Thursday, April 26, 2012
Mortgage Foreclosures and People with Disabilities. Information Bulletin #356 (4/2012)
On Sunday, April 22, 2012, Secretary of HUD, Shaun Donovan, met with several hundred ADAPT members in Washington, D.C. During a lively question and answer period, one suggestion particularly raised our interest and we wanted to share it. This suggestion to Secretary Donovan came via ADAPT member Eleanor Smith founder of Concrete Change.
Several million families have lost their homes to mortgage foreclosures in the past few years. Many of these foreclosed homes stand vacant.
These homes are owned by HUD, Fannie Mae, Freddie Mac, and/or many, many banks.
Here is a suggestion that could have a direct impact on people with disabilities who need accessible housing.
HUD, Fannie Mae, Freddie Mac and the Banks which hold these foreclosed homes should:
1. Identify (and publicize) which of these homes have a “no step” entrance and/or a one-step entrance.
2. Prioritize these homes, using the no step properties before the one step units.
3. Identify those foreclosed homes which also have a bathroom where the door entrance could be widened to 32” without moving a wall.
Those identified properties are the easiest and cheapest to make minimally accessible.
4. Require that this basic access be built into the resale of each foreclosed home.
5. Those identified properties should be advertised to people (and families) with disabilities who need accessible homes.
6. Funds for both making these units accessible and for purchasing them exist in your local and state-wide HOME Investment Partnership program and the Community Development Block Grant program and probably other programs.
7. Tax credits (banks always like those) and tax deductions are available to meet accessibility costs.
If your community has addressed this issue, please send us information.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Wednesday, April 18, 2012
Affordable, Accessible Low-Income Housing Tax Credit Apartments in Pennsylvania.
Affordable, Accessible Low-Income Housing Tax Credit Apartments in Pennsylvania. Information Bulletin # 355 (4/2012)
In 2003-04, Philadelphia’s Liberty Resources Center (“CIL”) and Pennsylvania ADAPT met with officials from the Pennsylvania Housing Finance Agency (“PHFA”), the state agency that administers the federal Low-Income Housing Tax Credit program. The purpose of the meetings was to explain the dire housing needs of low-income persons with disabilities, to advocate for increasing affordable, accessible housing, and to ensure accessible units were actually occupied by people who needed those features.
This Information Bulletin describes the successful results of those advocacy efforts.
In 2005, PHFA first offered incentives to LIHTC housing developers to increase the number of accessible apartments and to make them affordable at 20% of the Area Median Income (AMI). A special internal management fee was made available so housing developers could deeply subsidize units to an affordable level.
As a result of this and other PHFA initiatives, as of 12/31/2011 there were more than 1250 affordable and/or accessible apartments financed with LIHTC (but about half have not been completed or were not occupied at that time) in Pennsylvania.
The 20% AMI affordability structure is based on the goal that these apartments should be affordable to households whose only income is Social Security Income. The SSI level is sufficient to pay rent without being rent “burdened” in 38 of Pennsylvania’s 67 counties and is within $1000 annual income in 12 additional counties.
PHFA works with the Pennsylvania Department of Public Welfare, the Medicaid state agency that is supposed to move people from nursing homes to the community, in their effort to establish local clearinghouse organizations to streamline the process for assuring that appropriate candidates are referred in a timely fashion for specific income, accessibility and service targeted units.
Here are the results:
• Of the 634 accessible units actually occupied (as distinguished from “financed) as of 12/31/2011, 78% were occupied by people needing the accessibility features.
• This means there were 495 affordable, accessible LITCH apartments occupied by 495 people and their families who are on SSI and require an accessible unit.
• 48% of households occupying these units are at or below 20% of the Area Median Income. (This includes persons using housing choice vouchers and other rental assistance resources, as well as the tax credit units affordable at 20% AMI.)
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
In 2003-04, Philadelphia’s Liberty Resources Center (“CIL”) and Pennsylvania ADAPT met with officials from the Pennsylvania Housing Finance Agency (“PHFA”), the state agency that administers the federal Low-Income Housing Tax Credit program. The purpose of the meetings was to explain the dire housing needs of low-income persons with disabilities, to advocate for increasing affordable, accessible housing, and to ensure accessible units were actually occupied by people who needed those features.
