Thursday, May 17, 2012
HUD Issues Notice of Funding for Extremely Low-Income Non-Elderly People With Disabilities. Information Bulletin #358 (5/2012)
On Tuesday, May 15, 2012, HUD issued in the Federal Register its “FY 2012 Section 811 Project Rental Assistance NOFA.”
For background information, go to our Information Bulletin # 350 issued on February 10, 2012 at www.stevegoldada.com
This Section 811 Project based rental assistance program makes $85 million available for housing subsidies, aka vouchers
This is the first time that the federal funds require a connection between your State housing agencies (in most States it is the Finance Agency which administers your Low-Income Housing Tax Credits) and you State Medicaid agency. It is a joint effort between HUD and CMS. There must be a formal written agreement between these two State agencies.
You may ask, what’s the importance of this written agreement for advocates of people with disabilities?
The answer: Your State Medicaid/Waiver /MFP agencies will be able to ensure that people institutionalized, particularly those institutionalized primarily because they need financial housing subsidies to reside in the community, will have these Section 811 Project Rental Assistance to leave the institution and to reside in the community.
It’s a real win/win for your State Medicaid/Waiver/MFP agencies. They can save a substantial amount of Medicaid expenditures by using these Section 811 housing vouchers for people who are unnecessarily institutionalized, and it costs your States nothing! It’s also a real win for your State Housing Finance Agency, because they can ensure that the lowest income people will reside in tax credit units.
Here’s the kicker. Given the limited funds, your State must compete with other States and probably no more than 16 States will receive grants.
We are confident that both HUD and CMS will look more favorably on those applications where advocates in the disability community have been real partners. We are also confident that if your State Medicaid agency disses you, that you will let HUD and CMS know! Therefore, this gives disability advocates a meaningful opportunity to get to the table to move folks out of institutions.
Deadline for State applications to HUD is July 31, 2012. Disability Advocates “Get on your horses” now. Contact in writing your State Housing Finance Agency, your MFP folks, and your Medicaid administrators. Tell them you want to help them!
Tell them you want to participate in this process and that “Nothing About Us Without Us.”
A HOUSE KEEPING NOTE. A few folks have told me that these Information Bulletins have wound up in their spam. FYI – the list serve is about 8,000 people (directly) so that’s not surprising. Please add the address stevegoldada@stevegoldada.com into you contacts folder to prevent messages from being sent to the Spam folder or rejections up delivery.
Also, that address is NOT the same for emails from which you want responses. The email address from which I respond is stevegoldada1@gmail.com
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Thursday, May 3, 2012
Community First Choice Regulations Published. Information Bulletin # 357 (5/2012)
Let’s hear the trumpets and the Halleluiahs chorus.
Finally, the Department of Health and Human Services/Centers for Medicare & Medicaid Services issued the final regulations for the Community First Choice option. The regulations state that CFC’s scope is “designed to make available home and community-based attendant services and supports to eligible individuals, as needed, to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, or cueing.”
CMS listed CFC’s “Total Benefits” as providing “States with additional flexibility to finance home and community-based services and attendant services and supports.” The regulations state that CFC will “increase State and local accessibility to services that augment the quality of life for individuals through a person-centered plan of services and various quality assurances.…” CMS further noted that CFC “reduces the financial strain on States and Medicaid participants.”
CFC is a win-win for States to save money and for people who need community-based and attendant services to stay in their homes and apartments.
For many years, the Community First Choice was strongly supported and initiated by ADAPT, a national grass roots organization of people with disabilities of all ages and all disabilities. ADAPT organized large numbers of supporters, testified before Congressional committees, and last week demonstrated in front of HHS’ Washington offices demanding CMS release CFC’s regulations.
Now that the federal regulations have been released, the struggle shifts to you – disability and aging advocates in each State - to make sure this program is implemented in your State. Nothing happens automatically. Unless advocates demand CFC state-by-state, it will not happen. Yes, another local effort but quire worth the effort.
Here’s why your State should amend its Medicaid Plan to include the CFC – the federal government will pay an additional 6 percentages to your State’s Federal Medical Assistance percentages. (Go to http://aspe.hhs.gov/health/fmap.htm to see what the FMAP is now WITHOUT the additional six points.) That translates into a LOT of federal money!
Another reason: yes, your State can save a lot of State funds while at the same time complying with the ADA/Olmstead requirements to prevent unnecessary isolation and institutionalization of people with disabilities.
