HCBS Reductions? What Advocates Can Do.

HCBS Reductions? What Advocates Can Do. Information Bulletin # 324 (9/2010).

Has your State threatened to cut back or reduce Medicaid-funded home and community-based services ? Has your State actually reduced HCBS Medicaid services? What impact will these reductions have on people remaining in the community?

What can advocates do about these reductions? What should CMS do?

In addition to how the ADA and integration will be impacted if the reductions are implemented, another handle is the Medicaid statute itself?

To receive federal Medicaid funds, a State must have a written state plan that has been submitted to and approved by the Secretary of the U.S. Dept of Health and Human Services. CMS posts state MA plans and amendments at www.cms.gov/medicaid/stateplans/

State MA plans must be amended to reflect changes in federal policy, Court decisions, and “material changes” in policy, state law, or operation of the program. 42 Code of Federal Regulations § 430.12. Proposed State plan amendments must be submitted to the CMS regional office which must “consult with central office staff on questions regarding application of Federal policy.” 42 C.F.R § 430.14. CMS must make a “determination as to whether State plans (including plan amendments and administrative practice under the plans) originally meet or continue to meet the requirements for approval are based on relevant Federal statutes [including the ADA] and regulations.” 42 C.F.R § 430.15.

Hmmm. The United States Supreme Court in 1999 in the Olmstead decision found that unnecessary segregation in institutions violated the ADA - sure sounds like a Court decision. CMS has issued several “Dear State Medicaid Director” letters telling states that their State plans must comply with both the Medicaid and the ADA statutes, and these letters sure look like federal policy.
Therefore, when your State proposes reductions in HCBS, advocates must analyze what impact the reductions will have on causing or preventing unnecessary segregation. Advocates must ensure that CMS will disapprove the amendments based on Olmstead and its own policy requiring compliance with the ADA.

Advocates for older and younger Americans with disabilities should:

1. Find out if your Governor has reviewed the proposed amendments, a Medicaid requirement for State plan amendments?
2. Contact your regional CMS officials and obtain copies of documents between your State and CMS regarding the amendment.
3. Unbelievably, there is no requirement for public hearing or even an opportunity for public comment. Nevertheless, each State has a Medical Care Advisory Committee that reviews and comments on proposed changes. Get to them and make your voices heard.
4. Send your comments to the CMS regional office AND to the Secretary of HHS. Tell them how the amendments will impact on people unnecessarily being institutionalized.

Thanks very much to the National Health Law Program for their invaluable suggestions and observations, many of which are the basis for and incorporated in this Information Bulletin.

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 stevegoldada@cs.com or call 215-627-7100.

Rebalancing MA FY09 - How Is Your State Doing?

Rebalancing Medicaid’s Long-Term Care Expenditures: How Is Your State Doing? Information Bulletin #323 (9/2010).

In the Affordable Health Care Act in 2010, Congress provided that States would receive an increased federal match IF they “rebalance” their Medicaid expenditures from institutional expenditures to community expenditures. This was Section 10202 - “Incentives for States to Offer Home and Community-Based Services as a Long-Term Care Alternative to Nursing Homes”. States that spend less than 25% on community service could receive a 5% enhanced match and states that spend less than 50% could receive a 2% enhanced match.

In this Information Bulletin, we focus on why this section is important and how best it should be implemented to get the funding to the most states and to the states most out of balance regarding institutional and HCBS community spending.

Last Bulletin highlighted how well the DD Community has done in most states to reverse the institutional bias in Medicaid spending in relationship to the aging and physical disability community. Section 10202 could be used to make both the NF and ICF-MR funding streams more community based in states with the most inequitable systems.

Rebalancing of Medicaid’s long-term care expenditures is critical for older and younger people with disabilities eligible for nursing home services as well as persons with developmental disabilities. If your State shifts expenditures from the more expensive nursing home budget to the less expensive community budget, there will be more Medicaid funds available to serve more people in the community. By offering a larger federal match to move money from nursing homes to the community (HCBS), there will be a financial incentive for states to confront the lobby of the nursing home industry and increase funding for community services (HCBS).

