1. September 5, 2012 For the 4 th Annual Long Term Care Policy Summit

2. 2 David Ivers Mitchell Blackstock Ivers & Sneddon 1010 W. Third St. Little Rock, AR 72201 501 519-2072 divers@mitchellblackstock.com These materials are for instructional purposes only, and are not to be relied on for legal advice. Legal counsel should always be consulted for specific problems or questions.

3.  Offers states additional flexibility to finance home and community-based services (HCBS) attendant services and supports.  Provides 6% enhanced federal match (permanent).  State plan, not waiver, so services must be provided statewide, to all who qualify (entitlement).  Services must be provided without discrimination based on age, type or severity of disability, or form of services required.  State must spend as much or more on HCBS as in prior year.  Requires Development and Implementation Council with majority elderly and people with disabilities and representatives. 3

4.  Culture of protection has grown up around “waiver” services.  No state plan equivalent (before CFC) and waiting lists are often long.  States can use Development & Implementation Council to help with transition. 4

5.  Providers still trying to understand CFC.  Providers not used to this much change.  Providers feel there must be a “catch.”  States need to share data with providers and encourage realistic proposals.  Providers must work together -- CFC does not work unless providers cross traditional silos. 5

6. CFC most affordable for those states that offer fairly extensive personal assistance through state plan personal care or 1915(c) waivers Offers potential for state and providers to gain efficiencies through standardization, reduced administrative hassles Promotes greater integration of programs, funding, and state administration 6

7.  In Arkansas, preliminary figures show the state could serve existing beneficiaries and those on developmental disabilities waiver wait list with enhanced match.  DD typically has greater per person ave costs and wait list, so may have most to gain.  Other groups want greater variety of services, increased flexibility, and simply better reimbursement. 7

8.  CFC likely to bring about ◦ increased flexibility (rules have to accommodate all populations), ◦ fewer admin hassles (if state integrates admin functions), ◦ perhaps greater variety of services but with caps, ◦ better integration of services across populations (esp. helpful for elderly DD or MI; DD with MI; and so on). 8

9.  Published May 7, 2012 at 77 Federal Register 26828, effective July 6, 2012.  Considerable flexibility for states  All individuals must meet inst. LOC – reversed position in proposed rule – more complex analysis now 9

10.  For those who do not meet inst. LOC, state must decide-- ◦ Do not provide them services ◦ Offer same services without 6% ◦ Offer more limited package 10

11.  (1) Assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks through hands-on assistance, supervision, and/or cueing.  (2) Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks.  (3) Backup systems or mechanisms (electronic devices) to ensure continuity of services and  supports.  (4) Voluntary training on how to select, manage and dismiss attendants.  11

12.  (1) Expenditures for transition costs from institutions to HCBS settings.  (2) Expenditures relating to a need identified in an individual’s person-centered service plan that increases an individual’s independence or substitutes for human assistance, to the extent that expenditures would otherwise be made for the human assistance. 12

13.  Universal assessments, depending on how state assigns payments to each tier  State can limit amount, duration, and scope if non-discriminatory  Such limits may be key to containing costs if universal assessment does not 13

14.  Agency-provider model  Self-directed model  Other, if approved by CMS 14

15.  If income greater than 150% FPL, must be in eligibility category that includes nursing facility services  Catch-22: How to maintain eligibility for individuals with income above 150% FPL if state eliminates waiver?  Maintain waivers with one service (Maryland example) 15

16.  Basic Medicaid income limit is very low in Ark (about 75% FPL): $8,376/yr or $698/mo  Medicaid expansion 133% of FPL would be $14,856/yr or $1,238/mo  150% FPL for analysis under CFCO would be $16,755/yr or $1396/mo (not signif. factor in Ark)  Waiver levels are 3 x SSI: $25,128/yr or $2,094/mo 16

17.  “States may not differentiate the benefit package; however, services must be provided to individuals based on their needs.” (Final Rule) 17

18.  CFC services must be provided in a HCBS setting.  CMS plans to issue new proposed rule on “setting.”  A particular point of disagreement is likely to be CMS’ indication that it believes that there should be a “rebuttable presumption” that a “disability-specific housing complex” is not a home and community-based setting. 18

19.  Licensure/Competition  Desire to maintain specialized services  Giving up segregated funding across populations  Limits on amount, duration, and scope 19

20. Create flowchart: – Does service qualify as CFC? Yes – continue No -- exclude – Is the service currently offered to all populations? If no, could it be? Yes – continue No -- exclude – Do additional populations have to be added? If yes – cost. – Is it a State Plan or waiver service now? – If State Plan, what % of beneficiaries meet ILOC? (6% FMAP gain or “savings” for those) – If waiver, everyone currently served means 6% savings – If waiver, anyone on waiting list means additional cost. – “Woodwork” due to entitlement, enhanced services? If yes – cost. 20

21.  Must crosswalk old state plan and waiver programs into CFC  Requires comparing each state plan and waiver program with services that could qualify as CFC and then regrouping chosen ones under CFC  Must identify “gaps” – populations/ages not served currently 21

22.  Many if not most in MI population unlikely to meet ILOC  1915(i) offers more promise 22

23.  States permitted to stack CFC + BIP  CFC can be used to build BIP work plan  Universal assessment a key feature of both CFC and BIP 23