1. The Impact of Health Care Reform: Indiana Medicaid Initiatives Indiana Continuity of Care Annual Conference September 26, 2012 Presented by: Kristen Gentry Krieg DeVault LLP kgentry@kdlegal.com

2. Health Care Reform: Statistics 2010 US Census Bureau Statistics 49.9 Million uninsured individuals in the United States in 2010 Medicaid provided coverage for 15.9% of Americans Medicare provided coverage for 14.5% of Americans Employment-based coverage provided 55.3% (down from 56.1% in 2009; ) Largest growth in uninsured:  Families  Incomes less than $50K  “Early retirees” ages 45 to 64

3. Health Care Reform: Goals The Patient Protection and Affordable Care Act (“ACA”) was passed on March 23, 2010. The ACA has 3 goals: Reforming health insurance, Ensuring a minimum levels of health benefits (essential health benefits), and Increasing access to health coverage.

4. Health Care Reform: Goals To increase access to health coverage, the ACA takes a four-prong approach: Expanded coverage through the federal-state Medicaid and CHIP programs; Establishment of health insurance exchanges; Creation of premium tax credits; and Simplified and Streamlined enrollment and renewal processes across Insurance Affordability Programs (“IAP”). This presentation concerns the first prong—expanded coverage through the federal-state Medicaid and CHIP programs.

5. Health Care Reform: Eligibility Mandates  Beginning January 1, 2014, the ACA: Allows states participating in the Medicaid program to expand coverage to individuals with annual family incomes to 133% of the federal poverty level (“FPL”). National Federation of Independent Business v. Sebelius, 132 S.Ct. 2566 (2012). (Indiana looking to implement Hybrid with partial expansion to 100% FPL and utilizing Exchange and Premium Tax Credits for 100%-133%)  In the meantime, requires maintenance of effort (MOE) Prohibits states from cutting Medicaid eligibility for women (until January 1, 2014) and children (until September 30, 2019).  However, allows States to: Cut eligibility for adults with incomes over 133% of FPL if the state is facing a budget deficit. Cut provider reimbursement, optional Medicaid services. Scale back HCBS waivers to the slots actually being used or the number available on the date of the passage of the ACA.

6. Health Care Reform: Access Expansion Population coverage must include: Essential Health Benefits/ 10 Statutory Benefit categories Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

7. Health Care Reform: Implementation Implementation through:  Increased reliance on managed care for aged/ blind and disabled/ dual population: Indiana initiative to put dual population into managed care has seemingly died and has moved to Health Homes program for the Aged Blind and Disabled population  Health Homes Health Homes allows the State to get 90% FFP for a new service category that allows providers to perform care coordination and case management for certain individuals with chronic conditions (See below)  More HCBS waivers and new “super-waiver” programs to serve more people in the community  Bundled payments for a full continuum of care to providers  Other “Demonstration” programs through the CMI: Oregon Continuing Care Program  Program Integrity: I.E. increased scrutiny, self-reporting, audits, overpayments

8. Health Care Reform: Health Homes Health Homes:  The Affordable Care Act added §1945 of the Social Security Act (“the Act”) to provide a State Plan option to provide Health Homes for enrollees with chronic conditions.  States electing the Health Home option through a State Plan Amendment (“SPA”) shall provide for: medical assistance to eligible individuals with chronic conditions who select a designated provider, team of health care professionals operating with such provider, or a health team as the individual’s health home.  Intended to facilitate access to an inter-disciplinary array of medical care, behavioral health care, and community-based social services and supports for both children and adults with chronic conditions.

9. Health Care Reform: Health Homes  Chronic conditions include: a mental health condition, a substance use disorder, asthma, diabetes, heart disease, being overweight, as evidenced by a body mass index over 25, as well as other chronic conditions added by the Secretary, as authorized by the Act.  For the first 8 fiscal quarters, the FMAP for health home services is 90%, for the following specific health home services: comprehensive care management, care coordination, health promotion, comprehensive transitional care, patient and family support and referral to community and social support services.

