1. Medi-Cal Community Based Options A Summary Discussion For Aging & Disability Resource Connections (ADRC) Professionals California Health and Human Services Agency October 2010

2. Why are ADRCs getting so much attention HEALTH CARE COMMUNITY SUPPORTS

3. Since 1999 (US Supreme Court Olmstead Decision) Federal Medicaid policy has shifted from limited service menus to self direction and improving consumer access to community living options Demographics, life span, and baby boom explosion, assistive technology, and other factors have caused general assumptions about long- term care to be obsolete People can and do live actively and successfully with chronic conditions and “disability” NOT One size (services & supports) does NOT fit all

4. From Single Service Silos To ADRC Connections

5. ADRCs have what today’s consumers need! LTC information & resources Mentorship and advocacy Broad knowledge of health care and social supports Trustworthy and no/low cost info & service Expertise with accessibility issues Experience with current trends and emerging populations in need – people with economic, family or health care hardships and

6. Today’s Discussion by Popular (?) Request…. A brief venture into the world of Medi-Cal… Don’t be afraid...

7. Medicaid & Long-Term Care Since the early 1900’s there have been long-term care institutions – public and privately funded July 30, 1965, Medicaid was established under Title XIX of the Social Security Act (SSA)Social Security Act Nursing facility services are among the mandatory state benefits (more on this later) Home and community-based services (HCBS) were few and limited to specific sub-groups of consumer population—developmentally disabled, etc.

8. Medicaid Since 1967 Service provider networks grew around specific sub-groups of consumers; e.g. developmentally disabled, mentally ill, and others Medicaid waivers were developed with fixed menus of services intended to be available to a limited number of consumers State and federal policy, funding and reporting requirements formed service delivery silos that were not linked Improvements and growth were also in silos and depended on consumer advocacy

9. Olmstead & the Medicaid Bias 1999 Mandatory Medicaid coverage for inpatient nursing facility services means all who are eligible can get inpatient nursing facility care (assuming availability). AS COMPARED TO Optional Medicaid benefits (like personal care) and limited HCBS waivers with specified services menus and capped for the numbers of people to be served

10. Olmstead Planning 2000 to Present CA began convening department directors Identify CA service networks and gaps Policy in place and policy needed What changes require legislation and/or funding Public forums to gather consumer inputs Study of financing options Grant initiatives and demonstrations

11. Time out…..It’s confusing! Medicaid Called Medi-Cal in CA Health care coverage for those with low income and few assets Automatic Medi-Cal with SSI/SSP eligibility Those who are eligible are entitled to a scope of benefits determined by states Covers LTC Administered by States Medicare Health care coverage for those over 65 years old, those under age 65 with certain disabilities, and people of all ages with end stage renal disease (ESRD) Part A -- hospital care Part B -- primary medical care Part D -- prescription drugs Does NOT cover LTC (beyond about 90 days rehab) Administered by federal CMS

12. Medicaid/Medi-Cal Authority Federal HHS Federal Law - Title XIX of the Social Security Act (SSA) Mandatory Benefits Optional Benefits HCBS waivers Demonstrations Grants & Other initiatives State Single Medicaid Agency (DHCS in CA) (w/CMS approval) State Law - W&I Code Medi-Cal State Plan State Plan Amendments (SPA) Regulations CCR Title 22: Service approval criteria for medical necessity Demonstrations Waivers

13. Medicaid Roles and Responsibilities Federal CMS Medicare & Medicaid CMS part of federal HHS Oversight of State Single State Agencies Central & Regional Offices Approves/monitors/audits state policy, benefits, expenditures and operations State DHCS Medicaid is called Medi-Cal DHCS is Single State Agency Medi-Cal State Plan – Benefits modified by State Plan Amendments (SPA) Develops demonstrations and waivers subject to CMS approval Policy & Payment Accountability Quality & Audits

14. Some Basic Medicaid Requirements Privacy: States and providers may not reveal (without their permission) that any individual is eligible for Medicaid and must implement HIPAA requirements for protection of Personal Health Information(PHI) Informed Choice: Individuals must have information in order to have choice among qualified providers (unless choice is waived with approval from CMS); e.g. mandatory enrollment into a managed care plan Quality: States must have protocols to monitor quality of service Utilization Review: State accountability for medical necessity (utilization review) and fiscal responsibility Consumer Due Process: Consumers must be informed of due process (Fair Hearing) if there is denial or reduction of benefits Provider Appeals: Providers may appeal the state’s denial or reduction of services requested via the TAR process

15. Medicaid Benefits (Federal Law) Mandatory Benefits Doctor Visits Hospitalization Lab & X-Ray Inpatient Hospital EPSDT Rural Health Clinics Family Planning And others Optional Benefits States Decide Personal Care Home & Community Based Services Prosthetics Clinics Dental IMD (Institution for mental disease) And Others Are we having fun yet?

