1. Long Term Solutions for Long-Term Care Families USA Health Action 2009 Conference Gene Coffey National Senior Citizens Law Center

2. State Motivation for Reform Medicaid is the single largest purchaser of LTC in the nation ($99.3 billion in FY 2006, 49% of national LTC spending) Medicaid is the single largest purchaser of LTC in the nation ($99.3 billion in FY 2006, 49% of national LTC spending) 75% of Medicaid LTC spending for older people and adults with physical disabilities paid for institutional services 75% of Medicaid LTC spending for older people and adults with physical disabilities paid for institutional services Institutional services an entitlement under Medicaid; HCBS is not Institutional services an entitlement under Medicaid; HCBS is not Consumers, their family members and advocates have demanded more HCBS Consumers, their family members and advocates have demanded more HCBS Federal Law contains integration mandate Federal Law contains integration mandate Growth in older population will increase demand Growth in older population will increase demand

3. State Efforts to Transform Delivery of Long-Term Care Topics: Topics: –Money Follows the Person –Vermont Choices for Care Waiver –Rhode Island Global Consumer Compact Waiver –HCBS State Plan Option –Other developments

4. Money Follows the Person Congress authorized $1.7 billion to support state efforts to transition Medicaid-enrolled nursing facility residents to the community Congress authorized $1.7 billion to support state efforts to transition Medicaid-enrolled nursing facility residents to the community 31 states awarded grants ranging from $5 million to $140 million. Grants come in the form of enhanced federal match for HCBS services provided to MFP participants 31 states awarded grants ranging from $5 million to $140 million. Grants come in the form of enhanced federal match for HCBS services provided to MFP participants

5. Eligibility Requirements for MFP Eligible individuals must: Eligible individuals must: –Have resided in an institution for at least six months and no more than two years –Be receiving Medicaid coverage for their care –In the absence of HCBS, require the level of care provided in an institution –Be living in a qualified residence upon the first day of participation in MFP All states have had their protocols approved All states have had their protocols approved

6. Vermonts Choices for Care Program Medicaid Coverage for NF v. HCBS Medicaid Coverage for NF v. HCBS –Meeting LTC clinical eligibility standard Guarantees coverage for institutional services Guarantees coverage for institutional services Offers possibility of receiving HCBS, but only if: Offers possibility of receiving HCBS, but only if: –State is operating an HCBS waiver program –A slot is available in the program –State is within its spending limits Vermont program targets Medicaids institutional bias by making HCBS an entitlement Vermont program targets Medicaids institutional bias by making HCBS an entitlement

7. Choices for Care Framework Single clinical eligibility standard for Medicaid NF/HCBS waiver eligibility split into three tiers: Single clinical eligibility standard for Medicaid NF/HCBS waiver eligibility split into three tiers: –Highest Need –High Need –Moderate Need

8. Choices for Care Framework, continued Highest Need guaranteed coverage and choice of service (NF or HCBS) Highest Need guaranteed coverage and choice of service (NF or HCBS) High Need guaranteed choice of service but coverage only provided if funding is available High Need guaranteed choice of service but coverage only provided if funding is available Moderate Need eligible for select package of preventive services, coverage also dependent on funding availability Moderate Need eligible for select package of preventive services, coverage also dependent on funding availability

9. Attention to CFR Waiver has attracted national attention Waiver has attracted national attention Report on Choices for Care released in November 08. http://www.kaiserfamilyfoundation.org/me dicaid/7838.cfm Report on Choices for Care released in November 08. http://www.kaiserfamilyfoundation.org/me dicaid/7838.cfm http://www.kaiserfamilyfoundation.org/me dicaid/7838.cfm http://www.kaiserfamilyfoundation.org/me dicaid/7838.cfm Rhode Island incorporated Choices for Care general framework in its proposed Global Consumer Compact Waiver Rhode Island incorporated Choices for Care general framework in its proposed Global Consumer Compact Waiver

10. Rhode Island Global Consumer Compact Waiver Rhode Island to become first state to use global budgeting as a financing mechanism for all Medicaid populations and services Rhode Island to become first state to use global budgeting as a financing mechanism for all Medicaid populations and services Most significant changes are on the long- term care side Most significant changes are on the long- term care side RI incorporated Vermonts model into its waiver RI incorporated Vermonts model into its waiver

11. Global Consumer Compact Waiver, continued Highest Need, High Need and Preventive need Highest Need, High Need and Preventive need High need individuals may not receive coverage for institutional services High need individuals may not receive coverage for institutional services Rhode Island behind Vermont in delivering HCBS to older adults and persons with physical disabilities Rhode Island behind Vermont in delivering HCBS to older adults and persons with physical disabilities Options available to RI that were not available to Vermont Options available to RI that were not available to Vermont

12. HCBS State Plan Option Overview Overview –May only be made available to individuals who do not meet states Medicaid LTC standard –States may cap individuals receiving benefit and can choose not to comply with statewideness mandate –Services available include those specifically identified in 42 U.S.C. §1396n(c), not others requested by state that CMS might approve –No budget neutrality mandate –Income limit of 150% of FPL

13. HCBS State Plan Option, continued Two states have received approval to provide the service Two states have received approval to provide the service –Nevada will provide coverage for adult day services, home-based habilitation and, for persons with chronic mental illness, day treatment or partial hospitalization. –Iowa will provide coverage for case management and habilitation to individuals with a history of psychiatric illness.

14. Other Developments U.S. Administration on Agings Nursing Home Diversion program U.S. Administration on Agings Nursing Home Diversion program Aging and Disability Resources Centers Aging and Disability Resources Centers

15. Gene Coffey National Senior Citizens Law Center 1444 Eye Street, NW, Suite 1100 Washington, D.C. 20005 (202) 683-1992 gcoffey@nsclc.org