10. Health Care Reform: Health Homes  Appeal to States because: Can target the population served by health homes No comparability requirement, Flexibility allowed States to develop health homes.  Indiana Currently looking at Health Home programs for: Developmentally Disabled Serious Mental Illness Aged, Blind and Disabled (based on Oregon Continuing Care Organization Program)  See FSSA Presentation on Health Homes from the July 13, 2012 Dual Eligible Stakeholder Meeting.  See DDRS Presentation on Health Homes from the July 13, 2012 Dual Eligible Stakeholder Meeting

11. Health Care Reform: Health Homes Health Home Services:  Comprehensive care management  Care coordination  Health promotion  Comprehensive transitional care from inpatient to other settings  Individual and family support  Referral to community and social support services  Use of HIT as feasible and appropriate

12. Health Care Reform: Indiana’s HCBS Waiver Programs Indiana is currently administering five HCBS Waivers and two Demonstrations: Two waivers are administered by the Division of Aging (“DA”):  Aged and Disabled (“A&D”) waiver and Traumatic Brain Injury (“TBI”) waiver. Three waivers are administered by the Division of Disability and Rehabilitative Services (“DDRS”):  Autism (“AU”) waiver;  Developmental Disabilities (“DD”) waiver; and  Support Services (“SS”) waiver. Two Demonstrations administered by DA/DMHA:  Money Follows the Person (“MFP”) demonstration grant and  Community Alternative to Psychiatric Residential Treatment Facility (“CA-PRTF”) demonstration grant.

13. Health Care Reform: Home and Community Based Services  Indiana’s A&D Waiver:  Alternative to nursing facility admission for adults and persons of all ages with a disability.  Waiver services to help individuals remain in their own home, or to assist individuals living in nursing homes to return to community settings.  Effective March 1, 2012, the A&D waiver was amended to: add Medicaid aid categories, align with approved eligibility criteria in other Indiana HCBS waivers; remove the service limit on Attendant Care Service; remove the service limit on Respite Services; change the name of Adult Foster Care to Adult Family Care; etc. http://www.in.gov/fssa/da/3476.htmhttp://www.in.gov/fssa/da/3476.htm (last visited Sept. 20, 2012). http://www.in.gov/fssa/files/Aged_and_Disabled_Waiver_Amendment_2012-03-01.PDFhttp://www.in.gov/fssa/files/Aged_and_Disabled_Waiver_Amendment_2012-03-01.PDF (last visited Sept. 20, 2012).

14. Health Care Reform: Home and Community Based Services TBI Waiver:  Provides HCBS to individuals who, but for the provision of such services, would require institutional care.  Services are available to individuals who have suffered a traumatic brain injury, which is defined as a trauma that has occurred as a closed or open head injury by an external event that results in damage to brain tissue, with or without injury to other body organs.  The original TBI waiver was effective January 1, 2008, and is to expire on December 31, 2012.  Renewal application for the TBI Waiver submitted in May 2012. The requested approval period is for 5 years, effective January 1, 2013.  Medicaid looking to bring TBI patients back to Indiana for care http://www.in.gov/fssa/da/3476.htm (last visited Sept. 20, 2012).http://www.in.gov/fssa/da/3476.htm https://www.cms.gov/MedicaidStWaivProgDemoPGI/downloads/IN40197R0200.zip http://www.in.gov/fssa/files/TBI_Renewal_DRAFT-_05.16.12.pdf

15. Health Care Reform: Home and Community Based Services  Money Follows the Person (“MFP”) Demonstration Grant:  Funded through a grant from CMS  Helps States move individuals from institutional settings to HCBS  Participation in the MFP program lasts for 365 days, and after the 365 days, funding for the supports received by the participant changes from the MFP program to a partnering funding source  During the 365 days in the MFP program, the participant’s case manager monitors their safety and well-being and assists in ensuring their community-based needs are being met http://www.in.gov/fssa/da/3475.htm (last visited Sept. 20, 2012).http://www.in.gov/fssa/da/3475.htm https://myshare.in.gov/FSSA/dmha/caprtf/Lists/Announcements/Attachments/90/MFP- PRTF%20Bulletin%20082212.pdf (Sept. 1, 2012).https://myshare.in.gov/FSSA/dmha/caprtf/Lists/Announcements/Attachments/90/MFP- PRTF%20Bulletin%20082212.pdf