16. Medi-Cal Benefits Described in the Medi-Cal State Plan All Mandatory benefits Optional benefits – for example, personal care services (aka IHSS), drugs, prosthetics, therapies (PT, OT), home health and others Several Waivers Several Demonstrations

17. Medi-Cal Service Delivery & Financing  Fee For Service -- each authorized service provider is reimbursed per Medi-Cal rates set by DHCS  Medi-Cal Managed Care (MCMC)  County Operated Health System (COHS) – one plan  2 Plan Model (in a county, 1 non-profit and 1 commercial plan)  Geographic Managed Care (GMC) competitive procurement for many plans in a county

18. What is a TAR?  Treatment Authorization Request (TAR)  Medi-Cal system for obtaining “prior authorization”  Submitted by a provider on behalf of the person who needs service  Provider must be approved Medi-Cal provider of a specific type  Submitted to Medi-Cal Field Offices or to DHCS  Types of services requested  Quantity and frequency of services (for example, Home Health Agency services - One 2/hour visit each week)  Documentation of need  (conditions, diagnosis, labs, doctor orders (RX)  Treatment Plan in some situations  New providers can get training on Medi-Cal systems  New providers must sign agreement to Medi-Cal rules TAR FF

19. MEDI-CAL ALPHABET SOUP MEDI-CAL ALPHABET SOUP

20. What About Long-Term Care Under Medi-Cal? Nursing Facility State Plan Benefit DHCS sets rates for Fee For Service (FFS) NF services DPH/L&C Monitors State Licensure and Federal Certification Some Medi-Cal Managed Care Plans (MCMC) plans include inpatient NF care (COHSs for example) FFS NF TARs go to San Bern FO Typically, Medicare for short rehab, then Medi-Cal if eligible for long-term Home & Community Several HCBS Waivers, each for a consumer profile Personal Care Services/IHSS through County DSS Primary Care and Therapies that the person needs Mostly FFS TARs to office specified in waiver (more later) Demonstrations MFP – California Community Transitions TARs to DHCS in Sacramento

21. Medicaid Demonstrations Enables flexibility for states States apply to CMS to prove efficiency, quality or other benefit to consumers Allowed under SSA § 1115 Complex application describing benefits, quality monitoring and multi-year budget showing cost neutrality CA Example: Money Follows the Person Demonstration California Community Transitions

22. More about Medicaid Waivers Waives a specific federal Medicaid requirement in a sub-section ( § ) of SSA (CMS must approve) Waives choice, comparability, or statewideness For example, Sec 1915(b) waiver of choice enables states to have mandatory enrollment of members into managed care plans States must apply to CMS and describe what is being waived, how many people can be served, services are available, and among other things, how the state will ensure quality

23. Home & Community-Based Services (HCBS) Waivers Authorized under SSA § 1915© Specific population profile Specifies a menu of services HCBS services in lieu of inpatient nursing facility services Uses same T22 Level of Care (LOC) criteria as inpatient facility services to prove cost neutrality and “medical necessity” Services “prior authorized” by Medi-Cal employees (Field Offices or in Sacramento) via Treatment Authorization Requests (TAR)

24. Medi-Cal HCBS Waivers Medi-Cal HCBS Waivers Title Assisted Living AIDS Waiver Developmentally Disabled (DD) Multipurpose Senior Services Program (MSSP) Nursing Facility/Acute Hospital (NF/AH) Traumatic Brain Injury (TBI) (pending) Administered by DHCS and: DHCS (directly) DPH/Office on AIDS DDS CDA DHCS (directly) DOR ** DSS administers Personal Care Services -- IHSS is not a waiver) ** All Medi-Cal oversight is by DHCS

25. How Does a Person Apply for HCBS Waiver Services ? Currently HCBS entry points differ We’ll talk about this in a minute We’ll talk about this in a minute Application by TAR (prior authorization of services and documented need -- establishes need aka LOC) Major components of a home plan not covered by Medi-Cal Housing Non-medical transportation Meals (unless medical modified diet)

26. Eligibility for HCBS Waivers Level of Care (LOC) Consumer’s level of need (acuity) CCR Title 22 (State regulations) Used to authorize, modify or deny the TAR Establishes a consumer’s eligibility for NF Establishes cost neutrality of HCBS in lieu of inpatient NF services Establishes cost neutrality of HCBS in lieu of inpatient NF services NF LOC = CCR T22 ICF (NF-A) = CCR/T22 51120 ICF (NF-A) = CCR/T22 51120 Intermittent need for medical professional assessment & treatment; needs some assistance with ADL/IADLs* Intermittent need for medical professional assessment & treatment; needs some assistance with ADL/IADLs* NFB = CCR/T22 51124 NFB = CCR/T22 51124 Ongoing, long-term need for professional assessment & treatment & ongoing need for assistance with ADLs/IADLs* * Ridiculously over simplified

27. Review the List of Medi-Cal LTC Options

28. But What About Someone in MCMC? Authorization system depends on the managed care plan and included benefits HCBS usually “carved out” Either the person must: disenroll from MCMC get the HCBS service as FFS PACE and SCAN are not typical MCMC – both include some HCBS

29. So Not The End…. HEALTH CARE COMMUNITY SUPPORTS