This Information Bulletin describes the successful results of those advocacy efforts.
In 2005, PHFA first offered incentives to LIHTC housing developers to increase the number of accessible apartments and to make them affordable at 20% of the Area Median Income (AMI). A special internal management fee was made available so housing developers could deeply subsidize units to an affordable level.
As a result of this and other PHFA initiatives, as of 12/31/2011 there were more than 1250 affordable and/or accessible apartments financed with LIHTC (but about half have not been completed or were not occupied at that time) in Pennsylvania.
The 20% AMI affordability structure is based on the goal that these apartments should be affordable to households whose only income is Social Security Income. The SSI level is sufficient to pay rent without being rent “burdened” in 38 of Pennsylvania’s 67 counties and is within $1000 annual income in 12 additional counties.
PHFA works with the Pennsylvania Department of Public Welfare, the Medicaid state agency that is supposed to move people from nursing homes to the community, in their effort to establish local clearinghouse organizations to streamline the process for assuring that appropriate candidates are referred in a timely fashion for specific income, accessibility and service targeted units.
Here are the results:
• Of the 634 accessible units actually occupied (as distinguished from “financed) as of 12/31/2011, 78% were occupied by people needing the accessibility features.
• This means there were 495 affordable, accessible LITCH apartments occupied by 495 people and their families who are on SSI and require an accessible unit.
• 48% of households occupying these units are at or below 20% of the Area Median Income. (This includes persons using housing choice vouchers and other rental assistance resources, as well as the tax credit units affordable at 20% AMI.)
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Thursday, March 29, 2012
Comparing States on Access to Community-Based Services
Comparing States on Access to Community-Based Services. Information Bulletin #354 (3/2012).
There are various criteria one can use to evaluate a State’s commitment to provide services to persons with disabilities in the community instead of in an institution. The Kaiser Commission used four criteria together and ranked states. See “State Options That Expand Access to Medicaid Home and Community-Based Services,” [HCBS] [10/11], http://www.kff.org/medicaid/8241.cfm
The four criteria used are:
1. Participants receiving HCBS Per 1,000 Population in the State. Using this criterion eliminates differences among States with regards to size, wealth, and per capita. It says for every 1,000 persons (with and without a disability) in a State, how many people with disabilities receive HCBS.
2. Expenditures Per Capita. This criterion divides the total number of people in a State (with and without a disability) by the total HCBS expenditures for people with disabilities. The “per capita” is what each person in a State pays for HCBS. This eliminates State differences regarding wealthy states, big/small, etc.
3. % of HCBS to Total Medicaid Long-Term Care Participants. This looks at the total Medicaid number of people with disabilities in both the community and institutions, and shows the percentage of the total number of people with disabilities (in both the community and institutions) who receive Medicaid services in the community.
4. % of HCBS to Total Medicaid Long-Term Care Expenditures. Whereas #3 compares % of people with disabilities who receive services in the community, this criterion looks at the total Medicaid expenditures – the money – for people with disabilities in both the community and institutions, and shows the % of the total expenditures (again in both the community and institutions) spent in the community.
Here are the worst States using each criterion.
#1 Criterion - National average per 1,000 is 9.34. Best in country is 15.36. Worst:
HI 5.15
DE 5.03
NV 4.62
AL 4.61
MD 4.48
IN 3.86
UT 3.56
TN 3.42
VA 3.30
GA 3.22
#2 Criterion - National average per capita expenditure is $166. Best in country is $487. Worst:
AL $93
MI $84
FL $81
GA $76
IL $71
UT $64
MS $61
NV $59
# 3 Criterion - % of HCBS to total participants. National average is 62%. Best in country is 86%. Worst:
FL 46%
OH 45%
LA 45%
AL 45%
MS 44%
RI 44%
GA 43%
TN 37%
IN 34%
#4 Criterion - % of HCBS Expenditures to total expenditures. National average is 45%. Best is 83%. Worst:
AR 34%
KY 33%
IN 33%
AL 31%
NJ 31%
ND 30%
IL 30%
MS 30%
Caveats – A. this data includes both people with intellectual disabilities and people with physical and all other disabilities. Using these four criteria but focused on only ID or only A/PD would show different results; B. this data is a few years old.
