Medicaid Expansion, Disproportionate Share Hospital Payments, and a Train Wreck Waiting to Happen. Information Bulletin #367 (12/12). The Affordable Care Act has many pieces. Some of the pieces are interdependent. This Information Bulletin deals with two of those pieces to explain their interdependence and why it is important to you. When Congress enacted the Affordable Care Act in 2010, one provision (Medicaid Expansion) required Medicaid be provided to people who had not been previously eligible and whose incomes were under 133% of the federal poverty level, about $14,856 for a single person and $30,657 for a family of four. This mandatory Medicaid Expansion would have impacted approximately 21.3 million low-income people nationwide, beginning in January 2014. Another provision of the Affordable Care Act significantly reduced what was known as Medicaid payments to “Disproportionate Share Hospitals” (DSH). These were federal Medicaid reimbursements made annually to States for those hospitals that provided a significant amount of health care and service to many persons whose incomes had placed them above Medicaid, but who did not have private health insurance. At least 51% of these payments will be eliminated under the ACA by 2019. Medicaid DSH payments pretty much covered the same 21.3 million people Medicaid Expansion was intended to have covered. In 2010, when Congress enacted the ACA, Medicaid Expansion would have been mandatory on the States. The States would have had to provide Medicaid to the 21.3 million people. In return, the federal government would have paid 100% coverage of the costs of the 21.3 million for the first three year years and about 90% for the next three years. Mandatory Medicaid Expansion has virtually no incremental cost to the States. It has been estimated that between 2013 and 2012the federal share of the expansion to all States would be $800 billion and the States’ share $8 billion. Here’s how the DSH and the mandatory Medicaid Expansion were intended to be interdependent. With the enactment of the ACA, these 21.3 million people would have become Medicaid recipients and would have received services and care from the hospitals, which would then not need to have been reimbursed with DSH payments. As regular Medicaid recipients, no DSH reimbursement would have been necessary because States and then hospitals would have received direct Medicaid hospital reimbursement for these 21.3 million people. Then came the 2012 U.S. Supreme Court decision that held that Congress could not require States to implement Medicaid Expansion (even though it would cost the States virtually no State funds). What the Court did not deal with was that ACA had virtually eliminated DSH payments. Lo and behold – your hospitals can get royally shafted if your State does not opt to participate in the Medicaid Expansion. How? The States and then the hospitals will not receive either the DSH payments for these 21.3 million people that they had received prior to the ACA. If a State does not opt for Medicaid Expansion, these same 21.3 million people will still go to hospitals that must treat them, but the hospitals will not receive Medicaid reimbursement. Neither Medicaid nor DSH payments. For the hospitals and therefore for States that do not provide Medicaid Expansion, this is a train wreck waiting to happen. What’s the answer? States must provide for Medicaid Expansion so that hospitals can receive Medicaid reimbursements for care and services they provide to these 21.3 million people. Unfortunately, many States appear to be considering not voluntarily participating in Medicaid Expansion. We cannot believe that those States have factored in the DSH losses to their hospitals. From purely a financial viewpoint, States will significantly benefit if they expand Medicaid and ensure hospitals receive Medicaid reimbursement for the care and services they provide to the 21.3 million people. Disability and Elderly Advocates: 1. Get to your statewide Hospital Associations. They have paid lobbies that know how to work the political process. Join their efforts to convince your Governors and State legislators to enact Medicaid Expansion. Timing is critical since State budgets are being planned NOW for 2014. 2. Most newspapers, etc. do NOT understand how the ACA’s Medicaid Expansion fits together with the DSH payments. Explain it to them. Governors in the following States have threatened not to expand Medicaid in 2014. We are not sure how much is just huffing and puffing. Here are the approximate annual DSH Medicaid funds their States have received and potentially will lose, if Medicaid Expansion does NOT occur in these States. ANNUAL MEDICAID DSH PAYMENTS TO (SELECTED) STATES: Alabama $445,819,332 Arkansas $61,416,819 Connecticut $162,627,439 Florida $241,187,904 Indiana $121,122,632 Kansas $46,807,379 Kentucky $173,659,743 Louisiana $770,957,650 Michigan $338,776,418 Mississippi $204,084,644 Missouri $525,857,264 Nebraska $47,698,173 Nevada $95,232,395 New Jersey $975,416,270 New Mexico $28,851,260 Oklahoma $40,706,148 Ohio $566,951,426 Pennsylvania $534,244,593 Rhode Island $122,720,991 New Jersey $930,234,696 South Carolina $415,604,650 Tennessee $151,396,268 Texas $1,286,627,916 Utah $25,914,531 Virginia $192,435,368 West Virginia $55,087,700 Nationwide $15,019,365,273 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. 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.

SSI, People With Disabilities, and Reaching the Federal Poverty Level. Information Bulletin #366 (11/2012). Supplemental Security Income (SSI) is basically a federal program for people who are disabled (and older Americans). As of 2011, there were about 6.7 million people with disabilities who received SSI (another 1 million recipients were over 65). These people are the poorest of all the disabled people in the country. Most of them do not qualify for either Social Security or Medicare; some receive both SSI and Social Security, but combined only to the SSI level. Throughout the recent election campaign and well before that, there has been virtually no discussion, mention or let alone a moral outrage addressing a basic minimal, basic, livable support for people who struggle to survive on SSI. The current monthly federal SSI grant is $698 a month ($8,376 annually) for a single person and for a couple it’s $1,086 a month ($13,032 annually). SSI eligibility automatically triggers Medicaid eligibility. States have the option to provide a State Supplement to the federal SSI grant. Of the 6.7 million people with disabilities who somehow survive on SSI, only 1.6 million, who live in the community, receive a State Supplement. By and large, most States supplement SSI for persons who reside in personal care homes, Medicaid facilities, nursing homes, and other institutions – but not for people with disabilities who live independently in the community. The amount of institutional SSI State supplement is much higher than the SSI State supplement to live independently in the community. Hmmm. Sounds like another institutional bias, contrary to ADA’s “the most integrated setting” a la Olmstead. Let’s put the monthly federal SSI sums in some perspective. The federal poverty level is $10,890 for a single person and $14,710 for a couple, compared to the SSI federal $8,376 and $13,032 respectively. As inadequate as the federal poverty level is, it should be the bottom benchmark! For people with disabilities who must survive on SSI, they live on 75% of the federal poverty level for a single person and 83% of the FPL for a couple. This gap has been approximately the same for the last ten years. For those persons who reside in the community on SSI, to reach just the federal poverty level, the federal SSI grant (or a State supplement) would have to increase by $209 a month for a single person and $140 for a couple. Other than Alaska, no State provides that amount of a State Supplement for single persons with a disability who reside independently in the community. Only five States provide more than $140 a month for a couple. We all know how extremely difficult it is for a SSI recipient who is disabled to find a place to live that they can afford. The “2010 Priced Out” Report clearly demonstrated how the housing market overwhelmingly trumps the SSI grant. What advocates could do: 1. This is a federal issue. We do not believe any States will voluntarily increase their SSI State Supplements so people could afford to live healthy and safe lives independently in the community. 2. We need to make this a moral issue! It’s an outrage that the poorest disabled and elderly Americans are totally ignored and forgotten. 3. SSI cuts across all disability categories and the elderly. Therefore, increasing SSI is a great unifying and organizing issue. 4. Increasing the federal SSI amount even to the extremely inadequate federal poverty level is an economic stimulus on both a federal and State levels. People on SSI spend their entire grants just to survive, putting their entire grants into the economy. These are federal allocations well spent! 5. Where is the White House on this issue? Call the White House Domestic Policy, (202) 456-5594, and let them know. 6. Where are your U.S. Senators and House of Representatives who claim to represent and care about persons with disabilities and the elderly? Call them. 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. 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.