Here’s a brief summary of the final regulations:
1. CFC provides home and community-based attendant care services and supports to persons with disabilities.
2. Such services must assist the individual with activities of daily living, instrumental activities of daily living (e.g., shopping cleaning) and health-related tasks.
3. States can provide, at the State’s option, transition costs (rent and utility deposits, first month’s rent/utilities, basic kitchen/bedding needs).
4. Individual eligibility requires that the person with a disability meets your State’s institutional level of care criteria. The person need not be in the institution nor packing their bags or at risk of being imminently institutionalized. If the person meets the level of care for the institution, the CFC services can be provided.
5. Individual financial eligibility is the same as what your State has established for the institution.
6. Under the CFC, States must use a “person-centered service plan” and the services must be “self-directed,” either with “a self-directed service budget or an agency-provider model.”
7. This plan must be in writing and agreed to by the individual and must be based on a functional needs assessment. The regulations state that the “person-centered service plan … must reflect the services and supports that are important for the individual to meet the needs identified through an assessment of functional need.”
8. These plans “must be reviewed, and revised upon reassessment of functional needs, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual.”
What advocates must do:
1. Your State Medicaid Plan must be amended to include the CFC. Advocates should be at the table to ensure the services meet your needs.
2. You need a statewide, multi-disability coalition and strategy to ensure your State amends its Medicaid plan to include the CFC. If your State does not already have such a coalition, the CFC presents an opportunity to develop one. If your State has such a coalition, convene it!
3. You need to show your Governor why s/he should amend your State’s Medicaid plan to provide CFC services. This will require real live people who want and need CFC services. They must be ready to speak out. CFC is a critical opportunity to end waiting lists.
4. You should get to your media and explain how this program will save your State money, while bringing into your State additional Federal funds.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Thursday, April 26, 2012
Mortgage Foreclosures and People with Disabilities. Information Bulletin #356 (4/2012)
On Sunday, April 22, 2012, Secretary of HUD, Shaun Donovan, met with several hundred ADAPT members in Washington, D.C. During a lively question and answer period, one suggestion particularly raised our interest and we wanted to share it. This suggestion to Secretary Donovan came via ADAPT member Eleanor Smith founder of Concrete Change.
Several million families have lost their homes to mortgage foreclosures in the past few years. Many of these foreclosed homes stand vacant.
These homes are owned by HUD, Fannie Mae, Freddie Mac, and/or many, many banks.
Here is a suggestion that could have a direct impact on people with disabilities who need accessible housing.
HUD, Fannie Mae, Freddie Mac and the Banks which hold these foreclosed homes should:
1. Identify (and publicize) which of these homes have a “no step” entrance and/or a one-step entrance.
2. Prioritize these homes, using the no step properties before the one step units.
3. Identify those foreclosed homes which also have a bathroom where the door entrance could be widened to 32” without moving a wall.
Those identified properties are the easiest and cheapest to make minimally accessible.
4. Require that this basic access be built into the resale of each foreclosed home.
5. Those identified properties should be advertised to people (and families) with disabilities who need accessible homes.
6. Funds for both making these units accessible and for purchasing them exist in your local and state-wide HOME Investment Partnership program and the Community Development Block Grant program and probably other programs.
7. Tax credits (banks always like those) and tax deductions are available to meet accessibility costs.
If your community has addressed this issue, please send us information.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Wednesday, April 18, 2012
Affordable, Accessible Low-Income Housing Tax Credit Apartments in Pennsylvania.
Affordable, Accessible Low-Income Housing Tax Credit Apartments in Pennsylvania. Information Bulletin # 355 (4/2012)
In 2003-04, Philadelphia’s Liberty Resources Center (“CIL”) and Pennsylvania ADAPT met with officials from the Pennsylvania Housing Finance Agency (“PHFA”), the state agency that administers the federal Low-Income Housing Tax Credit program. The purpose of the meetings was to explain the dire housing needs of low-income persons with disabilities, to advocate for increasing affordable, accessible housing, and to ensure accessible units were actually occupied by people who needed those features.
This Information Bulletin describes the successful results of those advocacy efforts.
In 2005, PHFA first offered incentives to LIHTC housing developers to increase the number of accessible apartments and to make them affordable at 20% of the Area Median Income (AMI). A special internal management fee was made available so housing developers could deeply subsidize units to an affordable level.