This would be an opportunity for advocates in aging and disability organizations to join together to push for this new HCBS opportunity that begins October 1, 2011.

We decided to look at how state expenditures were made in FY 2009. Remember the Supreme Court ruled in Olmstead in 1999 over 10 years ago.

We use the state data compiled by Thompson Rueters under CMS contract. www.hcbs.org/browse.php/sby/Date/source/150/ThomsonReuters

From that data, we computed what follows.

Here’s what all the terminology and acronyms mean for this bulletin:

1. Long-term care (LTC) is the total Nursing Home (NH) and

Home and Community-Based Services (HCBS) spending;

2. Institutional is the total Nursing Home spending;

3. Home and Community-Based Services includes the total of Medicaid Waivers, Home Health and Personal Care Option spending.

Here’s what we found:

1. The Overall Picture -

In 2009, 66.2% went to NH and 33.8% went to HCBS.

While percentages are important we should also look at funds spent. In 2009, over $50 billion went to NH and over $25.5 billion went for HCBS.

2. A State Breakdown

In 2009, there were only four States that definitely spent less than 50% of A/D on nursing home institutions [WA, MN, OR, and Alaska]. These four therefore spent more than 50% of their LTC funds in the community for HCBS. It is likely that NM and CA are also in this category, but neither has reported all of its data for 2009. [In DD, only 6 states in FY 2009 spent less than 50% in community! Wow – absolutely opposite the A/D world.]

In 2009, there were 23 States that spent more than 75% of their Medicaid LTC A/D on nursing homes.[NE, ME, CT, OH, WY, AL*, MI, NJ, AZ, FL, UT, HI*, IL*, KY, PA, NH, IN, MS, MD, SD, DE, ND, RI*]. *All data not reported. These 23 States have not “rebalanced” their A/D expenditures and 10 years after Olmstead still are overwhelminingly institutionalized biased.

While the field as a whole is moving in the correct direction by increasing spending in the community for HCBS, these 23 states still lag far behind in overall HCBS expenditures.

Conclusion:

According to the FY 2009 data gathered for the above analysis 44-46 states would be eligible to apply for the 2% enhanced match offered in the Section 10202 HCBS Rebalancing language IF CMS makes the policy decision to have the percentages based on these funding streams.

23 states would be eligible to apply for the 5% enhanced match offered in Section 10202 HCBS Rebalancing language if CMS makes the policy decision to have the percentages based on funding streams.

If the policy goal of Congress was to “Rebalance” the LTC system, using Section 10202 to focus on the states with the most inequitable funding patterns, seems like a simple CMS policy decision to focus on those States with the most egregious unbalanced LTC services.

Tell Cynthia Mann, CMS Medicaid Director this is what you would like to see happen. (Cynthia.mann@cms.hhs.gov)

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 stevegoldada@cs.com or call 215-627-7100.

Comparing Olmstead Implementation Among Disabilities. I

Comparing Olmstead Implementation Among Disabilities. Information Bulletin #322 (9/2010).

For years, we have reviewed and compared Medicaid expenditures for people in institutions and in the community. For quite a number of these years, advocates for people who have an Intellectual/Developmental Disabilities have consistently used the Medicaid’s Home and Community-Based systems far better than advocates for older and younger people with physical disabilities, dementia.

To analyze how well the Olmstead's ADA mandate to end unnecessary institutionalization of people with disabilities has been accomplished, it is necessary to separate these two groups, ID/DD (previously MR/DD) vs. A/D(Aged/Disabled) (these are CMS designations). The reason this is necessary is, because depending on the disability label people have affixed to their heads, this label determines the institution into which you may be unnecessarily institutionalized and the funding stream you can access in the community.