Disabled and Elderly People in China. Information Bulletin #365 (11/2012) People with disabilities and elderly folks in China face many of the same issues we face in the U.S. What follows are some observations my wife and I have and what we learned during a recent trip to China. Obviously, what follows is limited to our observations and meetings with disability advocates. Background data: Out of the 1.3 billion people, approximately 85 million are people with disabilities and 190 million are people aged 60 or older. There are about 33 million elderly with various disabilities. China also ranks disabilities I – V, e..g., blindness in one eye ranked a # II but blindness in both eyes ranks as a # I. 1.Shanghai and Beijing each have about 3 percent of their elderly population (not clear about people with disabilities) who are in nursing facilities. In the past, elderly lived with their children as part of “filial piety.” Due to adult children’s pressure of work, their living costs, crowded housing, and geographically restricted medical insurance, such piety is quickly fading. There is no national health care and the available/affordable care depends on what Provence, like U.S. States, one lives in and one’s ability to pay for health insurance, Despite a poll that said “only” 5.5 percent of the respondents wanted to send their parents to a nursing home, there are no other options. When asked what if their parents do not want to go into a nursing home, one person responded that “we talk to our parents and they understand they have to go into one.” People with disabilities and the elderly are virtually forced into nursing homes. So much for choice. 2. China has only 300,000 caregivers, and one report indicated that most of them were unqualified. The same report estimated that about 11 million caregivers were needed So much for community-based services instead of institutional care. 3. China has a very medicalized view and definitions of disability. 4. Despite a marked increase in Provincial medical insurance coverage for the elderly in the past decade, one professor said that the “government should work out policies to guarantee adequate care for the elderly, which is an essential part of stable development. Government should increase the input and add the insurance for healthcare and rehabilitation, which will be much needed among the elderly but not covered by the current insurance system.” So much for a safety net. 5. China used the occasion of the 2008 Olympics to build curb cuts and install a number of accessible public bathrooms. During our recent visit, virtually every accessible bathroom in every city we visited was being used for storage and unusable by both disabled and nondisabled people. 6. Only in Beijing did we see a number of people with disabilities. In most other cities, we saw quite a number of disabled people who were begging in front of tourist attractions. One guide thought they were “professional beggars who maim themselves,” despite their obvious genetic impairments. The absence of people with disabilities in public places in other cities was really stark. 7. The value of people with disabilities was reflected in a conversation that people with disabilities should work. When asked what should be done if they could not work, given their impairments and how they would live, the response was that “with 1.3 billion people, their lives were not valuable and some people [i.e., people with disabilities] will not be missed.” 8. China does not have a viable, active disability or elderly advocacy network. The China Disabled Persons’ Federation is a government appointed and controlled entity which appears to reflect the central government’s positions. We were not surprised that the disability issues and problems were similar to many we face here. Disabled people of the world unite, you have nothing to lose…. 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. Information Bulletins are 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.

15 States Do Not Need Housing Vouchers for Disabled Persons to Leave Institutions. Information Bulletin #364 (8/2012). States had to file an application with HUD to be eligible to receive some of the FY 2012 Section 811 Project-based Rental Assistance Demonstration Grants, aka the Melville vouchers. The good news is that 35 States (and D.C.) applied and will compete to receive these vouchers. Congratulations to disability advocates who worked with your State agencies to develop and submit these applications. What is amazing is that 15 States did NOT apply. While we recognize that many of the 35 States that did apply may not win the competition, these 35 at least got into the race. What about the 15 States that did NOT apply? These 15 States obviously have an abundance of housing vouchers, just sitting around in some drawer, so that anyone who wishes to leave an institution will receive a voucher and not have housing as a barrier to living in the community. Right? These 15 States do not claim that their Money Follows the Person is hampered by housing, do they? Are we correct? Can disability advocates in the 15 States just telephone their State Housing Finance agency and/or Medicaid agency and pick up a housing voucher that is not being used? What are we missing? Why did these 15 States not compete? Here are the 15: Alabama Arizona Arkansas Hawaii Idaho Iowa Kansas Kentucky Nebraska New Mexico Oklahoma South Carolina Tennessee Virginia Wyoming 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.

ADA’s Olmstead “Most Integrated Setting” Mandate Will Be Undercut. Information Bulletin #363 (8/2012). Christine Gregoire, the Democratic Governor of Washington State, is deciding if she will threaten and undercut the right of people with disabilities to live in the community by eviscerating the Olmstead decision and the ADA’s “most integrated setting” mandate. How? In response to cuts to personal care services for approximately 45,000 Medicaid recipients, disability advocates sued the State of Washington. Democratic Governor Christine Gregoire argued in court that individuals with disabilities must be already institutionalized in order to be protected under the Olmstead decision. The Circuit court disagreed with Governor Gregoire. Now, Governor Gregoire is considering an appeal to the U.S. Supreme Court! She is putting the rights of people with disabilities at significant risk. If she takes the case to the Supreme Court, this Supreme Court will take the opportunity to turn back the clock on our rights. If appealed, “M.R. v. Dreyfus,” the name of the case, it will give the very activist U.S. Supreme Court an opportunity to substantially erode or completely eliminate Olmstead. The disability community in Washington State has urged Governor Gregoire to settle this case without going to the Supreme Court, but she has been unwilling to do so Disability Advocates must TAKE ACTION NOW to contact key people within the Gregoire administration and the national leaders in the Democratic Party to urge Governor Gregoire to settle this case and not take it to the Supreme Court. Our message: “Governor Gregoire should support the right of people with disabilities living in the most integrated setting in the community! Settle M.R. v. Dreyfus! No appeal to the U.S. Supreme Court.” The Olmstead decision is one of the few effective advocacy tools that the disability community has to fight against state budget cuts to home and community-based services that would force people with disabilities into unwanted and unwarranted institutionalization. TAKE THE FOLLOWING ACTIONS NOW. TIMING IS CRITICAL PLEASE DO IT TODAY: Please send emails, telephone and/or twitter to: 1. Marty Loesch, Chief of Staff for Governor Chris Gregoire, (360) 902-0499. Marty.loesch@gov.wa.gov 2. Kareem Dale, White House, Kareem_A._Dale@who.eop.gov 3. Telephone the White House’s Monthly Disability call • Date of Call: Friday, August 24, 2012 • Start Time: 2:00 p.m. EDT (dial in 5 minutes early) • Dial in: (800) 762-7308 • Code: White House Disability Call Valarie Jarrett will be on this call, and she is President Obama’s point person. Tell her what you think. 4. Telephone the Democratic Governors’ Assn. at 202-772-5600 or email them at http://democraticgovernors.org/contact/ 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.

