North Carolina Division of Medical Assistance Medicaid Clinical Policy and Programs Update on Medicaid In-Home Personal Care Services (PCS) Presented Larry Nason, Ed.D. Chief, Medicaid Facility by: and Community Care Karen Feasel, Ph.D. Medicaid Policy Analyst
Purpose of Presentation Describe Medicaid PCS and the scope of authorized services Illustrate PCS cost and utilization increases over the last eight years Provide a demographic profile and detailed analysis of cost and utilization for current PCS participants Describe the actions DMA is taking to comply with the legislative mandate contained in S.L. 2009-451
What is In-Home PCS? C. Scope of Services.--Personal care services (also known in States by other names such as personal attendant services, personal assistance services, or attendant care services, etc.) covered under a State s program MAY include a range of human assistance provided to persons with disabilities and chronic conditions of all ages that enables them to accomplish tasks that they would normally do for themselves if they did not have a (functional) disability. Source: CMS State Medicaid Manual
Scope of Authorized PCS States MAY provide the services of a paraprofessional aide to provide: Person-to-person hands-on assistance to help a functionally disabled individual to perform a task The task itself, if the individual is fully dependent on others Cueing or prompting the individual to perform the task Source: CMS State Medicaid Manual
Scope of Authorized PCS (Continued) Services MAY include assistance with: Activities of Daily Living (ADLs), such as eating, dressing, mobility, bathing, and toileting Instrumental Activities of Daily Living (IADLs), such as light housework, laundry, meal preparation, transportation, using the telephone, shopping, etc. Source: CMS State Medicaid Manual
Services Not Authorized Under PCS Skilled services that may be performed only by a licensed health professional are NOT considered personal care services Source: CMS State Medicaid Manual
How do States Provide PCS Under Medicaid? In 2006, State Medicaid agencies provided PCS through 238 different programs Thirty-one through state plan programs (i.e., as an optional service) Two-hundred and seven through Medicaid waivers Source: Office of the Inspector General United States Department of Health and Human Services
PCS Waiver vs. Optional Service PCS Provided under a 1915(c) HCBS Waiver Need for RN for a minimum of eight hours per day Daily observation and assessment of resident needs by a licensed nurse Administration and control of medication that must be performed by a licensed nurse Need for dialysis or mechanical ventilation that is required at least ten hours per day Source: NC Medicaid Clinical Coverage Policy for Nursing Facility Services NC PCS Benefit under State Medicaid Plan Paraprofessional service that does not include skilled medical or nursing care Not covered when recipient is not medically stable Not covered when recipient needs ongoing supervision Not covered when RN or LPN services are required Source: NC Medicaid Policy for In- Home Personal Care Services
Hierarchy of LTC Programs Nursing Facility Adult Care Homes PACE Waiver Programs CAP/DA Private Duty Nursing Personal Care Services
National Expenditures for PCS CY 2005 NH: $510,956 Range 25 Other States NC: $286,650,908 Texas: $459,179,146 NY: $2,045,068,149 California: $2,857,270,000 Percent Increase 2004 to 2005 30% 10% 6% 10% Source: Kaiser Commission on Medicaid and the Uninsured
Increase in PCS Participation SFY 2002 thru 2009 A v e r a g e M o n t h l y P a r t i c i p a n t s 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2002 2003 2004 2005 2006 2007 2008 2009 Series1 15,687 20,902 25,267 31,589 34,670 33,484 34,130 38,569 State Fiscal Year Source: Medicaid Program Expenditure Reports-June of each SFY
Increase in PCS Costs SFY 2002 thru 2009 $400,000,000 $350,000,000 A n n u a l E x p e n d i tu r e s $300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $- 2002 2003 2004 2005 2006 2007 2008 2009 SFY Source: Medicaid Program Expenditure Reports-June of each SFY
Budget Reduction Goals for PCS SFY 2010 and 2011 $350,000,000.00 $300,000,000.00 $250,000,000.00 $200,000,000.00 $150,000,000.00 $100,000,000.00 $50,000,000.00 $- 1 State Budget for PCS SFY 2009 SFY 2010 Budget for SFY 2009: $318,021,185 Budget for SFY 2010: $188,200,229 Budget Reduction: 41% Budget Reduction Goal for SFY 2010: $40 million state dollars Budget Reduction Goal for SFY 2011: $60 million state dollars
