The Money Follows the Person Demonstration in Massachusetts

Transcription

1 The Money Follows the Person Demonstration in Massachusetts Use of Concurrent 1915(b)(c) Waivers to Serve Elders and Adults with Disabilities Transitioning from Long-Stay Facilities HCBS Conference Arlington, VA September 2013

2 Agenda Massachusetts MFP Demonstration implementation strategies MFP 1915(c) waivers and the waiver services offered Concurrent operation of a 1915(b) waiver challenges in developing the waiver, operational issues and expected benefits 2

3 Massachusetts MFP Demonstration implementation strategies MFP Demonstration operation began with utilization of existing 1915(c) waivers as the most appropriate source of LTSS for Demonstration participants State submitted applications for additional MFP waivers to address a broad population Goal to include a managed behavioral health benefit for this population Determined that concurrent waivers would support the target population in a better way than 1915(c) waivers plus state plan behavioral health services 3

4 Money Follows the Person 1915(c) Waivers Massachusetts applied and received CMS approval for two additional HCBS waivers to serve elders and disabled adults MFP Community Living (MFP-CL) Waiver For participants who do not need 24-hour supports or supervision Provides access to a variety of community-based waiver services MFP Residential Supports (MFP-RS) Waiver Participants who require 24-hour staff availability and/or supervision and receive services in provider-operated and staffed settings Residential habilitation in a group home serving no more than 4 individuals Assisted living services Shared living 4

5 MFP Waiver Eligibility Applicants must: Be living in a nursing home or long-stay hospital for at least 90 consecutive days, excluding Medicare rehabilitation days; Be 18 years old or older and have a disability, or be age 65 or older; Meet the requirements for participation in the MFP Demonstration, including transitioning to an MFP qualified residence in the community; Participants must be able to be safely served in the community within the terms of the waivers. All participants in the MFP 1915(c) waivers are enrolled in a managed behavioral health benefit 5

6 MFP Community Living Waiver The MFP-CL Waiver is for participants who do not need 24-hour supports or supervision Case Manager and Participant must do risk assessment and develop 24-hour back up plan Service Limit of 12-hours per day on the following services, separately, or in combination: Homemaker Home Health Aide Personal Care Adult Companion Individual Support and Community Habilitation Supportive Home Care Aide 6

7 MFP Community Living Waiver Services Adult Companion Chore Service Community Family Training Day Services Home Accessibility Adaptations Home Health Aide Homemaker Independent Living Supports Individual Support and Community Habilitation Occupational Therapy Peer Support Personal Care Physical Therapy Prevocational Services Respite Shared Home Supports Skilled Nursing Specialized Medical Equipment Speech Therapy Supported Employment Supportive Home Care Aide Transportation Vehicle Modification 7

8 MFP Residential Supports Waiver The MFP-RS Waiver is for participants who need 24-hour staff availability and/or supervision The Participant must be assessed to need a residential support service within the terms of the MFP-RS waiver Case Manager and Participant must do risk assessment and develop 24-hour back up plan Provides access to 3 types of residential supports: Group Home (up to 4 residents) Shared Living 24-hr supports MFP-qualified Assisted Living 8

9 MFP Residential Supports Waiver Services Residential Habilitation (group home) Shared Living 24 Hour Supports Assisted Living Services Day Services Home Accessibility Adaptations Individual Support and Community Habilitation Occupational Therapy Peer Support Physical Therapy Prevocational Services Residential Family Training Skilled Nursing Specialized Medical Equipment Speech Therapy Supported Employment Transportation 9

10 Participant Direction in MFP Waivers The MFP Waivers allow participant to self-direct certain waiver services Employer Authority - allows the participant to select, train, schedule and supervise their own worker Fiscal Intermediary will process payroll including handling withholdings and taxes A support broker can be available Self-Directed Services with Employer Authority MFP-CL Waiver MFP-RS Waiver Adult Companion Y NA Chore Services Y NA Homemaker Y NA Individual Support and Community Habilitation Y Y Peer Support Y Y Waiver Personal Care Y NA 10

11 MFP 1915(b) Waiver (MFP-BH) Members participating in either the MFP-CL or MFP-RS waiver will receive managed behavioral health services, primarily through enrollment in the Massachusetts Behavioral Health Partnership (MBHP) Access to managed behavioral health services will help to address the significant role that behavioral health issues play in undermining community stability and precipitating institutional placement The MFP-BH Waiver provides access to the full range of community, outpatient, and inpatient services through MBHP for all such participants. 11

12 Massachusetts Behavioral Health Partnership NCQA accredited Covers 430,000 members enrolled in MassHealth PCC Plan Over 120,000 members access care each year Utilizes a network of 1,400 credentialed clinics, facilities, and providers for inpatient, diversionary, outpatient, emergency, and other behavioral health services MBHP undertakes Provider contracting and credentialing Utilization management Quality management for behavioral health and primary care clinicians Claims payment Fraud and abuse monitoring 12