Nevertheless, the data shows which States were far below the national average and overwhelmingly below the best States, and which States were not committed to implementing the ADA or complying with the Olmstead decision.
Disability Advocates - the ball is on your side of the court. Only you can change your States. Don’t expect CMS to do it. Don’t assume DOJ (or any other agency) will ride in to fix up your problem. Don’t think your Governor will see the light. If your State is among the worst, the responsibility is yours.
Power Concedes Nothing Without A Struggle. F. Douglas
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
There are various criteria one can use to evaluate a State’s commitment to provide services to persons with disabilities in the community instead of in an institution. The Kaiser Commission used four criteria together and ranked states. See “State Options That Expand Access to Medicaid Home and Community-Based Services,” [HCBS] [10/11], http://www.kff.org/medicaid/8241.cfm
The four criteria used are:
1. Participants receiving HCBS Per 1,000 Population in the State. Using this criterion eliminates differences among States with regards to size, wealth, and per capita. It says for every 1,000 persons (with and without a disability) in a State, how many people with disabilities receive HCBS.
2. Expenditures Per Capita. This criterion divides the total number of people in a State (with and without a disability) by the total HCBS expenditures for people with disabilities. The “per capita” is what each person in a State pays for HCBS. This eliminates State differences regarding wealthy states, big/small, etc.
3. % of HCBS to Total Medicaid Long-Term Care Participants. This looks at the total Medicaid number of people with disabilities in both the community and institutions, and shows the percentage of the total number of people with disabilities (in both the community and institutions) who receive Medicaid services in the community.
4. % of HCBS to Total Medicaid Long-Term Care Expenditures. Whereas #3 compares % of people with disabilities who receive services in the community, this criterion looks at the total Medicaid expenditures – the money – for people with disabilities in both the community and institutions, and shows the % of the total expenditures (again in both the community and institutions) spent in the community.
Here are the worst States using each criterion.
#1 Criterion - National average per 1,000 is 9.34. Best in country is 15.36. Worst:
HI 5.15
DE 5.03
NV 4.62
AL 4.61
MD 4.48
IN 3.86
UT 3.56
TN 3.42
VA 3.30
GA 3.22
#2 Criterion - National average per capita expenditure is $166. Best in country is $487. Worst:
AL $93
MI $84
FL $81
GA $76
IL $71
UT $64
MS $61
NV $59
# 3 Criterion - % of HCBS to total participants. National average is 62%. Best in country is 86%. Worst:
FL 46%
OH 45%
LA 45%
AL 45%
MS 44%
RI 44%
GA 43%
TN 37%
IN 34%
#4 Criterion - % of HCBS Expenditures to total expenditures. National average is 45%. Best is 83%. Worst:
AR 34%
KY 33%
IN 33%
AL 31%
NJ 31%
ND 30%
IL 30%
MS 30%
Caveats – A. this data includes both people with intellectual disabilities and people with physical and all other disabilities. Using these four criteria but focused on only ID or only A/PD would show different results; B. this data is a few years old.
Nevertheless, the data shows which States were far below the national average and overwhelmingly below the best States, and which States were not committed to implementing the ADA or complying with the Olmstead decision.
Disability Advocates - the ball is on your side of the court. Only you can change your States. Don’t expect CMS to do it. Don’t assume DOJ (or any other agency) will ride in to fix up your problem. Don’t think your Governor will see the light. If your State is among the worst, the responsibility is yours.
Power Concedes Nothing Without A Struggle. F. Douglas
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Friday, March 23, 2012
Why Does CMS Not Confront the Institutional Nursing Home Bias Against People With Disabilities.
Why Does CMS Not Confront the Institutional Nursing Home Bias Against People With Disabilities. Information Bulletin #353 (3/2012)
The federal agency, the Centers for Medicare and Medicaid Services (CMS), funds virtually every nursing home in the country. Last week, CMS announced a “new initiative” which is aimed “to improve the quality of care for people residing in nursing homes.” However, this “new initiative” will neither prevent institutionalization nor transition people out of nursing homes. Nor does it even address those issues.