PCS Expenditures SFY 2009 Actual vs. Budgeted $31,000,000 $30,000,000 $29,000,000 $28,000,000 $27,000,000 $26,000,000 $25,000,000 $24,000,000 JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Budgeted Actual Expenditures by DOS Source: Medicaid Monthly Claims Report January 2010
PCS Expenditures SFY 2010 YTD Actual vs. Budgeted $35,000,000 $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $- JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN Budgeted Expenditures by DOS Source: Medicaid Monthly Claims Report January 2010
CCME PCS Compliance Reviews April 2007-March 2009 347 Provider Agencies 3,732 Recipients On-site desk review RN home visit, interview, observation 7%- Two qualifying ADLs not documented in assessment 40%- RN review did not support recipient qualification DMA estimates 23% of current recipients do not qualify Associated with more than $6.5M per month, $79M per year, $219,000 per day in PCS claims
Current PCS Participants Demographic Profile PERCENT OF POPULATION 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% 100 to 106 96 to 100 91 to 95 86 to 90 81 to 85 76 to 80 71 to 75 66 to 70 61 to 65 56 to 60 51 to 55 46 to 50 41 to 45 36 to 40 31 to 35 26 to 30 21 to 25 16 to 20 11 to 15 6 to 10 0 to 5 30% M 70% F AGE RANGE Source: Medicaid Claims Database
Current PCS Participants ADL Scoring Methodology Level Description Medicaid PCS Coverage Assessment Score Supervision Only Individual requires supervision, oversight, encouragement, prompting, reminders, or cueing Not covered 1 Limited Assistance Extensive Assistance Individual is highly involved in activity, but requires hands-on assistance from another person for maneuvering of limbs for mobility, eating, bathing, dressing, and toileting Individual performs part of activity, but requires substantial or consistent hands-on assistance from another person for mobility, eating, bathing, dressing, and toileting Must require hands-on limited, extensive, or full dependence assistance with at least two of the qualifying ADLs 2 3 Full Dependence Individual is fully dependent on another person for mobility, eating, bathing, dressing, and toileting 4
Current PCS Participants Prevalence of ADL Needs 100 90 80 Percent of Recipients 70 60 50 40 30 97.9 94.5 57.5 20 10 0 Bathing Dressing Mobility 26.8 14.9 10.7 Toileting Continence Eating Source: PCS Recipient Assessments (N=35,047)
Recipient Functional Disability Sum of ADL Scores Percent of Recipients 42% 40% 38% 36% 34% 32% 30% 28% 26% 24% 22% 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 28.8% 33.0% 14.4% 7.2% Mean = 6.48 N = 35,047 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Recipient Functional Disability (Sum of ADL Scores) Source: PCS Recipient Assessments (N=35,047)
Current PCS Participants Average Number of Service Hours Authorized In Providers Plans of Care (POC) 60 55 50 45 40 35 Authorized Hours Provider Plans of Care Medical Necessity Review 30 25 20 15 10 5 0 0 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 1920 21 22 23 24 Recipient Functional Disability (Sum of ADL Scores) Source: PCS Recipient Assessments (N=35,047)
Implementation of S.L. 2009-451 Evaluate current PCS participants to determine if utilization is related to functional disability and not excessive Revise the current PCS Clinical Coverage Policy to address documented cost, compliance, and utilization problems Strengthen the role of the recipient s physician in the PCS admission process Automate the PCS program administration process Update, improve, and automate assessment tools, service authorizations, plans of care, audit reports, and reports
Implementation of S.L. 2009-451 (Continued) Automate and integrate with other HCBS programs quality improvement, utilization review, compliance review, and financial performance metrics to monitor program performance Integrate service authorizations with claims processing to ensure only authorized hours are paid Implement independent assessment of new PCS admissions, continuation reviews, and change of status reviews
CAP/DA Slot Allocation History Slots allocated in 2004 13,200 Slots originally funded 11,500 Slots not funded 1,700 Additional slots proposed: SFY 2009 600 SFY 2010 600 SFY 2011 500 NOT FUNDED
CAP/DA Slot Allocation 2010 SFY Budget Adjustment Reduce PCS slot allocations to July 1, 2008 level Slots must be reduced to 11,214 Reductions by county will be achieved through attrition