States Reluctant to Expand the Affordable Care Act’s Medicaid. Information Bulletin # 362 (7/2012) The Supreme Court has held that the Affordable Care Act is constitutional. It also ruled that Congress cannot “coerce” States to expand the Medicaid eligibility via the ACA to cover people whose incomes are less than 133% of the federal poverty level (about $14,856 for a single person and about $30,657 for a family of four). The purpose of this Information Bulletin is to suggest some arguments advocates can use, especially if your State is hinting that it may not expand Medicaid to cover low-income individuals and families. First, obviously, we bet that some of the posturing States are presently taking is related to the presidential election. If Obama is re-elected, then the reality might sink in and your State might quietly accept the expansion. If Romney is elected, your State might be fantasizing that the ACA may be amended. Second, it’s important that advocates use the State-specific data to make public arguments regarding why your State would be fiscally irresponsible not to expand its Medicaid program. Third, since the ACA phases out special MA reimbursements for “disproportionate share” hospitals, many hospitals, which in the past received extra reimbursements because they treated large numbers of low-income patients, will lose these MA funds! Yes, one natural ally in your State are the hospitals and state-wide Hospital Association. Fourth, this issue presents a natural potential for a “My Medicare Matters” alliance between the disability/elderly advocates and the low-income groups/AARPs/AAAs in your community. Call them up. Here’s some national data which may be helpful. • Between 2014 and 2022, the federal government will pay 93% of the total Medicaid expansion costs. • The federal government will spend $931 billion for the Medicaid expansion and the States about $73 billion between 2014 and 2022. • States currently spend $2.6 trillion on Medicaid without the ACA expansion. The additional $73 billion to cover the 133% expansion results on average in only a 2.8% increase on what States would have otherwise have spent. • The 2.8% is probably actually larger than what States will spend because it does not reflect increased savings States will realize because of other provisions in the ACA which reduce some existing costs, e.g., state and local costs for hospital care for the uninsured. • States savings from uncompensated care may fully cover States’ increases from the 133% Medicaid expansion. Here are 12 States where the Governors have said either they will not implement the Medicaid expansion or are on the fence. We use a 2014-2019 timeframe. • Alabama has 351,567 low-income people (133% of FPL) who will be denied coverage and will therefore lose $10,305 million federal dollars by not spending $470 million of State funds between 2014-19. If Alabama enrolled these people, the State’s share of Medicaid spending would increase by only 3.6%. • Florida has 951,622 low-income people (133% of FPL) who will be denied coverage and will therefore lose $20,050 million federal dollars by not spending $1,233 million of State funds between 2014-19. If Florida enrolled these people, the State’s share of Medicaid spending would increase by only 1.9%. • Louisiana has 366,318 low-income people (133% of FPL) who will be denied coverage and will therefore lose $7.273 million federal dollars by not spending $337 million of State funds between 2014-19. If Louisiana enrolled these people, the State’s share of Medicaid spending would increase by only 1.7%. • Kansas has 143,445 low-income people (133% of FPL) who will be denied coverage and will therefore lose $3,477 million federal dollars by not spending $166 million of State funds between 2014-19. If Kansas enrolled these people, the State’s share of Medicaid spending would increase by only 1.7%. • Kentucky has 329,000 low-income people (133% of FPL) who will be denied coverage and will therefore lose $11,878 million federal dollars by not spending $515 million of State funds between 2014-19. If Kentucky enrolled these people, the State’s share of Medicaid spending would increase by only 3.5%. • Maine has 43,468 low-income people (133% of FPL) who will be denied coverage and will therefore lose $1,857 million federal dollars by not NOT spending $ -118 million of State funds between 2014-19. If Maine enrolled these people, the State Medicaid spending would actually DECREASE by 1.5%. • Missouri has 307,872 low-income people (133% of FPL) who will be denied coverage and will therefore lose $8,395 million federal dollars by not spending $431 million of State funds between 2014-19. If Florida enrolled these people, the State’s share of Medicaid spending would increase by only 1.7%. • North Dakota has 28,864 low-income people (133% of FPL) who will be denied coverage and will therefore lose $595 million federal dollars by not spending $32 million of State funds between 2014-19. If North Dakota enrolled these people, the State’s share of Medicaid spending would increase by only 1.4%. • Ohio has 667,376 low-income people (133% of FPL) who will be denied coverage and will therefore lose $17,130 million federal dollars by not spending $830 million of State funds between 2014-19. If Ohio enrolled these people, the State’s share of Medicaid spending would increase by only 1.6%. • South Carolina has 344,109 low-income people (133% of FPL) who will be denied coverage and will therefore lose $10,919 million federal dollars by not spending $470 million of State funds between 2014-19. If South Carolina enrolled these people, the State’s share of Medicaid spending would increase by only 3.6%. • Texas has 1,798,314 low-income people (133% of FPL) who will be denied coverage and will therefore lose $52,537 million federal dollars by not spending $2,619 million of State funds between 2014-19. If Texas enrolled these people, the State’s share of Medicaid spending would increase by only 3.0%. • Wisconsin has 205,987 low-income people (133% of FPL) who will be denied coverage and therefore lose $4,252 million federal dollars by not spending $205 million of State funds between 2014-19. If Wisconsin enrolled these people, State’s share of Medicaid spending would increase by only 0.9%. The data for the 12 States are from the Kaiser Commission’s “Medicaid Coverage and Spending in Health Reform: National and State-by-State Results for Adults at or Below 133% FPL” at Table 1. The national data are from the Center on Budget and Policy Priorities, “Federal Government Will Pick Up Nearly All Costs of Health Reform’s Medicaid Expansion.” If your State is not one of the 12 listed in this Information Bulletin, Google the above Kaiser report. If you still have difficulty and want to know, email me at address below. 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.