13 Managed Behavioral Health Services Inpatient Inpatient Mental Health Services Inpatient Addiction Services Emergency Crisis Intervention Evaluation, Referral Community Crisis Stabilization Outpatient Individual/Group/Family Therapy Methadone Maintenance Acupuncture Detox Diversionary Mental Health Services Partial Hospitalization Psychiatric Day Treatment Community Support Program Diversionary Addiction Services Acute treatment substance abuse, including for pregnant women Enhanced ATS Partial Hospitalization for adults with cooccurring disorders Structured Outpatient Addiction Program Enhanced SOAP for adolescents and homeless members 13

14 MFP-BH 1915(b) Waiver The 1915(b) application requires states to demonstrate cost-effectiveness prospectively State must project waiver expenditures for the waiver period and PMPM development for the application State must assure that actual waiver costs will be less than or equal to waiver cost projections State must compare actual waiver costs to the approved projections and if necessary submit a prospective amendment modifying cost projections Massachusetts engaged actuaries for consultation on the waiver application and PMPM development 14

15 MFP-BH 1915(b) Waiver PMPM Development Proposed waiver population had not previously received managed behavioral health services; used population comparable to expected waivers participants Estimated behavioral health service costs for members and adjusted expenditures for expected cost impact of Medicare coverage Projected member month enrollment based on expected ramp up for 1915(c) waivers Estimated that 90% of 1915(c) waiver population would gain access to managed behavioral health care services through the 1915(b) waiver; remaining 10% already enrolled through an MCO or PCC plan Developed annualized trends for each major service category on a PMPM basis, using financial and encounter data from the MCOs for other populations Leveraged PMPM development work to develop capitation rates for payment 15

16 Planning considerations in 1915(b)(c) Development Complex intersection of federal reporting requirements for 1915(b) cost-effectiveness and MFP Demonstration CMS-64 Cost-effectiveness projections had to account for portions of PMPM that would be reported elsewhere due to MFP requirements Additional spreadsheets required for 5-year projections since web-based application and preprints were designed for 2-year projections Actuaries very helpful in explaining state s intent and issues to CMS State staff and actuaries presented proposed approach to CMS during application development and again on RAI; Considerable learning curve to understand requirements for completing the CMS 1915(b) application 1915(b) required wide staff involvement not previously engaged with 1915(c) waivers 1915(b) required MMIS system changes in order to allow managed care segment for the waiver population 16

17 1915(b)(c) Waiver Integration MBHP identified designated contact person for all MFP-related referrals Participants are enrolled only upon discharge from the facility, but for complex cases MBHP involvement is needed to assist in discharge planning MBHP and Waiver Staff meet face-to-face to discuss complex cases, participant needs and potential community services pre-discharge. These meetings serve as brainstorming session and allow all parties to better understand each others roles. Individual cases are discussed only after participant has given consent for information to be shared. The participant, his/her case manager and MBHP form a collaborative to plan for the participant s transition MBHP provides care management for certain participants in the PCC plan Work is currently underway to determine how this can be adapted for use with MFP waiver participants 17

18 Operational considerations in 1915(b)(c) Implementation Training needs Information/education for MBHP staff from MassHealth Waiver Unit staff MBHP training for nurses conducting waiver eligibility as well as for waiver case managers Use of MFP Transitional Assistance Services to ensure appropriate preparation for serving participants in the community; cap rate paid only postdischarge Population is largely new for MBHP to serve; mostly dually eligible MBHP extremely interested in MFP and in serving this population; have devoted good amount of time to learning, working out logistics, etc. 18

19 Person-Centered Transition Planning Once eligible, CM meets with enrollee to develop person centered care plans including transition plan and need for transitional assistance services For individuals with BH needs, CM obtains release to consult with MBHP MBHP can provide MFP transitional assistance services prior to discharge to prepare for community living and needs Identify need for pre-discharge BH services Plan for BH community-based services Identify appropriate providers to meet enrollee needs 19

20 Case example Susan A 48 year old woman who has been living in a nursing home for nearly 2 years. She applied for the MFP-CL waiver in May and was found eligible, pending her discharge to the community. She met and married her husband during her nursing home stay. He has since moved to an apartment nearby and Susan hopes to move into that apartment soon. Diagnoses include bipolar disorder, insulin dependent diabetes, hypertension and seizure disorder. She had a stroke that resulted in left hemi-paresis and is dependent in all ADLs. She has a history of inpatient psychiatric hospitalizations, including one about a year ago. Through MBHP, have arranged pre-discharge visits by behavioral health clinician who will continue to see her post-discharge. Pre-discharge visits will be covered as MFP Demonstration Transitional Assistance Service. 20

21 Discussion

22 Presenters Michele Goody, MPP Director of Cross Agency Integrated Care Coordination Massachusetts Office of Medicaid Amy Bernstein, MMHS Assistant Director Community Based Waivers Massachusetts Office of Medicaid