1. Mark Leeds Director of Long Term Care and Community Support Services April 26, 2012 Maryland Medicaid Advisory Committee: Balancing Incentive Program

2. 2  Improving access to home and community-based services (HCBS) ◦ Eliminate barriers to receiving HCBS ◦ Improve collaboration between agencies ◦ Enhance person-centered focus  Shift focus from institutional settings to HCBS ◦ Shift spending ◦ Increase self-direction options ◦ Take advantage of opportunities presented through the Affordable Care Act

3. 3 Balancing Incentive Program  Offers an enhanced federal medical assistance percentage (FMAP) for all HCBS covered during the “ balancing incentive period ” through September 30, 2015 ◦ Maryland qualifies for a 2% enhanced payment rate ◦ All enhanced federal payments must be used to fund new and expanded Medicaid community-based LTSS  By the end of the balancing incentive period Maryland must: ◦ Increase HCBS to 50% of total Medicaid LTSS spending ◦ Implement required structural changes  Three required structural changes: 1. Core Standardized Assessment 2. Single Entry Point / No Wrong Door 3. Conflict-Free Case Management

4. 4  BIP Assessment Requirements ◦ Data are captured Statewide for all populations seeking community LTSS ◦ Includes a Level I screen/Level II assessment process across populations  Level I screen is available for completion in person or over the phone  Level II assessment is completed in person by a qualified professional ◦ Used to determine eligibility, identify support needs, and inform service planning

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6. 6  Assessments must meet certain criteria  BIP Manual included a crosswalk to compare existing instruments to the new standards  DHMH conducted a review of instruments with stakeholder participation  Chose the interRAI suite of tools ◦ interRAI assessments have been tested for reliability and validity ◦ interRAI suite includes assessments for institutional care, home care, mental health, and intellectual disabilities

7. 7  DDA is using the Supports Intensity Scale  Community programs with Nursing Facility Level of Care will use the interRAI-HC ◦ Older Adults Waiver, Living at Home Waiver and State Plan Personal care  Phase in for nursing facilities, Medical Day Care waiver, hospitals  Pilot of screen and interRAI-HC assessment starting in May ◦ Main purpose is to ensure Nursing Facility Level of Care determinations are consistent with current regulations and transmittals  Phone Screen and interRAI-HC assessment will be part of the LTSS tracking system ◦ Tracking system includes the client profile, client history, screen, assessment, and programmatic information (application status, referrals, plans of service) for community programs with nursing facility level of care 7 Core Standardized Assessment, cont.

8. 8 Structural Change #2 Single Entry Point / No Wrong Door  Maryland Access Point (MAP) Sites ◦ MAP initiative led by Maryland Department of Aging ◦ Formalized partnerships between Area Agencies on Aging, Centers for Independent Living (CILs), Local Health Departments, and Departments of Social Services  BIP/MFP Expansion of MAP sites ◦ 1-800 number and website expansion ◦ MAP sites will be completing the assessment phone screen ◦ Increased funding and partnership requirements 8

9. 9  A provider agency which is financially impacted by increased or decreased service utilization cannot determine the level of services authorized under the care plan  DHMH to review all regulations for LTSS programs and ensure conflict-free case management  BIP requires separation of case management and service provision ◦ Exceptions for rural areas, managed care, etc. ◦ Administrative separation is acceptable

10. 10 Balancing Incentive Program  Maryland submitted an application to participate in BIP on February 10, 2012  CMS approved the application with a start date of April 1, 2012 to begin receiving the enhanced FMAP  Projected award of $106 million  A final work plan is due to CMS on August 10 th

11. 11  The award must be spent on services or administrative functions that increase services for people who meet institutional level of care ◦ Award cannot fund the required structural changes ◦ MFP Rebalancing will fund the required changes  Potential Projects ◦ Additional Waiver Slots ◦ Rate Increases ◦ Expanded participation through Community First Choice ◦ One-time spending ◦ Staffing 11 The Award

12. 12 Stakeholder Process  Monthly MFP / BIP workgroup meetings ◦ Next meeting is May 1, 2012 from noon to 3 p.m. in room L3 at DHMH ◦ Meetings are normally held the first Tuesday of each month ◦ Dedicated email address: LTCReform@dhmh.state.md.us LTCReform@dhmh.state.md.us 12