Long-Term Care Improvements under the Affordable Care Act (ACA) South Carolina Health Care Implementation Coalition September 17, 2010 JoAnn Lamphere, DrPH Director, State Government Relations Health & Long-term Care Issues AARP
Presentation Overview > Provisions Affecting Home and Community-Based Services (HCBS) o State Balancing Incentives Payments Program o Community First Choice Option o HCBS State Plan Option Changes o Money Follows the Person Rebalancing Demonstration o Spousal Impoverishment for HCBS o Aging and Disability Resource Centers o Co-Pays For Duals o Federal Coordinated Health Care Office > Provisions Affecting Nursing Home Residents and Consumers o Information and Disclosure o Oversight and Enforcement > Provisions to Improve Quality across all Settings o Criminal Background Checks o Elder Justice > CLASS Program AARP 2
Long Term Care (LTC) How the Law Changes LTC: > New Options and Incentives for Medicaid Home and Community Based Services (HCBS) > New Protections and Better Information for Consumers > New public, voluntary insurance program (CLASS) to help people plan/pay for long-term services and supports (LTSS) Benefits of the Law: > Significant New Medicaid Incentives to Expand Services > Helps People Live in the Setting of their Choice > Improves Consumer Decision-making and Quality of LTC AARP 3
LTC Provisions Affecting HCBS
South Carolina s Distribution of Spending on LTC ICF-MR 13.6% $154,255,458 Mental Health Facilities 3.4% $38,790,785 Nursing Facilities 44.5% $503,057,848 Home Health & Personal Care 38.5% $435,629,669 Total 100% $1,131,733,760 Source: KFF State Health Facts, 2008 AARP 5
Medicaid LTC Spending for Older People and Adults with Physical Disabilities in SC and US, 2008 South Carolina United States 73% Source: AARP Public Policy Institute AARP 6
Medicaid HCBS: State Balancing Incentives Payments Program (BIPP) > Goal: help states balance long-term services and supports (LTSS) systems (HCBS over institutional care) > States apply for grant & and agree to develop: statewide single entry point; conflict-free case management; standardized assessment; data collection > Grants through temporary (5 year) enhanced FMAP; $3 B federal cap > State maintenance of effort on eligibility > Begins Oct. 1, 2011 AARP 7
State Balancing Incentives Payment Program (BIPP) Increase HCBS from < 25% to 25% Increase HCBS to 50% (states with spending between 25 and 50%) 5 percentage point increase in the federal medical assistance percentage (FMAP) 2 percentage point FMAP increase Enhanced FMAP available for non-institutional Long-term Services and Supports Expenditures between 10/2011 and 9/2015 AARP 8
State Balancing Incentives Payment Program (cont d.) State must: > Use funds for new or expanded services > Apply and be determined eligible > Submit plan describing how it will expand and diversify coverage for non institutional services and how it will meet targeted percentage by October 1, 2015. > Not make eligibility requirements for non institutional LTSS more restrictive than those on 12/31/2010 > Have in place 3 structural components within 6 months of application AARP 9
Balancing Incentives Payment Program Will SC Participate? Attractive but strings attached Within 6 months of application: Develop No Wrong Door Single Entry Point System Ensure Conflict Free Case Management Services Develop Core Standardized Assessment Instruments Collect service and quality data. Maintenance of eligibility requirement (no more restrictive requirements than those in effect on December 31, 2010) Distance to Goal Those closer to a target (50% HCBS as a % of LTC $) may be more likely to apply Unknown whether CMS will split out populations (e.g., elderly and physically disabled) to calculate targets 10
BIPP Recommendations > Educate state policymakers and officials of funding > Work to lay groundwork for BIPP > Structural changes including conflict free case management and statewide SPE AARP 11
Community First Choice Option (CFC) Consumer controlled community-based attendant care services and supports Assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related tasks Statewide services; no cap or waiting list permitted FMAP increase on CFC services (no end date). MOE requirement but only for one year. AARP 12
Medicaid Community First Choice Option (CFC) > New state plan option to provide HCBS attendant services & supports > May require institutional level of care (unclear) > May provide coverage for certain transition costs > Must offer statewide; no limits on ## of participants; assistance with ADLs, IADLs, health-related tasks, etc. > Financial eligibility requirements for participation > Incentive: 6% enhanced FMAP (no end date) > Begins effective Oct. 1, 2011 AARP 13
Medicaid Community First Choice Option (CFC) > States must: > Make services available regardless of age, disability, form of services/supports required > Provide services in most integrated setting > Maintenance of effort (only 1 year) > Establish a Development and Implementation Council > Assist federal govt. in evaluating program by collecting and reporting data > Must have quality assurance and appeals system AARP 14