What is this “new initiative”? CMS states that “45% of hospital admissions among [nursing home residents] could have been avoided.” That’s 314,000 people with disabilities who reside in nursing homes funded by CMS who, due to the neglect of the nursing homes, wind up needing unnecessary – i.e., preventable -- hospitalizations!
Why has CMS proposed this “new initiative”? To save $2.6 billion in Medicaid and Medicare expenditures which CMS pays for these unnecessary hospitalizations of nursing home residents. The nursing homes do not pay – CMS and your States pay.
Obviously, “unnecessary hospitalizations” should be avoided. Many of these hospitalizations are from bedsores persons in nursing home develop. Why? People with disabilities are not repositioned on a regular basis in nursing homes. Why aren’t they? Take a guess. So CMS has a financial interest in not paying $2.6 billion in hospital costs for the nursing homes’ neglect.
Let’s look at what the CMS “new initiative” to prevent unnecessary hospitalizations will do:
1. “facilitate residents’ transitions to and from inpatient hospitals and nursing homes;”
2. “hire staff … to implement preventive services;” and
3. “work in cooperation with existing providers.”
Okay. Let’s focus on CMS’ financial interest as the primary motivating factor. Here are some suggestions that have been made for years, but for which CMS apparently does not deem important enough to address with a “new initiative.” Each one will produce significant financial savings, the obvious critical CMS motivating factor.
First, about 60.8% of nursing home residents’ admissions come directly from acute care hospitals – that’s 803,743 people. Now these hospitals are required by CMS’ existing federal regulations to do “discharge planning” which is supposed to include community-based services. If this were really happening, then people with disabilities would be offered Medicare and Medicaid services in their own homes and in the community – not forced to go to a nursing home institution without being offered appropriate and adequate community-based services.
Where is the CMS “new incentive” to require acute care hospitals to really do this discharge planning? Why has CMS neither enforced its own existing regulations or developed an incentive so that people in acute care hospitals are at least offered appropriate and adequate services in their own homes and not only in nursing facilities?
Remember, one of the CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “facilitate residents’ transitions to and from inpatient hospitals and nursing homes”? Why not the same initiative to facilitate transition from acute care hospitals to our own homes instead of to nursing homes?
Second, the recent AARP Raising ExpectationsScorecard report noted that more than at least 201,531persons with disabilities could be “new users of Medicaid long-term care services” who “would first receive services in their home and community based settings instead of nursing homes.” Yes, at least 201,531 people received their first Medicaid benefits in nursing institutions, instead of in the community.
CMS’ existing regulations require persons with disabilities be offered a real choice before they go into nursing homes. Living in the community instead of a nursing home institution saves big Medicaid money. CMS could save significant funds by enforcing their own regulations.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “hire staff … to implement preventive services” to avoid unnecessary hospitalizations. Why not a similar initiative to avoid unnecessary institutionalizations?
Third, the same AARP Raising Expectation report notes that there were hundreds of thousands of Medicaid nursing home “residents with low care needs [who could] be able to receive long term services in the community.” Now that’s not a novel idea under the ADA and Olmstead decision. These people are “unnecessarily institutionalized” and could/should be residing in the community with appropriate and adequate services.
Why has CMS not required States to offer these “low care needs” residents appropriate and adequate services in the community? Transitioning people to their own homes, with appropriate and adequate services, saves CMS and States money.
Fourth, the Minimum Data Set identifies persons with disabilities who are in nursing homes who state they want to live in the community. Why does CMS not require each State to end the “unnecessary institutionalization” of these people and make States comply with the ADA and Olmstead decision? CMS could require a very detailed written service plan which lists the specific services, amounts of services, hours, supports, etc., each person could receive in the community? We know the name and address of each of these people.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “work in cooperation with existing providers.” Why not a similar initiative to transition these people out of institutions? We do not expect the nursing homes to have the desire, interests or knowledge to write these plans. Why not hire ILCs to go into these nursing homes, work with each of these residents, and have the ILCs develop the specific written plan that the State Medicaid office will implement?
Sure CMS should avoid “unnecessary hospitalizations” and save money. But CMS should also avoid “unnecessary institutionalization” in nursing homes and save money.