What’s the Status of Your Vouchers for Non-Elderly Disabled Persons? Information Bulletin 361 (6/2012). In December, 2011, we sent out Information Bulletin #348 A, informing advocates that HUD had instructed 402 public housing authorities that the 55,041 vouchers which were allocated for non-elderly persons with disabilities MUST BE ACTUALLY used for 55,041 non-elderly persons with disabilities. That is what HUD Notice PIH 2011-32 requires. HUD graciously permitted these 402 public housing authorities until June 14, 2012 to comply. Well, has your Public Housing Authority allocated its NED [non-elderly disabled] vouchers to non-elderly disabled persons? Listed below are the 402 public housing authorities that must comply. Also, if your housing authority received Category 2 NED vouchers, make sure they are used to transition people out of institutions. A few of you are wondering, what should be done if your public housing authority either does not respond to your inquiries or cannot show you they really have complied? We suggest you put your request in writing to the Executive Director of your public housing authority requesting, again, for a meeting at which s/he can show you how they have complied. We think that a “cc” should be sent to your local HUD office and especially the HUD FHEO official. [For you young folks, a “cc” means “carbon copy,” which way back in the dark ages before even xerox copiers was how copies were made.] If you still do not receive a satisfactory response, consider filing an official complaint (a simple letter should suffice) with HUD alleging that your public housing authority is violating the Federal Fair Housing Act Amendments. Yes, it is discrimination against people with disabilities if these vouchers are not be used for people with disabilities, as Congress and HUD intended. 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. 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. HA Num HA Name NED NED Category 2 Total NED AK901 AK HSG FINANCE CORP 45 45 AL002 MOBILE HOUSING BOARD 122 122 AL006 H/A CITY OF MONTGOMERY 100 100 AL069 HA LEEDS 1 1 AL086 HA JEFFERSON COUNTY 175 175 AL129 HA WALKER COUNTY 34 34 AR131 JONESBORO URBAN RENEWAL & HSG AUTHORITY 100 100 AR161 CONWAY COUNTY HOUSING AUTH 125 125 AR197 WHITE RIVER REGIONAL HOUSING AUTHORITY 100 100 AZ005 CITY OF MESA 150 150 AZ033 PIMA COUNTY 0 25 25 CA001 SAN FRANCISCO HSG AUTH 91 91 CA002 COUNTY OF LOS ANGELES HOUSING AUTH. 100 100 CA003 OAKLAND HOUSING AUTHORITY 85 85 CA004 CITY OF LOS ANGELES HSG AUTH 300 300 CA006 CITY OF FRESNO HSG AUTH 75 75 CA007 COUNTY OF SACRAMENTO HOUSING AUTHORITY 100 100 CA008 HOUSING AUTHORITY COUNTY OF KERN 75 75 CA019 COUNTY OF SAN BERNARDINO HSG AUTH 75 75 CA021 COUNTY OF SANTA BARBARA HSG AUTH 0 25 25 CA028 COUNTY OF FRESNO HSG AUTH 75 75 CA056 SAN JOSE HOUSING AUTHORITY 175 175 CA059 COUNTY OF SANTA CLARA HOUSING AUTH. 0 10 10 CA062 CITY OF ALAMEDA HOUSING AUTHORITY 75 75 CA063 SAN DIEGO HOUSING COMMISSION 200 200 CA067 ALAMEDA COUNTY HSG AUTH 0 10 10 CA068 CITY OF LONG BEACH HSG AUTH 200 200 CA073 HSG AUTHORITY CITY OF NAPA 100 100 CA076 CITY OF SANTA BARBARA H/A 100 100 CA077 CITY OF CARLSBAD HOUSING & REDEVELOPMENT 75 75 CA079 CITY OF PASADENA COMMUNITY DEVELOPMENT COMMISSION 60 40 100 CA093 CITY OF SANTA ANA HSG AUTH 200 200 CA094 COUNTY OF ORANGE HOUSING AUTHORITY 0 50 50 CA102 GARDEN GROVE HOUSING AUTHORITY 100 100 CA104 CITY OF ANAHEIM HOUSING AUTHORITY 175 175 CA106 CITY OF REDDING HSG AUTH 34 34 CA128 CITY OF ROSEVILLE 75 75 CA132 CITY OF OCEANSIDE COMM DEV COMMISSION 100 100 CA143 IMPERIAL VALLEY HOUSING AUTHORITY 100 100 CA155 CITY OF ENCINITAS HOUSING AUTHORITY 50 50 CO001 HOUSING AUTHORITY OF THE CITY AND COUNTY OF DENVER 75 75 CO016 BOULDER CITY HSG AUTH 181 181 CO034 LOVELAND HOUSING AUTHORITY 75 75 CO041 FORT COLLINS HSG AUTH 200 200 CO051 GRAND JUNCTION HSG AUTH 150 150 CO052 AURORA HOUSING AUTHORITY 75 75 CO061 BOULDER COUNTY HSG AU 35 35 CO072 JEFFERSON COUNTY HOUSING AUTHORITY 175 175 CO901 COLORADO DEPARTMENT OF HUMAN SERVICES 1100 1100 CO911 COLORADO DIVISION OF HOUSING 350 350 CT005 NEW BRITAIN HOUSING AUTHORITY 75 75 CT006 WATERBURY HOUSING AUTHORITY 76 76 CT009 MIDDLETOWN HOUSING AUTHORITY 50 50 CT019 GREENWICH HOUSING AUTHORITY 78 78 CT020 DANBURY HOUSING AUTHORITY 202 202 CT025 WINCHESTER HOUSING AUTHORITY 20 20 CT026 MANCHESTER H A 36 36 CT028 VERNON/ROCKVILLE HOUSING AUTHORITY 15 15 CT029 WEST HAVEN HOUSING AUTHORITY 100 100 CT032 WINDSOR LOCKS HOUSING AUTHORITY 32 32 CT047 NAUGATUCK HOUSING AUTHORITY 20 20 CT048 WINDSOR H A 30 30 CT901 CONN DEPT OF SOCIAL SERVICES 300 300 DC001 D.C HOUSING AUTHORITY 547 547 FL003 HA TAMPA 150 150 FL004 ORLANDO H/A 400 400 FL005 MIAMI DADE HOUSING AUTHORITY 210 210 FL009 HA WEST PALM BEACH GENERAL FUND 175 175 FL019 HA COCOA 75 75 FL020 HA BREVARD COUNTY 200 200 FL025 HA OF THE CITY OF TITUSVILLE 125 125 FL041 HA FORT PIERCE 100 100 FL060 HA PUNTA GORDA 25 25 FL066 HIALEAH H/A 298 298 FL079 BROWARD COUNTY HOUSING AUTHORITY 75 75 FL081 HA DEERFIELD BEACH 52 52 FL089 HILLSBOROUGH COUNTY-BOCC 100 100 FL092 CITY OF PENSACOLA SECTION 8 50 50 FL119 HA BOCA RATON 75 75 FL141 COLLIER COUNTY HA 0 25 25 GA006 HA ATLANTA GA 175 175 GA011 HA OF THE CITY OF DECATUR 0 35 35 GA285 Northwest GA Housing Authority 175 175 GQ901 GUAM HSG AND URBAN RENEWAL AUTH 175 175 HI901 HAWAII PUBLIC HOUSING AUTHORITY 175 175 IA018 SIOUX CITY HOUSING SERVICES DIVISION 50 50 IA020 CITY OF DES MOINES MUNICIPAL HOUSING AGENCY 53 53 IA022 CITY OF IOWA CITY 100 100 IA024 CITY OF CEDAR RAPIDS 100 100 IA050 WATERLOO HOUSING AUTHORITY 100 100 IA087 DUBUQUE DEPT OF HUMAN RIGHTS 40 40 IA129 NORTHWEST IOWA REGIONAL HA 35 35 IA133 MID IOWA REGIONAL HOUSING AUTHORITY 35 35 ID013 BOISE CITY HOUSING AUTHORITY 100 100 ID016 SOUTHWESTERN IDAHO COOPERATIVE HOUSING AUTHORITY 30 30 ID021 ADA COUNTY HOUSING AUTHORITY 100 100 ID901 IDAHO HOUSING AND FINANCE ASSOCIATION 400 400 IL002 CHICAGO HOUSING AUTHORITY 850 850 IL003 PEORIA HOUSING AUTHORITY 100 100 IL004 SPRINGFIELD HOUSING AUTHORITY 0 10 10 IL024 HOUSING AUTHORITY OF JOLIET 45 45 IL025 HOUSING AUTHORITY OF COOK COUNTY 175 175 IL056 HSG AUTHORITY OF THE COUNTY OF LAKE 100 100 IL103 OAK PARK HOUSING AUTHORITY 0 15 15 IN003 FORT WAYNE HA-CITY OF FORT WAYNE 75 75 IN012 HA NEW ALBANY 200 200 IN016 HA CITY OF EVANSVILLE 100 100 IN047 CRAWFORDSVILLE HOUSING AUTHORITY 40 40 IN080 NOBLESVILLE HOUSING AUTHORITY 75 75 IN092 LOGANSPORT HOUSING AUTHORITY 31 31 IN101 GOSHEN HOUSING AUTHORITY 80 80 IN103 MARSHALL CO. HOUSING AUTHORITY 100 100 IN901 INDIANA HOUSING & COMMUNITY DEVELOPMENT AUTHORITY 200 200 KS002 TOPEKA HOUSING AUTHORITY 75 75 KS004 WICHITA HOUSING AUTHORITY 266 266 KS053 LAWRENCE- DOUGLAS COUNTY HOUSING AUTHORITY 80 80 KS162 JOHNSON COUNTY HOUSING AUTHORITY 25 25 KS170 ELLIS COUNTY PHA 75 75 KY001 LOUISVILLE HOUSING AUTHORITY 230 230 KY160 CUMBERLAND VALLEY HOUSING AUTHORITY 100 100 KY161 APPALACHIAN FOOTHILLS HA 85 85 KY171 BOWLING GREEN HOUSING AUTHORITY 50 50 KY901 KENTUCKY HOUSING CORPORATION 350 350 LA002 SHREVEPORT HSG AUTHORITY 200 200 LA005 LAFAYETTE (CITY) HOUSING AUTHORITY 75 75 LA013 JEFFERSON PARISH HOUSING AUTHORITY 200 200 LA103 Slidell Housing Authority 25 25 LA211 TERREBONNE PARISH CONSOLIDATED GOVT 75 75 LA247 Town of Kinder 75 75 MA002 BOSTON HOUSING AUTHORITY 500 500 MA003 CAMBRIDGE HOUSING AUTHORITY 100 100 MA017 TAUNTON HOUSING AUTHORITY 400 400 MA018 ATTLEBORO HSG AUTHORITY 35 35 MA022 MALDEN HOUSING AUTHORITY 50 50 MA023 LYNN HOUSING AUTHORITY 65 35 100 MA024 BROCKTON HOUSING AUTHORITY 100 100 MA028 FRAMINGHAM HOUSING AUTHORITY 240 240 MA031 SOMERVILLE HOUSING AUTHORITY 200 200 MA035 SPRINGFIELD HSG AUTHORITY 75 75 MA040 DEDHAM HSG AUTHORITY 175 175 MA044 BEVERLY HOUSING AUTHORITY 75 75 MA057 ACTON HSG AUTHORITY 15 15 MA059 PLYMOUTH HOUSING AUTHORITY 40 40 MA074 WAKEFIELD H A 110 110 MA081 METHUEN HOUSING AUTHORITY 135 135 MA094 FRANKLIN CTY REG HSG AUTHORITY 25 25 MA095 YARMOUTH HSG AUTHORITY 60 60 MA108 CHELMSFORD HSG AUTHORITY 163 163 MA109 NORWOOD HSG AUTHORITY 40 40 MA181 SANDWICH HSG AUTHORITY 25 25 MA901 COMM DEV PROG COMM OF MA.,E.O.C.D. 800 800 MD002 HOUSING AUTHORITY OF BALTIMORE CITY 175 40 215 MD003 HOUSING AUTHORITY OF THE CITY OF FREDERICK 50 50 MD004 MONTGOMERY CO HOUSING AUTHORITY 660 660 MD021 ST MARY'S COUNTY HOUSING AUTHORITY 100 100 MD023 HOWARD COUNTY HOUSING COMMISSION 25 10 35 MD024 COUNTY COMMISSIONERS CHARLES COUNTY 100 100 MD032 CARROLL COUNTY HSG & COMMUNITY DEV 100 100 MD033 BALTIMORE CO. HOUSING OFFICE 100 50 150 MD901 MARYLAND DEPT OF HSG & COMMUNITY DEVELOPMENT 0 12 12 ME015 WESTBROOK HOUSING AUTHORITY 75 75 ME030 AUGUSTA HSG AUTHORITY 100 100 ME901 MAINE STATE HSG AUTHORITY 275 275 MI003 DEARBORN HOUSING COMMISSION 50 50 MI023 GREENVILLE HSG. COMM. 45 45 MI045 PLYMOUTH HOUSING COMMISSION 100 100 MI055 LIVONIA HOUSING COMMISSION 25 25 MI064 ANN ARBOR HOUSING COMMISSION 100 100 MI073 GRAND RAPIDS HSG. COMM. 100 100 MI080 TRAVERSE CITY HSG. COMM. 0 10 10 MI115 WYOMING HOUSING COMMISSION 100 100 MI160 DEARBORN HEIGHTS HSG. COMM. 100 100 MI186 MONTCALM COUNTY HSG. COMM. 100 100 MI901 MICHIGAN STATE HSG. DEV. AUTH. 290 290 MN002 MINNEAPOLIS PHA 400 400 MN163 METROPOLITAN COUNCIL HRA 200 200 MN170 PLYMOUTH HRA 15 15 MN180 TODD COUNTY HRA 25 25 MO002 HOUSING