As a result of this and other PHFA initiatives, as of 12/31/2011 there were more than 1250 affordable and/or accessible apartments financed with LIHTC (but about half have not been completed or were not occupied at that time) in Pennsylvania.
The 20% AMI affordability structure is based on the goal that these apartments should be affordable to households whose only income is Social Security Income. The SSI level is sufficient to pay rent without being rent “burdened” in 38 of Pennsylvania’s 67 counties and is within $1000 annual income in 12 additional counties.
PHFA works with the Pennsylvania Department of Public Welfare, the Medicaid state agency that is supposed to move people from nursing homes to the community, in their effort to establish local clearinghouse organizations to streamline the process for assuring that appropriate candidates are referred in a timely fashion for specific income, accessibility and service targeted units.
Here are the results:
• Of the 634 accessible units actually occupied (as distinguished from “financed) as of 12/31/2011, 78% were occupied by people needing the accessibility features.
• This means there were 495 affordable, accessible LITCH apartments occupied by 495 people and their families who are on SSI and require an accessible unit.
• 48% of households occupying these units are at or below 20% of the Area Median Income. (This includes persons using housing choice vouchers and other rental assistance resources, as well as the tax credit units affordable at 20% AMI.)
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
In 2003-04, Philadelphia’s Liberty Resources Center (“CIL”) and Pennsylvania ADAPT met with officials from the Pennsylvania Housing Finance Agency (“PHFA”), the state agency that administers the federal Low-Income Housing Tax Credit program. The purpose of the meetings was to explain the dire housing needs of low-income persons with disabilities, to advocate for increasing affordable, accessible housing, and to ensure accessible units were actually occupied by people who needed those features.
This Information Bulletin describes the successful results of those advocacy efforts.
In 2005, PHFA first offered incentives to LIHTC housing developers to increase the number of accessible apartments and to make them affordable at 20% of the Area Median Income (AMI). A special internal management fee was made available so housing developers could deeply subsidize units to an affordable level.
As a result of this and other PHFA initiatives, as of 12/31/2011 there were more than 1250 affordable and/or accessible apartments financed with LIHTC (but about half have not been completed or were not occupied at that time) in Pennsylvania.
The 20% AMI affordability structure is based on the goal that these apartments should be affordable to households whose only income is Social Security Income. The SSI level is sufficient to pay rent without being rent “burdened” in 38 of Pennsylvania’s 67 counties and is within $1000 annual income in 12 additional counties.
PHFA works with the Pennsylvania Department of Public Welfare, the Medicaid state agency that is supposed to move people from nursing homes to the community, in their effort to establish local clearinghouse organizations to streamline the process for assuring that appropriate candidates are referred in a timely fashion for specific income, accessibility and service targeted units.
Here are the results:
• Of the 634 accessible units actually occupied (as distinguished from “financed) as of 12/31/2011, 78% were occupied by people needing the accessibility features.
• This means there were 495 affordable, accessible LITCH apartments occupied by 495 people and their families who are on SSI and require an accessible unit.
• 48% of households occupying these units are at or below 20% of the Area Median Income. (This includes persons using housing choice vouchers and other rental assistance resources, as well as the tax credit units affordable at 20% AMI.)
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Thursday, March 29, 2012
Comparing States on Access to Community-Based Services
Comparing States on Access to Community-Based Services. Information Bulletin #354 (3/2012).
There are various criteria one can use to evaluate a State’s commitment to provide services to persons with disabilities in the community instead of in an institution. The Kaiser Commission used four criteria together and ranked states. See “State Options That Expand Access to Medicaid Home and Community-Based Services,” [HCBS] [10/11], http://www.kff.org/medicaid/8241.cfm
The four criteria used are:
1. Participants receiving HCBS Per 1,000 Population in the State. Using this criterion eliminates differences among States with regards to size, wealth, and per capita. It says for every 1,000 persons (with and without a disability) in a State, how many people with disabilities receive HCBS.
2. Expenditures Per Capita. This criterion divides the total number of people in a State (with and without a disability) by the total HCBS expenditures for people with disabilities. The “per capita” is what each person in a State pays for HCBS. This eliminates State differences regarding wealthy states, big/small, etc.
3. % of HCBS to Total Medicaid Long-Term Care Participants. This looks at the total Medicaid number of people with disabilities in both the community and institutions, and shows the percentage of the total number of people with disabilities (in both the community and institutions) who receive Medicaid services in the community.