We know CMS can play hardball when it wants. Recently, it stood up to Texas and cut off $35 million in Medicaid funds for that State’s refusal to provide women on Medicaid with health care services provided by Planned Parenthood.
Each year CMS knows which States have huge and growing waiting lists to prevent people from being unnecessarily institutionalized into nursing facilities and from transitioning out of nursing facilities. This occurs throughout the country. Why does CMS not cut off those States’ nursing home funds the same is it went after Texas?
Disability Advocates - use the AARP Raising Expectations report for your state and tell your newspapers, elected officials, and candidates for office how they can save Medicaid funds while implementing the ADA and Olmstead.
It’s really a sad commentary that CMS has not applied to nursing homes the historically lessons we have learned from institutions for persons with mental illness and for persons with intellectual disabilities.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
The federal agency, the Centers for Medicare and Medicaid Services (CMS), funds virtually every nursing home in the country. Last week, CMS announced a “new initiative” which is aimed “to improve the quality of care for people residing in nursing homes.” However, this “new initiative” will neither prevent institutionalization nor transition people out of nursing homes. Nor does it even address those issues.
What is this “new initiative”? CMS states that “45% of hospital admissions among [nursing home residents] could have been avoided.” That’s 314,000 people with disabilities who reside in nursing homes funded by CMS who, due to the neglect of the nursing homes, wind up needing unnecessary – i.e., preventable -- hospitalizations!
Why has CMS proposed this “new initiative”? To save $2.6 billion in Medicaid and Medicare expenditures which CMS pays for these unnecessary hospitalizations of nursing home residents. The nursing homes do not pay – CMS and your States pay.
Obviously, “unnecessary hospitalizations” should be avoided. Many of these hospitalizations are from bedsores persons in nursing home develop. Why? People with disabilities are not repositioned on a regular basis in nursing homes. Why aren’t they? Take a guess. So CMS has a financial interest in not paying $2.6 billion in hospital costs for the nursing homes’ neglect.
Let’s look at what the CMS “new initiative” to prevent unnecessary hospitalizations will do:
1. “facilitate residents’ transitions to and from inpatient hospitals and nursing homes;”
2. “hire staff … to implement preventive services;” and
3. “work in cooperation with existing providers.”
Okay. Let’s focus on CMS’ financial interest as the primary motivating factor. Here are some suggestions that have been made for years, but for which CMS apparently does not deem important enough to address with a “new initiative.” Each one will produce significant financial savings, the obvious critical CMS motivating factor.
First, about 60.8% of nursing home residents’ admissions come directly from acute care hospitals – that’s 803,743 people. Now these hospitals are required by CMS’ existing federal regulations to do “discharge planning” which is supposed to include community-based services. If this were really happening, then people with disabilities would be offered Medicare and Medicaid services in their own homes and in the community – not forced to go to a nursing home institution without being offered appropriate and adequate community-based services.
Where is the CMS “new incentive” to require acute care hospitals to really do this discharge planning? Why has CMS neither enforced its own existing regulations or developed an incentive so that people in acute care hospitals are at least offered appropriate and adequate services in their own homes and not only in nursing facilities?
Remember, one of the CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “facilitate residents’ transitions to and from inpatient hospitals and nursing homes”? Why not the same initiative to facilitate transition from acute care hospitals to our own homes instead of to nursing homes?
Second, the recent AARP Raising ExpectationsScorecard report noted that more than at least 201,531persons with disabilities could be “new users of Medicaid long-term care services” who “would first receive services in their home and community based settings instead of nursing homes.” Yes, at least 201,531 people received their first Medicaid benefits in nursing institutions, instead of in the community.
CMS’ existing regulations require persons with disabilities be offered a real choice before they go into nursing homes. Living in the community instead of a nursing home institution saves big Medicaid money. CMS could save significant funds by enforcing their own regulations.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “hire staff … to implement preventive services” to avoid unnecessary hospitalizations. Why not a similar initiative to avoid unnecessary institutionalizations?
Third, the same AARP Raising Expectation report notes that there were hundreds of thousands of Medicaid nursing home “residents with low care needs [who could] be able to receive long term services in the community.” Now that’s not a novel idea under the ADA and Olmstead decision. These people are “unnecessarily institutionalized” and could/should be residing in the community with appropriate and adequate services.