AUTHORITY OF KANSAS CITY, MISSOURI 200 200 MO004 ST. LOUIS COUNTY HOUSING AUTHORITY 100 100 MO199 LINCOLN COUNTY PUB HSG AGENCY 74 74 MO205 FRANKLIN COUNTY PUBLIC HSG AGENCY 46 46 MO212 RIPLEY COUNTY PHA 50 50 MO227 St. Charles County Housing Authority 26 26 MS030 HA MISSISSIPPI REGIONAL NO 5 75 75 MS058 MISS REGIONAL H/A VI 75 75 MT003 BUTTE HOUSING AUTHORITY 10 10 NC001 HOUSING AUTHORITY OF THE CITY OF WILMINGTON 50 5 55 NC003 HA OF THE CITY OF CHARLOTTE 275 275 NC007 HSG AUTHORITY OF THE CITY OF ASHEVILLE 75 75 NC011 GREENSBORO HOUSING AUTHORITY 400 400 NC012 HA WINSTON-SALEM 378 378 NC013 HA DURHAM 200 200 NC021 HA COUNTY OF WAKE 100 100 NC039 HA LEXINGTON 50 50 NC043 TROY HOUSING AUTHORITY 25 25 NC057 GASTONIA H/A 100 100 NC120 CHATHAM COUNTY HSG AUT 50 50 NC134 TOWN OF EAST SPENCER HOUSING AUTHORITY 50 50 NC140 WESTERN CAROLINA COMM ACTION 30 30 NC141 COASTAL COMMUNITY ACTION, INC. 50 50 NC155 FRANKLIN VANCE WARREN OPP'TY INC 150 150 NC167 NORTH WESTERN REGIONAL HOUSING AUTHORITY 64 64 ND017 MINOT HOUSING AUTHORITY 75 75 NE004 KEARNEY HOUSING AUTHORITY 30 30 NH001 MANCHESTER HOUSING AUTHORITY 100 100 NH009 LEBANON HOUSING AUTHORITY 14 14 NH010 KEENE HOUSING AUTHORITY 100 100 NH901 NEW HAMPSHIRE HOUSING FINANCE AUTH 106 106 NJ002 NEWARK HOUSING AUTHORITY 75 75 NJ003 ELIZABETH HOUSING AUTHORITY 50 50 NJ009 JERSEY CITY HOUSING AUTHORITY 300 300 NJ014 ATLANTIC CITY HOUSING AUTHORITY 75 75 NJ047 CARTERET HOUSING AUTHORITY 150 150 NJ061 MILLVILLE HOUSING AUTHORITY 60 60 NJ067 BERGEN COUNTY HOUSING AUTHORITY 175 175 NJ073 CLEMENTON HOUSING AUTHORITY 20 20 NJ084 HUNTERDON HOUSING AUTHORITY 50 50 NJ091 PATERSON DCD HOUSING AUTHORITY 150 150 NJ095 MONMOUTH COUNTY HOUSING AUTHORITY 175 175 NJ097 SOMERVILLE HOUSING AUTHORITY 10 10 NJ204 GLOUCESTER HOUSING AUTHORITY 227 227 NJ912 NEW JERSEY DEPARTMENT OF COMMUNITY AFFAIRS 290 100 390 NM001 ALBUQUERQUE HSG AUTHORITY 139 139 NM003 LAS CRUCES HSG AUTHORITY 100 100 NM020 TRUTH OR CONSEQUENCES HSG AUTHORITY 28 28 NM057 BERNALILLO COUNTY HSG DEPT 244 244 NV001 CITY OF RENO HSG AUTHORITY 75 75 NV007 NORTH LAS VEGAS HOUSING AUTHORITY 71 71 NV013 COUNTY OF CLARK HOUSING AUTHORITY 333 333 NV018 Southern Nevada Regional HA 1175 1175 NV905 NEVADA RURAL HSG AUTH 75 75 NY001 HA OF SYRACUSE 135 135 NY002 BUFFALO MUNICIPAL HOUSING AUTH 400 400 NY005 NEW YORK CITY HOUSING AUTHORITY 1050 1050 NY027 CITY OF OSWEGO 30 30 NY028 HA OF SCHENECTADY 100 100 NY041 HA OF ROCHESTER 131 131 NY065 HA OF NORWICH 20 20 NY089 NEWARK HOUSING AUTHORITY 75 75 NY091 TOWN OF AMHERST 75 20 95 NY110 THE CITY OF NEW YORK 100 100 NY134 PORT JERVIS COMMUNITY DEVELOPMENT AGENCY 15 15 NY158 VILLAGE OF KIRYAS JOEL HOUSING AUTHORITY 50 50 NY408 TOWN OF COLONIE 20 20 NY422 TOWN OF GUILDERLAND 10 10 NY427 TOWN OF BETHLEHEM 10 10 NY430 TOWN OF NISKAYUNA 10 10 NY433 CITY OF JOHNSTOWN 29 29 NY443 CITY OF UTICA 200 200 NY516 TOWN OF ROTTERDAM 20 20 NY557 TOWN OF COEYMANS 10 10 NY561 TOWN OF STILLWATER 10 10 NY904 NYS Housing Trust Fund Corporation 350 350 OH001 COLUMBUS METRO. HA 805 805 OH002 YOUNGSTOWN MHA 26 26 OH003 CUYAHOGA MHA 400 400 OH004 CINCINNATI METROPOLITAN HSG.AUTH. 0 100 100 OH005 DAYTON METROPOLITAN HA 175 175 OH006 LUCAS MHA 240 60 300 OH009 ZANESVILLE MET HA 50 50 OH012 LORAIN MHA 175 175 OH014 JEFFERSON MHA 200 200 OH015 BUTLER MET.HA 200 200 OH018 STARK METROPOLITAN HOUSING AUTH. 100 100 OH021 SPRINGFIELD MET.HA 200 200 OH024 CHILLICOTHE MET HA 50 50 OH027 MEDINA MHA 10 10 OH038 CLERMONT MET.HSG AUTH. 75 75 OH040 JACKSON COUNTY HA 100 100 OH041 ATHENS MET HA 100 100 OH043 LICKING METRO HA 240 240 OH049 WARREN MET.HA 75 75 OH056 FAYETTE METRO HSG AUTH 50 50 OH059 PICKAWAY METROPOLITAN HOUSING AUTH. 41 41 OH063 TUSCARAWAS MHA 30 30 OH065 MIDDLETOWN PUBLIC HOUSING AGENCY 675 675 OH070 FAIRFIELD MHA 20 20 OH075 SENECA MHA 20 20 OH076 MARION METRO HOUSING AUTHORITY 75 75 OH079 DELAWARE METRO HOUSING AUTHORITY 95 95 OH081 BROWN METRO HOUSING AUTHORITY 7 7 OH082 HANCOCK MHA 600 600 OH083 MORROW METRO. HSG. AUT 30 30 OH085 BOWLING GREEN HA 20 20 OH086 HIGHLAND METROPOLITAN HOUSING AUTHORITY 50 50 OK002 OKLAHOMA CITY HOUSING AUTHORITY 250 250 OK073 TULSA HOUSING AUTHORITY 100 100 OK099 MUSKOGEE HOUSING AUTHORITY 200 200 OR002 HOUSING AUTHORITY OF PORTLAND 120 120 OR003 HOUSING AUTHORITY OF DOUGLAS COUNTY 25 25 OR011 HOUSING AUTHORITY OF THE CITY OF SALEM 100 100 OR015 HOUSING AUTHORITY OF JACKSON COUNTY 175 175 OR016 HOUSING AUTHORITY OF YAMHILL COUNTY 175 175 OR019 LINN-BENTON HOUSING AUTHORITY 100 100 OR028 NORTHWEST OREGON HOUSING AGENCY 95 95 OR034 CENTRAL OREGON REGIONAL HOUSING AUTHORITY 200 200 PA002 PHILADELPHIA HOUSING AUTHORITY 775 775 PA007 CHESTER HOUSING AUTHORITY 25 25 PA008 HARRISBURG HOUSING AUTHORITY 150 150 PA010 HSG AUTH OF THE COUNTY OF BUTLER 225 225 PA023 DELAWARE COUNTY HOUSING AUTHORITY 75 75 PA028 MONROE COUNTY HOUSING AUTHORITY 25 25 PA035 DAUPHIN COUNTY HOUSING AUTHORITY 50 10 60 PA046 HOUS AUTH OF THE CO OF CHESTER 100 100 PA051 BUCKS COUNTY HOUSING AUTHORITY 150 150 PA069 BLAIR COUNTY HOUSING AUTHORITY 25 25 PA079 HSG AUTHORITY OF THE COUNTY OF WARREN 25 25 PA081 LEHIGH COUNTY HOUSING AUTHORITY 290 290 PA082 HOUSING AUTHORITY OF UNION COUNTY 25 25 PA089 VENANGO COUNTY HOUSING AUTHORITY 50 50 PA090 REDEVELOPMENT AUTHORITY OF THE COUNTY OF LANCASTER 50 50 PA091 ADAMS COUNTY HOUSING AUTHORITY 14 14 RI003 WOONSOCKET H A 35 35 RI005 NEWPORT HOUSING AUTHORITY 100 100 RI007 EAST PROVIDENCE H A 40 40 RI009 JOHNSTON HOUSING AUTHORITY 50 50 RI010 CUMBERLAND HOUSING AUTHORITY 81 81 RI016 COVENTRY HOUSING AUTHORITY 100 100 RI017 NORTH PROVIDENCE HOUSING AUTHORITY 25 25 RI019 TOWN OF BRISTOL H A 65 65 RI022 WARREN HOUSING AUTHORITY 25 25 RI901 RHODE ISLAND HSG MORT FIN CORP 275 275 RQ056 MUNICIPALLITY OF VEGA ALTA 50 50 SC002 HA COLUMBIA 100 100 SC026 HA BEAUFORT 10 10 SC911 S C STATE HOUSING FINANCE & DEV 200 200 SD016 SIOUX FALLS HOUSING & REDEVELOPMENT COMMISSION 100 100 SD036 HURON HOUSING AUTHORITY 42 42 SD045 PENNINGTON COUNTY HSG & REDEVELOPMENT COMM 150 150 SD058 YANKTON HSG & REDEV COMMISSION 57 57 SD059 BUTTE COUNTY HOUSING & REDEVELOPMENT COMMISSION 20 20 TN003 KNOXVILLE COMMUNITY DEVEL CORP 175 175 TN004 CHATTANOOGA H/A 275 275 TN005 METROPOLITAN DEVELOPMNT & HSG AGNCY 800 800 TN088 HA OAK RIDGE 40 40 TX001 AUSTIN HOUSING AUTHORITY 0 36 36 TX005 HOUSTON HOUSING AUTHORITY 175 175 TX006 SAN ANTONIO HOUSING AUTHORITY 75 75 TX008 CORPUS CHRISTI HOUSING AUTHORITY 100 100 TX009 HOUSING AUTHORITY OF DALLAS 100 100 TX018 HOUSING AUTHORITY OF LUBBOCK 100 100 TX033 Housing Authority of Corsicana 75 75 TX431 TARRANT COUNTY HOUSING ASSISTANCE PROGRAM 175 175 TX433 ARLINGTON HOUSING AUTHORITY 175 175 TX461 WALKER COUNTY HOUSING AUTHORITY 45 45 TX470 HOUSING AUTHORITY OF SAN ANGELO 20 20 TX472 AMARILLO HOUSING AUTHORITY 103 103 TX480 TRAVIS COUNTY HOUSING AUTHORITY 75 75 TX512 DEEP EAST TX COUNCIL OF GOVTS 150 150 TX542 TEXOMA COUNCIL OF GOVERNMENTS 50 50 TX560 MONTGOMERY COUNTY HA 75 75 TX901 TEXAS DEPT HOUSING & COMMUNITY AFFAIRS 35 35 UT003 HOUSING AUTHORITY OF THE COUNTY OF SALT LAKE 25 25 UT004 HOUSING AUTHORITY OF SALT LAKE CITY 375 375 UT007 HOUSING AUTHORITY OF THE CITY OF PROVO 50 50 UT009 DAVIS COUNTY HOUSING AUTHORITY 75 75 UT011 HOUSING AUTHORITY OF UTAH COUNTY 100 100 UT025 WEST VALLEY CITY HOUSING AUTHORITY 100 100 UT026 LOGAN CITY HOUSING AUTHORITY 75 75 UT030 BEAR RIVER REGIONAL HOUSING AUTHORITY 75 75 UT031 CEDAR CITY HOUSING AUTHORITY 35 35 VA001 PORTSMOUTH REDEVELOPMENT & H/A 93 93 VA003 NEWPORT NEWS REDEVELOPMENT & HA 50 50 VA006 NORFOLK REDEVELOPMENT & H/A 225 225 VA014 HARRISONBURG REDEVELOPMENT & H/A 170 170 VA019 FAIRFAX CO RED AND HNG AUTHORITY 100 100 VA022 WAYNESBORO REDEVELOPMENT & H/A 20 20 VA039 CITY OF VIRGINIA BEACH 175 175 VA040 ACCOMACK-NORTHHAMPTON REGIONAL HOUSING AUTHORITY 150 150 VA046 PRINCE WILLIAM COUNTY 136 136 VA901 VIRGINIA HOUSING DEVELOPMENT AUTHORITY 75 75 VT001 BURLINGTON HOUSING AUTHORITY 527 527 VT005 BARRE HOUSING AUTHORITY 50 50 VT006 WINOOSKI HOUSING AUTHORITY 70 70 VT901 VERMONT STATE HOUSING AUTHORITY 275 275 WA001 SEATTLE HOUSING AUTHORITY 500 500 WA002 KING COUNTY HOUSING AUTHORITY 1250 1250 WA004 HOUSING AUTHORITY OF THE COUNTY OF CLALLAM 100 15 115 WA005 HOUSING AUTHORITY OF THE CITY OF TACOMA 0 100 100 WA006 HOUSING AUTHORITY CITY OF EVERETT 200 200 WA007 HOUSING AUTHORITY CITY OF LONGVIEW 400 35 435 WA008 HOUSING AUTHORITY OF THE CITY OF VANCOUVER 75 75 WA011 HA OF THE CITY OF RENTON 52 52 WA012 HOUSING AUTHORITY CITY OF KENNEWICK 150 150 WA024 HOUSING AUTHORITY OF ISLAND COUNTY 15 15 WA025 BELLINGHAM HOUSING AUTHORITY 75 75 WA036 KITSAP COUNTY CONSOLIDATED HOUSING AUTHORITY 25 25 WA039 HOUSING AUTHORITY OF SNOHOMISH COUNTY 305 50 355 WA042 HOUSING AUTHORITY OF THE CITY OF YAKIMA 0 15 15 WA049 HOUSING AUTHORITY OF THURSTON COUNTY 425 425 WA054 PIERCE COUNTY HOUSING AUTHORITY 200 200 WA055 SPOKANE HOUSING AUTHORITY 611 611 WA061 HOUSING AUTHORITY OF SKAGIT COUNTY 220 220 WI002 HA OF THE CITY OF MILWAUKEE 100 100 WI011 MARSHFIELD HA 45 45 WI083 WEST BEND HOUSING AUTHORITY 100 100 WI195 KENOSHA HOUSING AUTHORITY 100 100 WV001 CHARLESTON/KANAWHA HA 100 100 WV004 HUNTINGTON WV HOUSING AUTHORITY 156 156 WV009 THE CITY OF FAIRMONT HSG AUTH 75 75 WV037 HOUSING AUTHORITY OF MINGO COUNTY 200 200 Totals: 54093 948 55041