4. % of HCBS to Total Medicaid Long-Term Care Expenditures. Whereas #3 compares % of people with disabilities who receive services in the community, this criterion looks at the total Medicaid expenditures – the money – for people with disabilities in both the community and institutions, and shows the % of the total expenditures (again in both the community and institutions) spent in the community.
Here are the worst States using each criterion.
#1 Criterion - National average per 1,000 is 9.34. Best in country is 15.36. Worst:
HI 5.15
DE 5.03
NV 4.62
AL 4.61
MD 4.48
IN 3.86
UT 3.56
TN 3.42
VA 3.30
GA 3.22
#2 Criterion - National average per capita expenditure is $166. Best in country is $487. Worst:
AL $93
MI $84
FL $81
GA $76
IL $71
UT $64
MS $61
NV $59
# 3 Criterion - % of HCBS to total participants. National average is 62%. Best in country is 86%. Worst:
FL 46%
OH 45%
LA 45%
AL 45%
MS 44%
RI 44%
GA 43%
TN 37%
IN 34%
#4 Criterion - % of HCBS Expenditures to total expenditures. National average is 45%. Best is 83%. Worst:
AR 34%
KY 33%
IN 33%
AL 31%
NJ 31%
ND 30%
IL 30%
MS 30%
Caveats – A. this data includes both people with intellectual disabilities and people with physical and all other disabilities. Using these four criteria but focused on only ID or only A/PD would show different results; B. this data is a few years old.
Nevertheless, the data shows which States were far below the national average and overwhelmingly below the best States, and which States were not committed to implementing the ADA or complying with the Olmstead decision.
Disability Advocates - the ball is on your side of the court. Only you can change your States. Don’t expect CMS to do it. Don’t assume DOJ (or any other agency) will ride in to fix up your problem. Don’t think your Governor will see the light. If your State is among the worst, the responsibility is yours.
Power Concedes Nothing Without A Struggle. F. Douglas
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
There are various criteria one can use to evaluate a State’s commitment to provide services to persons with disabilities in the community instead of in an institution. The Kaiser Commission used four criteria together and ranked states. See “State Options That Expand Access to Medicaid Home and Community-Based Services,” [HCBS] [10/11], http://www.kff.org/medicaid/8241.cfm
The four criteria used are:
1. Participants receiving HCBS Per 1,000 Population in the State. Using this criterion eliminates differences among States with regards to size, wealth, and per capita. It says for every 1,000 persons (with and without a disability) in a State, how many people with disabilities receive HCBS.
2. Expenditures Per Capita. This criterion divides the total number of people in a State (with and without a disability) by the total HCBS expenditures for people with disabilities. The “per capita” is what each person in a State pays for HCBS. This eliminates State differences regarding wealthy states, big/small, etc.
3. % of HCBS to Total Medicaid Long-Term Care Participants. This looks at the total Medicaid number of people with disabilities in both the community and institutions, and shows the percentage of the total number of people with disabilities (in both the community and institutions) who receive Medicaid services in the community.
4. % of HCBS to Total Medicaid Long-Term Care Expenditures. Whereas #3 compares % of people with disabilities who receive services in the community, this criterion looks at the total Medicaid expenditures – the money – for people with disabilities in both the community and institutions, and shows the % of the total expenditures (again in both the community and institutions) spent in the community.
Here are the worst States using each criterion.
#1 Criterion - National average per 1,000 is 9.34. Best in country is 15.36. Worst:
HI 5.15
DE 5.03
NV 4.62
AL 4.61
MD 4.48
IN 3.86
UT 3.56
TN 3.42
VA 3.30
GA 3.22
#2 Criterion - National average per capita expenditure is $166. Best in country is $487. Worst:
AL $93
MI $84
FL $81
GA $76
IL $71
UT $64
MS $61
NV $59
# 3 Criterion - % of HCBS to total participants. National average is 62%. Best in country is 86%. Worst:
FL 46%
OH 45%
LA 45%
AL 45%
MS 44%
RI 44%
GA 43%
TN 37%
IN 34%
#4 Criterion - % of HCBS Expenditures to total expenditures. National average is 45%. Best is 83%. Worst:
AR 34%
KY 33%
IN 33%
AL 31%
NJ 31%
ND 30%
IL 30%
MS 30%
Caveats – A. this data includes both people with intellectual disabilities and people with physical and all other disabilities. Using these four criteria but focused on only ID or only A/PD would show different results; B. this data is a few years old.
