Trends ACA Implementation: –Enrollment increased (12.2% in FY 14, expecting 18% in FY 15); –20 states exceeded 20% enrollment growth; –Most adults in the new Medicaid expansion group will be getting services through “Alternative Benefit Plans” (ABPs); –Primary care physician rates increased; –Increase in community health centers (FQHCs) and workforce funding; 7

8. Factors Shaping Medicaid Programs 8 Medicaid Delivery System Reform Ongoing Program Implementation Economic Conditions ACA Implementation Kaiser Family Foundation

9. Mandatory Services Inpatient and outpatient hospital services; Physician, midwife and nurse practitioner services; EPSDT (early and periodic screening, diagnosis and tx.); Lab and x-ray; Family planning; Freestanding birth centers; Nursing facility services Home health (for persons who qualify for NF); Tobacco cessation Pharmacotherapy for pregnant women; Non-emergency transportation to medical care. 9

10. Optional Services Dental services; Therapies: OT/PT, speech, etc.; Prosthetic devices; Case management; Personal care; Hospice; Rehabilitative services; IMDs (Institutions for Mental Disease) excluded. 10

11. Long Term Services and Supports Medicaid is the primary source of health insurance for seniors and persons with disabilities (LTSS), nursing facility care and home and community based services (HCBS); Historically a greater proportion of long term care services had a structural bias toward institutional care; Medicaid must cover nursing facility care but HCBS are covered at the state’s option. 11

12. Long Term Supports and Services LTSS spending estimated at $357 billion in 2011; Medicaid accounted for 40% of total LTSS spending ($142 billion) with HCBS accounting for $52.7 billion of that total; Medicare accounted for 21% of total LTSS; States/CMS have increased attention to “rebalancing” nursing care with HCBS services; In 2012 almost 524,000 persons were on 1915 (c) waiver [HCBS] waiting lists that exceeded two years; 12

13. 13 Medicaid Institutional and HCBS Expenditures as a Percentage of Total Medicaid LTSS Expenditures, FFY 2000 - 2012 CMS, 2014 73%

14. Cost Comparisons—Annual Cost 14 Nursing home care$90,000 Assisted living $42,000 Home health aide In-home PSH support $ 21,000 $5,000 KF Foundation 2014

15. HCBS HCBS determined based on “needs based criteria” HCBS provides assistance with daily living for persons with physical or cognitive functional limitations that result from age or disability; HCBS includes a range of benefits, such as residential services, adult day care programs, home health aide, personal care and case management. 15

16. HCBS Beneficiary self-direction is used as an alternative service delivery model for HCBS; Requires person-centered service plan; The newer 1915(i) authority provides more eligibility criteria flexibility--but requires statewideness and independent evaluation of need. 16

17. Medicaid Managed Care Section 1915(a), (b), (k), (J) and 1115 are primary managed care authorities; 1115 is a 5 year demonstration, 1915(a) is voluntary and 1915(b) is more restrictive and typically uses a centralized broker and can use savings for additional services; HCBS can be provided as part of a managed care system. 17

18. Factors That Shape How Medicaid Relates to SH 18 Medicaid Delivery System Reform SH policy/ provisions Type and availability services and supports P.I.: Access Req./ Policies

19. How Medicaid Relates to SH Provides access to health care—essential for persons enrolled in Medicaid to maintain stable lives; Medicaid can be a valuable fund source for services for persons enabling persons to get and keep housing; State plans and Waiver design, policies, services and practice must be aligned with housing policy and vice versa A small but predictable % of SH costs can’t be covered by Medicaid. 19

20. Key Issues--Opportunities Finding ways to fill the rental subsidy gap; Transactional costs and steps: –Timeliness of referral; –Reducing redundancies; –Managing change (eligibility, provider, moving); –Matching referrals to unit availability; –Recognizing key location issues as part of housing policy; Taking advantage of changes in Medicaid, Supportive Housing and disability policy (ADA Title II-Olmstead). 20

21. Key Issues---Opportunities Aligning policy/practice to match persons with high needs (Medicaid costs) to SH; Establishing goals and requirements for care coordinators, care managers, high risk care managers; Being responsive when service/housing needs change. 21

22. HCBS Settings Rule Intent: Ensure individuals receiving long-term care services and supports through home and community based services (HCBS) programs under 1915(c), 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate; Rule published in January 2014; first proposed in 2011 and CMS received over 2,000 comments before issuing. 22

23. HCBS Settings Rule Defines, describes and aligns home and community- based setting requirements across three Medicaid authorities; Defines person-centered planning requirements for persons in HCBS settings under 1915(c) HCBS and 1915(i) HCBS State Plan Authorities; Implements regulations for 1915(i) HCBS State Plan. 23

24. HCBS Settings Rule Establishes requirements for the qualities of home and community based settings, defines settings that are not home and community-based, establishes compliance and transition requirements; It’s a tool to assist states with a adhering to the Olmstead mandate and requirements of the ADA; Focus is people’s experience rather than naming and type of setting/service. 24

25. HCBS Settings Rule Facilitates individual choice regarding services and supports and who provides them; Is selected by the individual from among setting options including non-disability specific settings; Establishes requirements for provider-owned or controlled residential settings; Person has choices: articulated in person-centered plan. 25

26. HCBS Settings Rule Settings that are presumed to be unallowable are facilities providing inpatient institutional services on the grounds or adjacent to a public institution; or settings that have effect of isolating HCBS recipients from the broader community; These could be settings: –designed specifically for persons with disabilities/with specific disabilities; –comprised of persons primarily with persons with disabilities and staff providing services; –use restrictive interventions; –that have effect of isolating recipients from the broader community; –where persons with disabilities are provided multiple services onsite. 26

27. HCBS Implementation Requirements States must submit transition plans to CMS that outline changes to the HCBS program to come into compliance with new regulations; For existing programs, due date for plans is 3-17-15; For renewals, plans must be submitted with the renewal application; 1915(c) Plan (transition) can take as long as five years; State required to make plan available to public for comment; CMS will issue further guidance. 27

28. Take Aways Medicaid is the primary health care fund source for persons with low incomes and extremely low incomes in the US; Medicaid is complex---but it’s the complexities that offer opportunities for increasing community services and support; The settings rule is yet another challenge and opportunity; HFAs and state human services have desired outcomes in common but relationship to achieve outcomes takes work and time; 28

29. Marti Knisley mknisley@tacinc.org www: tacinc.org mknisley@tacinc.org 29