Why has CMS not required States to offer these “low care needs” residents appropriate and adequate services in the community? Transitioning people to their own homes, with appropriate and adequate services, saves CMS and States money.
Fourth, the Minimum Data Set identifies persons with disabilities who are in nursing homes who state they want to live in the community. Why does CMS not require each State to end the “unnecessary institutionalization” of these people and make States comply with the ADA and Olmstead decision? CMS could require a very detailed written service plan which lists the specific services, amounts of services, hours, supports, etc., each person could receive in the community? We know the name and address of each of these people.
Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “work in cooperation with existing providers.” Why not a similar initiative to transition these people out of institutions? We do not expect the nursing homes to have the desire, interests or knowledge to write these plans. Why not hire ILCs to go into these nursing homes, work with each of these residents, and have the ILCs develop the specific written plan that the State Medicaid office will implement?
Sure CMS should avoid “unnecessary hospitalizations” and save money. But CMS should also avoid “unnecessary institutionalization” in nursing homes and save money.
We know CMS can play hardball when it wants. Recently, it stood up to Texas and cut off $35 million in Medicaid funds for that State’s refusal to provide women on Medicaid with health care services provided by Planned Parenthood.
Each year CMS knows which States have huge and growing waiting lists to prevent people from being unnecessarily institutionalized into nursing facilities and from transitioning out of nursing facilities. This occurs throughout the country. Why does CMS not cut off those States’ nursing home funds the same is it went after Texas?
Disability Advocates - use the AARP Raising Expectations report for your state and tell your newspapers, elected officials, and candidates for office how they can save Medicaid funds while implementing the ADA and Olmstead.
It’s really a sad commentary that CMS has not applied to nursing homes the historically lessons we have learned from institutions for persons with mental illness and for persons with intellectual disabilities.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
Thursday, February 23, 2012
Considerations Regarding Managed Care, People with Disabilities
Considerations Regarding Managed Care, People with Disabilities and 1115 Waivers. Information Bulletin # 352 (2/2012)
As discussed in the last Information Bulletin, the AARP and NASUAD recently released report “On the Verge: The Transformation of Long-Term Services and Supports” pointed out that 12 states already have Medicaid Managed Long Term Services and Supports (MMLTSS) and another 11 states report plans to implement managed care LTSS in 2012 and 2013.
Here are some points that advocates might want to consider about managed care for people with disabilities.
1. There should be a “blended rate” per person with a disability. That is, your state should enter a contract to pay the managed care entity the same rate per person whether the person is in the community or in a nursing home, a state center or an ICF-MR. This gives the managed care entity an incentive to provide services in the community.
2. Blended rates contain assumptions, based on your state’s previous year’s data regarding the numbers of people receiving LTSS services in the community and in a nursing home.
3. Publish and mandate “performance requirements,” e.g., what must be in an assessment and care plan. Make sure services in a care plan are actually developed and provided in the community within 15-30 days of the assessment and agreed on care plan.
4. Require Quality Improvement Reports [QIOs], conducted by separate, outside, independent contractors to evaluate the managed care entity’s performance. CILs are a natural for this.
5. Make sure that appeal rights and clearly delineated, especially with regards to type and amount of community-based services.
6. Build into the contract with the managed care entity both carrots and sticks, i.e., if there is too high an admission rate to institutions with managed care, penalize them via the capitation rate. Similarly, if they serve more people in the community than was anticipated, reward them the same way.
7. Build in specific incentives to keep people in the community with home and community-based services, including self-direction, relatives being paid for personal assistance services.
8. Do no permit “carve outs” regarding location of service. That is, the managed care company should be fully and entirely responsible for both institutional and community-based services for as long as a person is MA eligible. In managed-care parlance, there should be no “risk corridors” whereby the State assumes payment of institutional care if the person is instititutionalized for a specific number of days. This should give managed care companies a financial incentive to serve persons with adequate and appropriate community-based services.
9. Do not permit “carve outs” based on type of disability. If managed care is good and proper for some people with disabilities, it can and should serve people with any disability.