Nevertheless, the data shows which States were far below the national average and overwhelmingly below the best States, and which States were not committed to implementing the ADA or complying with the Olmstead decision.
Disability Advocates - the ball is on your side of the court. Only you can change your States. Don’t expect CMS to do it. Don’t assume DOJ (or any other agency) will ride in to fix up your problem. Don’t think your Governor will see the light. If your State is among the worst, the responsibility is yours.
Power Concedes Nothing Without A Struggle. F. Douglas
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Friday, March 23, 2012
Why Does CMS Not Confront the Institutional Nursing Home Bias Against People With Disabilities.
Why Does CMS Not Confront the Institutional Nursing Home Bias Against People With Disabilities. Information Bulletin #353 (3/2012)
The federal agency, the Centers for Medicare and Medicaid Services (CMS), funds virtually every nursing home in the country. Last week, CMS announced a “new initiative” which is aimed “to improve the quality of care for people residing in nursing homes.” However, this “new initiative” will neither prevent institutionalization nor transition people out of nursing homes. Nor does it even address those issues.
What is this “new initiative”? CMS states that “45% of hospital admissions among [nursing home residents] could have been avoided.” That’s 314,000 people with disabilities who reside in nursing homes funded by CMS who, due to the neglect of the nursing homes, wind up needing unnecessary – i.e., preventable -- hospitalizations!
Why has CMS proposed this “new initiative”? To save $2.6 billion in Medicaid and Medicare expenditures which CMS pays for these unnecessary hospitalizations of nursing home residents. The nursing homes do not pay – CMS and your States pay.
Obviously, “unnecessary hospitalizations” should be avoided. Many of these hospitalizations are from bedsores persons in nursing home develop. Why? People with disabilities are not repositioned on a regular basis in nursing homes. Why aren’t they? Take a guess. So CMS has a financial interest in not paying $2.6 billion in hospital costs for the nursing homes’ neglect.
Let’s look at what the CMS “new initiative” to prevent unnecessary hospitalizations will do:
1. “facilitate residents’ transitions to and from inpatient hospitals and nursing homes;”
2. “hire staff … to implement preventive services;” and
3. “work in cooperation with existing providers.”
Okay. Let’s focus on CMS’ financial interest as the primary motivating factor. Here are some suggestions that have been made for years, but for which CMS apparently does not deem important enough to address with a “new initiative.” Each one will produce significant financial savings, the obvious critical CMS motivating factor.
First, about 60.8% of nursing home residents’ admissions come directly from acute care hospitals – that’s 803,743 people. Now these hospitals are required by CMS’ existing federal regulations to do “discharge planning” which is supposed to include community-based services. If this were really happening, then people with disabilities would be offered Medicare and Medicaid services in their own homes and in the community – not forced to go to a nursing home institution without being offered appropriate and adequate community-based services.
Where is the CMS “new incentive” to require acute care hospitals to really do this discharge planning? Why has CMS neither enforced its own existing regulations or developed an incentive so that people in acute care hospitals are at least offered appropriate and adequate services in their own homes and not only in nursing facilities?
Remember, one of the CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “facilitate residents’ transitions to and from inpatient hospitals and nursing homes”? Why not the same initiative to facilitate transition from acute care hospitals to our own homes instead of to nursing homes?
Second, the recent AARP Raising ExpectationsScorecard report noted that more than at least 201,531persons with disabilities could be “new users of Medicaid long-term care services” who “would first receive services in their home and community based settings instead of nursing homes.” Yes, at least 201,531 people received their first Medicaid benefits in nursing institutions, instead of in the community.
CMS’ existing regulations require persons with disabilities be offered a real choice before they go into nursing homes. Living in the community instead of a nursing home institution saves big Medicaid money. CMS could save significant funds by enforcing their own regulations.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “hire staff … to implement preventive services” to avoid unnecessary hospitalizations. Why not a similar initiative to avoid unnecessary institutionalizations?
Third, the same AARP Raising Expectation report notes that there were hundreds of thousands of Medicaid nursing home “residents with low care needs [who could] be able to receive long term services in the community.” Now that’s not a novel idea under the ADA and Olmstead decision. These people are “unnecessarily institutionalized” and could/should be residing in the community with appropriate and adequate services.
