1. January 29, 2010 Health Care Reform and Expanding Home and Community-Based Services in Medicaid: A Closer Look Rhonda Richards Senior Legislative Representative Government Relations and Advocacy AARP

2. 2 Overview and Caveat > Provisions described are in the Senate Patient Protection and Affordable Care Act (H.R. 3590) > Removal of Barriers to Providing Home and Community-Based Services (HCBS) (Sec. 2402) > Spousal Impoverishment Protections for Medicaid Home and Community-Based Services (Sec. 2404) > Status of the provisions is unclear at this time – part of health care reform legislation > AARP urges Congress to enact health care reform that includes the HCBS/CLASS provisions and other priorities

3. AARP 3 Medicaid HCBS State Plan Option – Current Law > State option enacted in 2006 to expand HCBS without a waiver to individuals who need less than institutional level of care – few states have taken up the option (Sec. 6086 of the Deficit Reduction Act) > Income eligibility limit 150% of the federal poverty line > Needs-based eligibility criteria (such as ADLs) > Statutory limit on services offered > States project individuals receiving HCBS and can limit number of persons eligible and establish wait lists

4. AARP 4 Medicaid HCBS State Plan Option – Current Law > States can modify eligibility criteria without HHS approval if certain conditions are met – includes provisions re: persons receiving HCBS when criteria change > Assessment and individualized care plan > States can offer self-direction option > Presumptive eligibility option > Quality provisions

5. AARP 5 HCBS State Plan Option Proposed Changes > Empowered at Home Act (S. 434/H.R. 2688) sponsored by Senators Kerry (D-MA) and Grassley (R-IA) and Representatives Pallone (D-NJ) and DeGette (D-CO) > Home and Community Balanced Incentives Act (S. 1256) sponsored by Senators Cantwell (D-WA) and Kohl (D-WI) > Provisions incorporated into Senate health care reform bill (H.R. 3590)

6. AARP 6 Medicaid HCBS State Plan Option Proposed Changes H.R. 3590 > Expands scope of covered services – allows states to include services not listed in statute with CMS approval > Requires statewideness > Removes caps on the number of individuals covered > Allows states to waive comparability > Protects individuals from losing services if states modify needs-based eligibility criteria (as long as individuals meet pre-modified criteria)

7. AARP 7 Medicaid HCBS State Plan Option Proposed Changes H.R. 3590 > States taking up the HCBS state plan option also have an option to provide HCBS under the state plan option to individuals eligible for HCBS waiver services with incomes up to 300% of SSI > HCBS may vary in type, amount, duration or scope from HCBS under the overall state plan option > States can target HCBS to targeted populations; vary type, amount, duration, or scope of such services; and phase-in enrollment and/or services during the initial five years; allows renewal

8. AARP 8 Medicaid HCBS State Plan Option Proposed Changes H.R. 3590 > Allows states to provide full Medicaid benefits to individuals receiving HCBS under the state plan option (optional categorical eligibility) > Effective date: first day of first fiscal year quarter that begins after the enactment date > Income limit improvements still needed

9. AARP 9 How Changes Would Help > Individuals receiving services wont lose them if states change eligibility (as long as individuals are eligible under pre-modified criteria) > No enrollment caps or wait lists and benefit under main option would be statewide > States can cover more services to meet individuals needs and help keep them out of institutions > Helps more people within the income limit be eligible for services > Better for individuals overall and more states may take up the option

10. AARP 10 HCBS Spousal Impoverishment Protections > Extends same spousal impoverishment protections provided to spouses of Medicaid nursing home residents to the spouses of individuals receiving Medicaid HCBS > Effective date: Five years beginning Jan. 1, 2014 > Could urge states to adopt the change voluntarily sooner – it is another way to help level the playing field between HCBS and institutional care

11. AARP 11 Other HCBS Provisions > Money Follows the Person Extension and Eligibility Modification > Aging and Disability Resource Center Funding All these HCBS Provisions Complement: > Community First Choice Option > State Balancing Incentives Payments Program > Array of tools and options for states to expand HCBS

12. AARP 12 Regulatory Considerations Include > Impact of changes on current policy and implementation of the state plan option > Interaction with other new HCBS options > Areas where guidance from CMS would be helpful to consumers and states

13. AARP 13 How to Take Advantage of Changes (if enacted) > Look at current state long-term services and supports system > Consider how state could expand services or possibly prevent cuts to services by using the HCBS state plan option and/or other options – consider federal, federal/state, and state only programs > Consider how state may take advantage of multiple new HCBS options or particular ones – what is needed, would work in the state, or could be a building block for further HCBS? > Bipartisanship of HCBS > Consider long-term implications of CLASS (if enacted)

14. AARP 14 How to Take Advantage of Changes (if enacted) > Is state legislative or administrative/regulatory action needed, or both? > Partners – aging and disability communities, providers, workforce, family caregivers, others – build on existing partnerships at the state level and relationships among national partners and their state affiliates > Consider HCBS cost-effectiveness, the role of family caregivers, and potential impact of caregiving on employers – use research to buttress your advocacy > Learn from other states > Budgetary crises sometimes provide opportunities for significant policy advances

15. AARP 15 Useful Resources > National Governors Association: www.nga.orgwww.nga.org > National Association of State Medicaid Directors: http://www.nasmd.org/Home/home_news.asphttp://www.nasmd.org/Home/home_news.asp > National Conference of State Legislatures: www.ncsl.orgwww.ncsl.org > Kaiser Family Foundation: www.kff.orgwww.kff.org > HCBS Clearinghouse: www.hcbs.orgwww.hcbs.org > Family Caregiver Alliance: www.caregiver.orgwww.caregiver.org > National Alliance for Caregiving: www.caregiving.orgwww.caregiving.org > CMS Medicaid page: www.cms.hhs.gov/home/medicaid.aspwww.cms.hhs.gov/home/medicaid.asp > National Clearinghouse for Long-Term Care Information: www.longtermcare.govwww.longtermcare.gov > Lessons from other advocates and other states > Health Affairs Article: H. Stephen Kaye, Mitchell LaPlante, and Charlene Harrington (2009) Do Noninsitutional Long-Term Care Services Reduce Medicaid Spending, Health Affairs 28 No 1 > AARP Resources: > Balancing Act Report: http://www.aarp.org/research/ppi/ltc/hcbs/articles/A_Balancing_Act__State_Long- Term_Care_Reform.html http://www.aarp.org/research/ppi/ltc/hcbs/articles/A_Balancing_Act__State_Long- Term_Care_Reform.html > Caregiving in the US 2009: http://www.aarp.org/research/surveys/care/ltc/hc/articles/caregiving_09.html http://www.aarp.org/research/surveys/care/ltc/hc/articles/caregiving_09.html > Economic Value of Family Caregiving: http://www.aarp.org/research/ppi/health-care/health- costs/articles/i13_caregiving.htmlhttp://www.aarp.org/research/ppi/health-care/health- costs/articles/i13_caregiving.html > Across the States: http://www.aarp.org/research/ppi/ltc/Other/articles/across_the_states_2009__profiles_of_long- term_care_and_independent_living.html http://www.aarp.org/research/ppi/ltc/Other/articles/across_the_states_2009__profiles_of_long- term_care_and_independent_living.html > HCBS Cost Effectiveness: http://www.aarp.org/research/ppi/ltc/hcbs/articles/i26_hcbs.htmlhttp://www.aarp.org/research/ppi/ltc/hcbs/articles/i26_hcbs.html