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.
Thursday, February 23, 2012
Tuesday, February 14, 2012
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.
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.
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.
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