Why has CMS not required States to offer these “low care needs” residents appropriate and adequate services in the community? Transitioning people to their own homes, with appropriate and adequate services, saves CMS and States money.
Fourth, the Minimum Data Set identifies persons with disabilities who are in nursing homes who state they want to live in the community. Why does CMS not require each State to end the “unnecessary institutionalization” of these people and make States comply with the ADA and Olmstead decision? CMS could require a very detailed written service plan which lists the specific services, amounts of services, hours, supports, etc., each person could receive in the community? We know the name and address of each of these people.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “work in cooperation with existing providers.” Why not a similar initiative to transition these people out of institutions? We do not expect the nursing homes to have the desire, interests or knowledge to write these plans. Why not hire ILCs to go into these nursing homes, work with each of these residents, and have the ILCs develop the specific written plan that the State Medicaid office will implement?
Sure CMS should avoid “unnecessary hospitalizations” and save money. But CMS should also avoid “unnecessary institutionalization” in nursing homes and save money.
We know CMS can play hardball when it wants. Recently, it stood up to Texas and cut off $35 million in Medicaid funds for that State’s refusal to provide women on Medicaid with health care services provided by Planned Parenthood.
Each year CMS knows which States have huge and growing waiting lists to prevent people from being unnecessarily institutionalized into nursing facilities and from transitioning out of nursing facilities. This occurs throughout the country. Why does CMS not cut off those States’ nursing home funds the same is it went after Texas?
Disability Advocates - use the AARP Raising Expectations report for your state and tell your newspapers, elected officials, and candidates for office how they can save Medicaid funds while implementing the ADA and Olmstead.
It’s really a sad commentary that CMS has not applied to nursing homes the historically lessons we have learned from institutions for persons with mental illness and for persons with intellectual disabilities.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
The federal agency, the Centers for Medicare and Medicaid Services (CMS), funds virtually every nursing home in the country. Last week, CMS announced a “new initiative” which is aimed “to improve the quality of care for people residing in nursing homes.” However, this “new initiative” will neither prevent institutionalization nor transition people out of nursing homes. Nor does it even address those issues.
What is this “new initiative”? CMS states that “45% of hospital admissions among [nursing home residents] could have been avoided.” That’s 314,000 people with disabilities who reside in nursing homes funded by CMS who, due to the neglect of the nursing homes, wind up needing unnecessary – i.e., preventable -- hospitalizations!
Why has CMS proposed this “new initiative”? To save $2.6 billion in Medicaid and Medicare expenditures which CMS pays for these unnecessary hospitalizations of nursing home residents. The nursing homes do not pay – CMS and your States pay.
Obviously, “unnecessary hospitalizations” should be avoided. Many of these hospitalizations are from bedsores persons in nursing home develop. Why? People with disabilities are not repositioned on a regular basis in nursing homes. Why aren’t they? Take a guess. So CMS has a financial interest in not paying $2.6 billion in hospital costs for the nursing homes’ neglect.
Let’s look at what the CMS “new initiative” to prevent unnecessary hospitalizations will do:
1. “facilitate residents’ transitions to and from inpatient hospitals and nursing homes;”
2. “hire staff … to implement preventive services;” and
3. “work in cooperation with existing providers.”
Okay. Let’s focus on CMS’ financial interest as the primary motivating factor. Here are some suggestions that have been made for years, but for which CMS apparently does not deem important enough to address with a “new initiative.” Each one will produce significant financial savings, the obvious critical CMS motivating factor.
First, about 60.8% of nursing home residents’ admissions come directly from acute care hospitals – that’s 803,743 people. Now these hospitals are required by CMS’ existing federal regulations to do “discharge planning” which is supposed to include community-based services. If this were really happening, then people with disabilities would be offered Medicare and Medicaid services in their own homes and in the community – not forced to go to a nursing home institution without being offered appropriate and adequate community-based services.
Where is the CMS “new incentive” to require acute care hospitals to really do this discharge planning? Why has CMS neither enforced its own existing regulations or developed an incentive so that people in acute care hospitals are at least offered appropriate and adequate services in their own homes and not only in nursing facilities?
Remember, one of the CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “facilitate residents’ transitions to and from inpatient hospitals and nursing homes”? Why not the same initiative to facilitate transition from acute care hospitals to our own homes instead of to nursing homes?