Will SC Take Up the CFC Option? Is it Needed? Many CFC features can be accomplished under prior law There is a fiscal incentive Enhanced FMAP (forever? No end date noted) could be attractive to a state that is almost there Need to evaluate 1-year MOE Targeted service package favored by consumers and advocates Can be part of a states continued or new initiative to rebalance care Entitlement and prescriptive service package may scare some states Eligible population may be less expansive than for PCA services Can eligibility be limited to persons with LOC? Currently unclear Need for CMS guidance to evaluate feasibility for a particular state 15
Medicaid HCBS State Plan Option Since 2006, State Medicaid plan option (Section 1915(i)) available to expand HCBS without a waiver to individuals who need less than institutional level of care Few states have taken up the option AARP 16
1915(i) State Plan Option Changes through ACA Prior to Reform After Reform Enrollment caps allowed LOC: less stringent than institutional standard Limited service array Income standard: no more than 150% FPL No caps/waiting list: Must serve any eligible meeting criteria Can also serve persons meeting institutional LOC Same service array as under a HCBS waiver allowed May use special income std (up to 300% SSI); creates optional eligibility category May offer different 1915(i) benefit package or target services within a single 1915(i) benefit May phase-in target groups and services AARP 17
Medicaid HCBS State Plan Option > Clinical eligibility must be less restrictive than for nursing home or waiver services, but states may also serve persons meeting NH LOC > State may tighten clinical eligibility if projected enrollment is exceeded. (Grandfather clause) > Income eligibility is 150% FPL except: > States can choose to offer HCBS under state plan option to individuals eligible for waiver services with incomes up to 300 SSI; and > States that participate in BIPP and propose to expand HCBS under state plan option may increase eligibility limit up to 300% SSI AARP 18
Considerations for NY on Implementation of 1915(i)? Fixes some previous limitations/ problems Expands scope of services Includes institutional LOC group Expands income eligibility But eliminates some features that were attractive to states Ability to cap enrollment/use a waiting list Ability to limit geographically (but does allow phase-in) Other issues/ observations Difficult to project interest level among states Might be appealing for behavioral health HCBS 19
Medicaid HCBS: Money Follows the Person Rebalancing Demonstration (MFP) > Grants awarded to states to transition Medicaid enrolled nursing home residents to homes or community settings through FY 2016 > Minimum Nursing Home residency requirement reduced from 6 months to 90 days Medicare rehab days excluded > Begins: April 22, 2010 > Authorized and funded for additional 5 years at $450 million each year FY 2012-2016 AARP 20
Money Follows the Person Demonstration New MFP States Existing MFP States MFP Demo Grant Planning Grant Due January 7 for new applicants Grants up to $200,000 for creating operational protocol for MFP demo Due September 7 Modification Of Existing Grants States can expand and modify grants to include additional populations, increase number of transitions, geographic scope, etc. AARP 21
MFP: SC State Decisions > SC already applied for and received MFP grant funding States have five years to use funds > Build relationships with key staff in agency and encourage use of funding > Build relationships with key legislative committees overseeing agency where money is held > Work with aging/disability community allies to put pressure on agency to use funds AARP 22
Medicaid HCBS: Spousal Impoverishment > Current law allows the spouse of a nursing home resident with Medicaid to keep a certain level of income and assets to protect against impoverishment and allow him/her to live at home > New law requires state to extend same spousal impoverishment protections to the spouses of individuals receiving Medicaid HCBS for 5 years > Begins Jan. 1, 2014 AARP 23
Spousal Impoverishment State Decisions Extend protections sooner than required (2014)? Extend protections to medically needy sooner than required? AARP 24
Aging and Disability Resource Centers > $10 million per year for five years starting in 2010 for Aging and Disability Resource Centers one-stop shops for information and other assistance regarding long-term services and supports > SC received one of first ADRC grants > New funds will help to expand current system statewide > RFP possible at end of 2010 AARP 25
Other HCBS Related Provisions > No Medicare Part D cost sharing for full dual eligibles (persons with Medicare and Medicaid) receiving home and communitybased services (HCBS) who would otherwise receive institutional care > Federal Coordinated Health Care Office within CMS to coordinate coverage and services for dual eligibles AARP 26
LTC Provisions Affecting Nursing Home Residents and Consumers
Nursing Homes: Information and Disclosure New law provides better and easier access to information on: o o o o o o Nursing Home Ownership/Organizational Structure Standardized Staffing Data based on Payroll Records Complaints and How to Make Complaints Crimes Expenditures Survey Reports and Investigations States must have/maintain comprehensive nursing home websites CMS Nursing Home Compare Website will be modified to include: o o o Timely updates of inspection information Links to state government nursing home websites and inspection forms Consumer rights page with state specific information GAO to study Five Star Rating System and report to Congress AARP 28