16. Health Care Reform: Home and Community Based Services MFP-PRTF program for youth, effective October 1, 2012. Provides youth who are transitioning out of a PRTF or state-owned facility (“SOF”), assistance in receiving intensive, community-based services. Amendment to the operational protocol for Indiana’s MFP Program to allow for youth transitioning out of a PRTF/SOF to receive Money Follows the Person Psychiatric Rehabilitation Treatment Facility (MFP- PRTF) services. Eligible to receive up to 365 days of MFP-PRTF services, after which time, the youth will be transitioned to traditional outpatient and/or community-based services that may be covered by Medicaid Clinic Option or Medicaid Rehabilitation Option

17. Health Care Reform: Home and Community Based Services CA-PRTF Demonstration Grant:  Intensive community-based services for youth ages 6 through 20, who are residing in a PRTF or who may be eligible for admission to a PRTF because of their high level need for mental health services.  Sustainability plan for CA-PRTF Grant includes submitting an application for a 1915(i) State Plan Amendment to service disabled children who have been assessed to need an institutional level of care.  DMHA intends to partner with OMPP to sustain access of CA-PRTF demonstration participations through the MFP program and a §1915(i).  DMHA is continuing to respond to questions from CMS on the 1915(i) application, but anticipated approval of the application is on or about July 1, 2013.  Until then, DMHA plans to provide for the transfer of services previously covered by the CA-PRTF grant to the MFP grant, and kids receiving services by September 30, 2012 will continue receiving services.  Indiana requested a 1915(c) HCBS PRTF Transition Waiver, effective October 1, 2012 to continue intensive, community-based wraparound services for kids/youth enrolled in and receiving CA-PRTF Demonstration Grants services as of Sept 30, 2012. http://www.in.gov/fssa/dmha/files/2012_-_2013_Indiana_State_Plan_for_Mental_Health_and_Addiction.pdf (Aug 31, 2011).http://www.in.gov/fssa/dmha/files/2012_-_2013_Indiana_State_Plan_for_Mental_Health_and_Addiction.pdf http://www.in.gov/fssa/files/DMHA_June_QFR_Presentation_FINAL_-_8-10-12.pdf (Aug. 10, 2012).http://www.in.gov/fssa/files/DMHA_June_QFR_Presentation_FINAL_-_8-10-12.pdf https://myshare.in.gov/FSSA/dmha/caprtf/PoliciesProcedures/PRTF%20Transition%20Waiver/PRTF%20Waiver%20Bulletin%200712.pdf (July 17, 2012).https://myshare.in.gov/FSSA/dmha/caprtf/PoliciesProcedures/PRTF%20Transition%20Waiver/PRTF%20Waiver%20Bulletin%200712.pdf

18. Health Care Reform: Indiana Medicaid and Rulemaking Authority 2012 Legislative Session: Emergency Rulemaking Authority Pre-2011 Rulemaking Authority required the State to be facing a budgetary shortfall in order for FSSA to make an emergency rule Under this authority, the State cut Medicaid hospital and other provider rates by 5% beginning in January 2010-set to expire June 30, 2013 2011 HB 1001 (“Budget Bill”)—broadened FSSA’s authority to make an emergency rule to include rules for any federal Medicaid waiver programs and Federal programs administered by FSSA, without a sunset; and removed emergency rule 90-day effective period so that FSSA was not required to promulgate a rule though the normal rulemaking process regardless of budget shortfall 2012 HB 1376---Adds a sunset date of 12-31-12 to FSSA’s authority to adopt rules for Federal Medicaid waiver program and Federal programs administered by FSSA; and requires emergency rules adopted by FSSA for Federal Medicaid Waiver programs and Federal programs it administers to expire no later than June 30, 2013.

19. Questions? Kristen Gentry, Esq. Krieg DeVault LLP kgentry@kdlegal.com (317)238-6288