Second, the recent AARP Raising ExpectationsScorecard report noted that more than at least 201,531persons with disabilities could be “new users of Medicaid long-term care services” who “would first receive services in their home and community based settings instead of nursing homes.” Yes, at least 201,531 people received their first Medicaid benefits in nursing institutions, instead of in the community.
CMS’ existing regulations require persons with disabilities be offered a real choice before they go into nursing homes. Living in the community instead of a nursing home institution saves big Medicaid money. CMS could save significant funds by enforcing their own regulations.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “hire staff … to implement preventive services” to avoid unnecessary hospitalizations. Why not a similar initiative to avoid unnecessary institutionalizations?
Third, the same AARP Raising Expectation report notes that there were hundreds of thousands of Medicaid nursing home “residents with low care needs [who could] be able to receive long term services in the community.” Now that’s not a novel idea under the ADA and Olmstead decision. These people are “unnecessarily institutionalized” and could/should be residing in the community with appropriate and adequate services.
Why has CMS not required States to offer these “low care needs” residents appropriate and adequate services in the community? Transitioning people to their own homes, with appropriate and adequate services, saves CMS and States money.
Fourth, the Minimum Data Set identifies persons with disabilities who are in nursing homes who state they want to live in the community. Why does CMS not require each State to end the “unnecessary institutionalization” of these people and make States comply with the ADA and Olmstead decision? CMS could require a very detailed written service plan which lists the specific services, amounts of services, hours, supports, etc., each person could receive in the community? We know the name and address of each of these people.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “work in cooperation with existing providers.” Why not a similar initiative to transition these people out of institutions? We do not expect the nursing homes to have the desire, interests or knowledge to write these plans. Why not hire ILCs to go into these nursing homes, work with each of these residents, and have the ILCs develop the specific written plan that the State Medicaid office will implement?
Sure CMS should avoid “unnecessary hospitalizations” and save money. But CMS should also avoid “unnecessary institutionalization” in nursing homes and save money.
We know CMS can play hardball when it wants. Recently, it stood up to Texas and cut off $35 million in Medicaid funds for that State’s refusal to provide women on Medicaid with health care services provided by Planned Parenthood.
Each year CMS knows which States have huge and growing waiting lists to prevent people from being unnecessarily institutionalized into nursing facilities and from transitioning out of nursing facilities. This occurs throughout the country. Why does CMS not cut off those States’ nursing home funds the same is it went after Texas?
Disability Advocates - use the AARP Raising Expectations report for your state and tell your newspapers, elected officials, and candidates for office how they can save Medicaid funds while implementing the ADA and Olmstead.
It’s really a sad commentary that CMS has not applied to nursing homes the historically lessons we have learned from institutions for persons with mental illness and for persons with intellectual disabilities.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Thursday, February 23, 2012
Considerations Regarding Managed Care, People with Disabilities
Considerations Regarding Managed Care, People with Disabilities and 1115 Waivers. Information Bulletin # 352 (2/2012)
As discussed in the last Information Bulletin, the AARP and NASUAD recently released report “On the Verge: The Transformation of Long-Term Services and Supports” pointed out that 12 states already have Medicaid Managed Long Term Services and Supports (MMLTSS) and another 11 states report plans to implement managed care LTSS in 2012 and 2013.
Here are some points that advocates might want to consider about managed care for people with disabilities.
1. There should be a “blended rate” per person with a disability. That is, your state should enter a contract to pay the managed care entity the same rate per person whether the person is in the community or in a nursing home, a state center or an ICF-MR. This gives the managed care entity an incentive to provide services in the community.
2. Blended rates contain assumptions, based on your state’s previous year’s data regarding the numbers of people receiving LTSS services in the community and in a nursing home.
3. Publish and mandate “performance requirements,” e.g., what must be in an assessment and care plan. Make sure services in a care plan are actually developed and provided in the community within 15-30 days of the assessment and agreed on care plan.
4. Require Quality Improvement Reports [QIOs], conducted by separate, outside, independent contractors to evaluate the managed care entity’s performance. CILs are a natural for this.
5. Make sure that appeal rights and clearly delineated, especially with regards to type and amount of community-based services.
6. Build into the contract with the managed care entity both carrots and sticks, i.e., if there is too high an admission rate to institutions with managed care, penalize them via the capitation rate. Similarly, if they serve more people in the community than was anticipated, reward them the same way.