CMS’ Proposed Definition of “Home and Community-based Settings.” Information Bulletin #360 (6/2012). The Center for Medicare and Medicaid Services has issued its Proposed Rules which define what it means to live in “a home and community-based setting.” See 77 Federal Register at 26382. We think it is important for your voices to be heard and your comments must be submitted and received before 7/2/12. While some disability advocates have responded to CMS previously regarding the same issue, many providers and other service entrepreneurs (for profit and not-for-profit) have a different view regarding what “home and community-based setting” means. CMS, instead of just doing the right thing, seems to have gotten frightened by the outpouring from the providers and has requested additional comments. In a thumbnail, we always thought that people with disabilities want to live in settings just like people without disabilities with the same rights and responsibilities. What a revolutionary idea! Hmmm. Here are some points you might want to include if you write to CMS 1.Nondisabled people do not have their housing conditioned on whether or not they accept services. Therefore, housing rights for people with disabilities should be entirely separated from services that a person may or may not want, need or desire without any conditions related to services. 2. Nondisabled people are afforded the protections (and assume the responsibilities) from eviction under your State’s landlord tenant law. Therefore, disabled people should have the same rights, protections and responsibilities under your State’s landlord tenant law. 3. Nondisabled people, wherever they reside, have an absolute right, wherever they reside to the following minimum rights. Therefore, if a person with a disability resides in a “provider-owned or controlled residential setting,” the following minimum rights should be required – no wiggle room, no “if, and, or buts,” no presumptions of any kind that undercut or infringe on these minimums: a. A lease under the State’s landlord tenant law protecting against illegal evictions. b. Privacy in sleeping and living units. This means a lockable entrance. c. Sharing units ONLY if person with disability freely and knowingly wants to share and with person of one’s choice. d. Right to decorate sleeping and living units. e. Control own schedules and access to food at any time. f. Visitors of their choosing at any time. g. Physically accessible. Nondisabled persons would not consider it a “home” if they did not have ALL of these protections. Tell CMS no restrictions of basic housing rights for persons with disabilities. Tell CMS not to fund services in settings which do not comply.. Are we missing something? Aren’t these basic, minimal human rights? What does it matter if the person is disabled or nondisabled? Advocates -- send your comments to: Centers for Medicare & Medicaid Services Dept. of Health and Human Services Attention: CMS-2249-P2 P.O.Box 8016 Baltimore, MD 21244-8016 These must be received before July 2, 2012. 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.