10. Every disabled person who is currently on MA, regardless whether s/he is in the community or in an institution should be part of the managed care program and capitation rate.
11. Require the managed care entity to have a “transition out” program for persons already institutionized. The capitation rate could include one-time transition costs to ensure people already institutionalized received the start-up items they require.
12. We know that many people with disabilities go directly from an acute care hospital to an institution without being offered any real choice and without adequate and appropriate community-based services being offered. Therefore, make sure the managed care contract has a requirement that the managed care entity and the hospitals must enter an agreement to ensure hospitals do not continue dumping people with disabilities in nursing homes.
We know that many advocates are vehemently against managed care for people with disabilities. The purpose of this Information Bulletin is not to advocate for or against MMLTSS. Rather, since 23 states have left or are leaving the station, we think there should be some public dialogue.
Special thanks to Leslie Hendrickson for his time, insights and suggestions.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
As discussed in the last Information Bulletin, the AARP and NASUAD recently released report “On the Verge: The Transformation of Long-Term Services and Supports” pointed out that 12 states already have Medicaid Managed Long Term Services and Supports (MMLTSS) and another 11 states report plans to implement managed care LTSS in 2012 and 2013.
Here are some points that advocates might want to consider about managed care for people with disabilities.
1. There should be a “blended rate” per person with a disability. That is, your state should enter a contract to pay the managed care entity the same rate per person whether the person is in the community or in a nursing home, a state center or an ICF-MR. This gives the managed care entity an incentive to provide services in the community.
2. Blended rates contain assumptions, based on your state’s previous year’s data regarding the numbers of people receiving LTSS services in the community and in a nursing home.
3. Publish and mandate “performance requirements,” e.g., what must be in an assessment and care plan. Make sure services in a care plan are actually developed and provided in the community within 15-30 days of the assessment and agreed on care plan.
4. Require Quality Improvement Reports [QIOs], conducted by separate, outside, independent contractors to evaluate the managed care entity’s performance. CILs are a natural for this.
5. Make sure that appeal rights and clearly delineated, especially with regards to type and amount of community-based services.
6. Build into the contract with the managed care entity both carrots and sticks, i.e., if there is too high an admission rate to institutions with managed care, penalize them via the capitation rate. Similarly, if they serve more people in the community than was anticipated, reward them the same way.
7. Build in specific incentives to keep people in the community with home and community-based services, including self-direction, relatives being paid for personal assistance services.
8. Do no permit “carve outs” regarding location of service. That is, the managed care company should be fully and entirely responsible for both institutional and community-based services for as long as a person is MA eligible. In managed-care parlance, there should be no “risk corridors” whereby the State assumes payment of institutional care if the person is instititutionalized for a specific number of days. This should give managed care companies a financial incentive to serve persons with adequate and appropriate community-based services.
9. Do not permit “carve outs” based on type of disability. If managed care is good and proper for some people with disabilities, it can and should serve people with any disability.
10. Every disabled person who is currently on MA, regardless whether s/he is in the community or in an institution should be part of the managed care program and capitation rate.
11. Require the managed care entity to have a “transition out” program for persons already institutionized. The capitation rate could include one-time transition costs to ensure people already institutionalized received the start-up items they require.
12. We know that many people with disabilities go directly from an acute care hospital to an institution without being offered any real choice and without adequate and appropriate community-based services being offered. Therefore, make sure the managed care contract has a requirement that the managed care entity and the hospitals must enter an agreement to ensure hospitals do not continue dumping people with disabilities in nursing homes.
We know that many advocates are vehemently against managed care for people with disabilities. The purpose of this Information Bulletin is not to advocate for or against MMLTSS. Rather, since 23 states have left or are leaving the station, we think there should be some public dialogue.
Special thanks to Leslie Hendrickson for his time, insights and suggestions.
Steve Gold, The Disability Odyssey continues
Back issues of other Information Bulletins are available online at http://www.stevegoldada.com
with a searchable Archive at this site divided into different subjects.
As of August, 2010, Information Bulletins will also be posted on my blog located at http://stevegoldada.blogspot.com/
To contact Steve Gold directly, write to stevegoldada1@gmail.com or call 215-627-7100. Ext 227.
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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