Under the federal Medicaid statute, people with a ID/DD label are institutionalized in State Centers and ICF-MR (Intermediate Care Facilities for Mentally Retarded), and older and younger people with, for example, physical disabilities, dementia or anything other than the ID/DD label, are unnecessarily institutionalized in nursing homes.

These institutions, though similar in how they treat people, differ dramatically when measured by per person spending which carries over directly into the Medicaid Home and Community-based Waiver system and therefore into the amount and package of services a person will receive. Therefore, the label triggers the institution which triggers the amount of Medicaid community-based services one receives.

This long-winded explanation is necessary to understand that when one compares Medicaid community vs. institutional expenditures, the label determines both the institutional and community-based expenditures.

With this background information, we can now compare Olmstead's ADA mandate by looking at the Medicaid expenditures for the two groups. Here's what we find:

* In FY 2004, nationally the distribution of Medicaid Long Term Care expenditures for MR/DD services spent 42.4% in the institutions (State Centers and ICF-MRs) and 57.6% of the total LTC in the community. In dollars, $12 billion went to MR/DD institutions and $16 billion for services in the community.

* In the same year, FY 2004, nationally the distribution of MA LTC expenditures for A/D services spent 74.9% institutions (nursing homes) and 25.1% in the community. In dollars, $46 billion went to A/D institutions and $15 billion for services in the community.

Let's see what changes occurred in five years. Was there a leveling and how much progress was made?

* In FY 2009, nationally the distribution of Medicaid Long Term Care Expenditures for ID/DD services spent 34.4% in the institutions (State Centers and ICF-MRs) and 65.6% in the community. In dollars, $13 billion went to MR/DD institutions and $26 billion for services in the community.

* In FY 2009, nationally the distribution of expenditures for A/D services spent 66.2% institutions (nursing homes) and 33.81% in the community. In dollars, $50 billion went to A/G institutions and $26 billion for services in the community.

The FY2004 data and statistics were only five years after the Olmstead decision. However, the FY 2009 data is ten years after Olmstead. Though there has been a lot of improvement, there is still a significant institutional bias if one has the A/D label.

Let's compare the two funding groups over the five years:

The good news is that between 2004 and 2009, both groups had increased the distribution of Medicaid expenditures in the community as compared to their respective institutions.

But the inexplicable fact remains: people with a ID/DD label have a significantly better chance of residing in the community than people with an A/D label.

Just the facts!

There were 17 States in FY 2009 that expended more than 80% of their Medicaid funds inthe community for people with ID/DD. Congratulations!
There were only 2 States in FY 2009 that expended more than 60% (that's correct) of their Medicaid funds for people with A/D in the community! Wow.

Here are a few examples: Why in FY 2009 would Michigan spend 99.2% of Medicaid funds for people with ID/DD in the community but only 21.5% in the community for people with A/D? Similarly, New Hampshire spent 98.1% for ID/DD in the community but only 17.7% in the community for A/D; Alabama spent 87.8% for ID/DD in the community but only 14.9% for A/D in the community.

Why are there such marked differences based on a label?

Are the ID/DD advocates better than the A/D advocates?

Do younger and older people with physical disabilities prefer nursing homes over community services?

Why can State administrators (Medicaid Directors) continue to shift Medicaid funds from ID/DD institutions to the community while at the same time increase significantly faster the pace of shifting the A/D Medicaid funds to the community?

If the goal is to rebalance the entire long-term service and support system, then we need to look at how each of the funding streams are faring and develop rebalancing strategies to meet our overall goal of a total community integrated system.

Disability advocates - whether older or younger are people with disabilities. Whether your label is A/D or ID/DD or MI or....... , we all want services in the most integrated setting. The Olmstead decision was about all of us. Isn't it about time we confront the labels and the different funding streams?

The people united will never be defeated. El pueblo unido jamás será vencido!

Thanks to Thompson/Reuters for compiling the above state MA expenditures data.

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 stevegoldada@cs.com or call 215-627-7100.