Increasing Accessible Housing in Your Community Above the 5 Percent Minimum. Information Bulletin # 359 (6/2012). As you know from many previous Information Bulletins, State, cities, counties and private entities which receive “federal financial assistance” for housing – whether from the HOME Investment Partnership, Community Development Block Grants, Public Housing, and/or “project based” housing vouchers - must have “a minimum of five percent” of the units accessible for “persons with mobility impairments.” HUD’s federal regulations note that “HUD may prescribe a higher percentage [than five percent] … upon request by any affected recipient … based upon demonstration … of a need for a higher percentage based on census data … or evidence of a need for a higher percentage … in any manner.” What this means is that advocates must show HUD that your area needs more accessible housing than the minimum five percent. Here’s what advocates have to do to and how to do it. The Census Bureau’s American Fact Finder has completed the “2010 American Community Survey.’ Go to http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml There are two boxes: 1. “Topic or Table” and 2. “State, County or Place.” In the first box type Disability and in the second type the name of your State and then the name of your city or county. It’ll drop down and click on it. What will then pop up is a table with “S1810 Disability Characteristics”; click on it. Magically, a table entitled “Disability Characteristics” will appear with the name of your county or city. This table is divided both by age and type of impairment. In the column labeled “Estimate,” add up the three rows for “ambulatory” (listed by ages 5 -17, 18 -64, and 65 years and older). The sum of those three numbers should be divided by the number on the row entitled “Total civilian noninstitutionalized population” in the column labeled “Estimate”. The result is the 2010 Census percentage of persons with mobility impairments in your city or state. That is the lowest percent of persons who require accessible housing in your area. Advocates should keep in mind that the above percentage does NOT include any institutionalized persons! Obviously, if you know the number of mobility impaired persons in the institutions, whether nursing homes, state centers, state hospitals for persons with mental illness, intermediate care facilities for persons with intellectual disabilities, you should include that number so the percentage would be higher. If the percent computed from the 2010 American Community Survey in your area exceeds the minimum five percent that HUD established in 1988, advocates must request your locale HUD office to require the recipients of federal funds to increase the number of accessible units to the required percentage. Since the lack of accessible housing for persons with mobility impairments is an impediment to fair housing, and HUD requires Consolidated Plans to identify “Analyses of Impediments,” we expect HUD will be very cooperative with advocates to ensure this barrier/impediment is eliminated. After all, the housing with the barriers has been funded by HUD! 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.