7. Build in specific incentives to keep people in the community with home and community-based services, including self-direction, relatives being paid for personal assistance services.
8. Do no permit “carve outs” regarding location of service. That is, the managed care company should be fully and entirely responsible for both institutional and community-based services for as long as a person is MA eligible. In managed-care parlance, there should be no “risk corridors” whereby the State assumes payment of institutional care if the person is instititutionalized for a specific number of days. This should give managed care companies a financial incentive to serve persons with adequate and appropriate community-based services.
9. Do not permit “carve outs” based on type of disability. If managed care is good and proper for some people with disabilities, it can and should serve people with any disability.
10. Every disabled person who is currently on MA, regardless whether s/he is in the community or in an institution should be part of the managed care program and capitation rate.
11. Require the managed care entity to have a “transition out” program for persons already institutionized. The capitation rate could include one-time transition costs to ensure people already institutionalized received the start-up items they require.
12. We know that many people with disabilities go directly from an acute care hospital to an institution without being offered any real choice and without adequate and appropriate community-based services being offered. Therefore, make sure the managed care contract has a requirement that the managed care entity and the hospitals must enter an agreement to ensure hospitals do not continue dumping people with disabilities in nursing homes.
We know that many advocates are vehemently against managed care for people with disabilities. The purpose of this Information Bulletin is not to advocate for or against MMLTSS. Rather, since 23 states have left or are leaving the station, we think there should be some public dialogue.
Special thanks to Leslie Hendrickson for his time, insights and suggestions.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
As discussed in the last Information Bulletin, the AARP and NASUAD recently released report “On the Verge: The Transformation of Long-Term Services and Supports” pointed out that 12 states already have Medicaid Managed Long Term Services and Supports (MMLTSS) and another 11 states report plans to implement managed care LTSS in 2012 and 2013.
Here are some points that advocates might want to consider about managed care for people with disabilities.
1. There should be a “blended rate” per person with a disability. That is, your state should enter a contract to pay the managed care entity the same rate per person whether the person is in the community or in a nursing home, a state center or an ICF-MR. This gives the managed care entity an incentive to provide services in the community.
2. Blended rates contain assumptions, based on your state’s previous year’s data regarding the numbers of people receiving LTSS services in the community and in a nursing home.
3. Publish and mandate “performance requirements,” e.g., what must be in an assessment and care plan. Make sure services in a care plan are actually developed and provided in the community within 15-30 days of the assessment and agreed on care plan.
4. Require Quality Improvement Reports [QIOs], conducted by separate, outside, independent contractors to evaluate the managed care entity’s performance. CILs are a natural for this.
5. Make sure that appeal rights and clearly delineated, especially with regards to type and amount of community-based services.
6. Build into the contract with the managed care entity both carrots and sticks, i.e., if there is too high an admission rate to institutions with managed care, penalize them via the capitation rate. Similarly, if they serve more people in the community than was anticipated, reward them the same way.
7. Build in specific incentives to keep people in the community with home and community-based services, including self-direction, relatives being paid for personal assistance services.
8. Do no permit “carve outs” regarding location of service. That is, the managed care company should be fully and entirely responsible for both institutional and community-based services for as long as a person is MA eligible. In managed-care parlance, there should be no “risk corridors” whereby the State assumes payment of institutional care if the person is instititutionalized for a specific number of days. This should give managed care companies a financial incentive to serve persons with adequate and appropriate community-based services.
9. Do not permit “carve outs” based on type of disability. If managed care is good and proper for some people with disabilities, it can and should serve people with any disability.
10. Every disabled person who is currently on MA, regardless whether s/he is in the community or in an institution should be part of the managed care program and capitation rate.
11. Require the managed care entity to have a “transition out” program for persons already institutionized. The capitation rate could include one-time transition costs to ensure people already institutionalized received the start-up items they require.
12. We know that many people with disabilities go directly from an acute care hospital to an institution without being offered any real choice and without adequate and appropriate community-based services being offered. Therefore, make sure the managed care contract has a requirement that the managed care entity and the hospitals must enter an agreement to ensure hospitals do not continue dumping people with disabilities in nursing homes.
We know that many advocates are vehemently against managed care for people with disabilities. The purpose of this Information Bulletin is not to advocate for or against MMLTSS. Rather, since 23 states have left or are leaving the station, we think there should be some public dialogue.
Special thanks to Leslie Hendrickson for his time, insights and suggestions.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
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