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.

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.

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.

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.

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.

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.

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.

Medicaid Managed Care and Long-Term Services and Supports

Medicaid Managed Care and Long-Term Services and Supports: Information Bulletin # 351 (2/2012).

Medicaid managed care for persons who needed acute care, doctors, prescriptions, etc. has been around for years. In the past, States “carved out” persons with disabilities for, at least, “long-term services and supports,” i.e., nursing home institutions and community-based waivers, personal care options and home health.

Recently, the AARP and National Assn. of States United for Aging and Disabilities issued a report entitled “On the Verge: The Transformation of Long-Term Services and Supports.” In this Information Bulletin, we try to highlight some important points raised in this report. One important caveat is that not all States responded to the AARP/NASUAD survey.

1. 12 states already have Medicaid Managed Care for Long-Term Services and Supports, and another 11 states have plans for implementation in 2012 or 2013.

a. 13 have or require mandatory enrollment; 4 have not yet decided.
b. 4 States plan to expand statewide or to larger areas.
c. 5 States have or will require mandatory enrollment with opt-out, 2 states a voluntary opt-in, and 1 state both opt-in and opt-out.
d. 6 states have a mandatory enrollment and no opt-out.
e. Home and community-based services included in 18 States (10 of the 18 will include 1915(i) services), but 4 States excluded HCBS.
f. 15 states include nursing facilities in MMLTSS. Some states with existing MMLTSS include nursing facilities within their capitation rates.
g. 16 include self-directed personal care services

2. 28 states are focusing on integrating Medicare and Medicaid services for the dual eligibles – MA and Medicare. “On the Verge” wrote that “these individuals typically are poorer and sicker than other Medicare beneficiaries, use more health care services and thus account for a disproportionate share of both Medicare and Medicaid spending.”

a. 13 states integrate services for dual eligibles or have definite plans to do so. 8 are considering integrating.

3. Fewer states made cuts to Medicaid LTSS in 2011 than in 2010.

a. 6 states restricted HCBS benefits in 2011 and 2012.
b. 10 states increased HCBS Waiver expenditures by less than 5%, and 17 by more than 5%.

4. Of 36 responding States, 20 reported declines in MA nursing facility residents, 9 expected the number unchanged and 7 States had increases in the number of nursing home residents in 2010-11. In 2011-12, 17 reported a decrease, 15 stayed the same and 5 reported an increase.

5. With regards to taking advantage of various provisions in the Affordable Care Act, there was a lot of uncertainty due to the pending litigation. Nevertheless,

a. 21 States were considering the Balancing Incentive Program, 9 “don’t know,” and 3 decided to take advantage of the extra federal match.
b. 22 States were considering the 1915(i) State Plan Option, 3 decided they would definitely implement it, and 7 States reported they would not pursue it.
c. Despite the 6 enhanced federal percentage points, 18 States reported they were considering the Community First Choice Option, and 5 States indicated they definitely would implement.
6. In 2010, of the 39 States reporting, 17 increase nursing home provider reimbursement, 7 increased personal care and 9 waiver provider reimbursements. In 2011, of the 36 States reporting, 26 increased nursing home provider reimbursements, 3 States increased personal care, and 9 increased waivers.
7. In 2011, of the 36 States reporting, 25 decreased nursing home provider reimbursements, 6 decreased personal care and 8 decreased waiver provider reimbursements

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.

811 Rental Assistance for Non-Elderly Adults with Disabilities

811 Rental Assistance for Non-Elderly Adults with Disabilities, MFP and Medicaid. Information Bulletin #350 (2/2012).

In the next few months, HUD will issue a Request for Proposals pursuant to the Melville Housing Investment Act which will significantly impact on non-elderly disabled people both institutionalized and in the community. This Information Bulletin reviews one aspect of the Act where Disability Advocates should focus their advocacy.

The Melville Act provides for “Project Rental Assistance” grants – rent subsidies for low-income disabled persons. This rental assistance can be affixed to either a new or existing multifamily project that (primarily) receives low-income housing tax credits or HOME Investment Partnership assistance. Most likely, your State housing finance agency, the entity that administers your LIHTC, will be the applicant for this rental assistance.

However, there is another State Agency which is critical - your Medicaid state agency -- the same state agency which funds Money Follows the Person grants and the same state agency that funds nursing homes and home and community-based services via Medicaid’s waiver or personal care option programs.

Here’s how the two State agencies fit together with regards to Project Rental Assistance grants.

Before a State housing finance agency (or other agency) can apply for project rental assistance funds, the State housing finance agency must have “entered into [an] agreement” with your State Medicaid agency. Statutorily, this written agreement must:

1. “identify the target populations to be served by the project;”
2. “set forth methods for outreach and referral” to receive the project rental assistance grants; and
3. “make available appropriate services for tenants of the project,” if services are necessary.

Therefore, MFP programs, CILs, and other disability advocates must:

1. Make sure your State Medicaid office’s written agreement with the State housing finance agency targets potential MFP consumers. These project rental assistance grants provide housing subsidies institutionalized people desperately need.
2. Get your outreach and referrals ready to roll.
3. Determine what services a person might need to transition out of the institution. Be specific.

Your State housing finance agency cannot apply for these housing funds without your State Medicaid agency’s agreement. This means that your State Medicaid agency can ensure that these Project Rental Assistance grants are used to transition people out of institutions and addresses the MFP population.

We will send another Information Bulletin when HUD issues its RFP, but MFP, CILs, and other disability advocates should initiate a dialogue NOW with your state Medicaid officials. Don’t wait. Do it now.

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.