Nursing Homes: Oversight and Enforcement > States must establish complaint resolution processes that meet specified criteria > Some Medicare and Medicaid fines may be used to benefit residents or support consumer involvement > New requirements (& penalties) in the event of facility closure > Two new demonstration projects on culture change and information technology authorized AARP 29
State Actions Nursing Homes States must have/maintain comprehensive nursing home website that includes timely posting of inspection records, plans of correction, and other info TBD by Secretary to assist consumers States must also develop complaint resolution process AARP 30
Provisions to Improve Quality Across All Settings
South Carolina Overall Health Care Quality Compared to All States Source: Agency for Health Care Research and Quality AARP 32
SC Ranks in the Lower Half of the US on Health System Performance AARP 33
Using Medicaid to Transform Health Care Delivery > Health Homes States taking up option get 90% FMAP for two years (1/1/2011) > Incentives for Healthy Lifestyles > Bundled Payments demonstration to reward quality care > Health Care Workforce training, residencies, physician payment AARP 34
HCR Grant for Medical Homes > Planning grants are up to $25 million total for all states. Could receive enhanced federal matching payments during the first two years of operation for state plan option. > SC State Action - Apply for planning grant and potentially amend Medicaid state plan option to establish medical homes to provide care coordination, chronic disease management, and community support for those with chronic conditions. AARP 35
Criminal Background Checks and Elder Justice > National program for national and state criminal background checks on certain employees of long-term care providers both home and community-based and institutional settings o Federal dollars to states to help fund the program > Elder Justice elder abuse prevention, detection, response, and coordination of efforts o Must be funded before programs can start AARP 36
Community Living and Assistance Supports and Services (CLASS) Program
CLASS Program > New public, voluntary insurance program to help individuals plan and pay for long-term services and supports (LTSS) > New financing option that helps people live in the setting of their choice and potentially delay or avoid impoverishing themselves to qualify for Medicaid LTSS. > One part of the solution to address the LTSS challenges facing individuals and federal and state governments. > No medical underwriting to participate AARP 38
CLASS: Who Can Participate Individuals age 18 and older who are working Must earn enough to qualify for a quarter of social security (About $1,100 a year in 2010) Individuals whose employers participate in program Automatic payroll deduction of monthly premiums Employees can opt out Individuals whose employers do not participate in program Also self-employed or who have more than one employer Can participate through alternate mechanism AARP 39
CLASS: What are the Premiums? > TBD by Secretary of HHS at a level to insure program solvency for 75 years. > Working full-time students and individuals with incomes below the federal poverty line pay a nominal premium. > Varies by age -- younger enrollees pay lower premiums than older enrollees. > CBO estimated an average monthly premium of $123. > Would generally remain level with a couple exceptions: Program Solvency Lapse in payment AARP 40
CLASS Benefits How do you qualify for benefits? Vesting requirement of 5 years Work at least 3 of the first 5 years enrolled in program Functional limitation, certified by licensed HC practitioner, expected to last for at least 90 continuous days Must continue paying premiums to receive benefits AARP 41 Individuals with lapses in coverage of more than 3 months must also pay premiums for at least 24 months
CLASS What are the Benefits? Minimum cash benefit of $50 (provided through debit card) Higher benefits for individuals with higher disability level Participants can roll over benefits from month to month (for up to 12 months) No lifetime benefit limits Benefit can be used to pay caregivers (family, neighbors, friends) *CBO assumed average daily benefit of $75/day *Benefits may not cover all LTSS needs; can be supplemented with personal savings, care from family/friends, private LTC Insurance, and other public and private programs AARP 42
CLASS: Implementation Dates and Issues > CLASS effective date is January 1, 2011; > Statute does not specify when enrollment must begin > Secretary to establish a Personal Care Attendants Workforce Advisory Panel by June 21, 2010 > Secretary of HHS is required to designate a CLASS benefit plan by October 1, 2012 AARP 43
CLASS: Interaction with Medicaid > CLASS enrollees who qualify for Medicaid may retain a portion of their CLASS benefits: > Nursing Home residents may retain 5 percent of benefit > HCBS recipients may retain 50 percent (States will be required to meet certain Medicaid criteria in order to receive 50 percent of CLASS benefit) > CLASS benefits do not affect eligibility for benefits under any federal, state or local assistance program AARP 44
CLASS: Interaction with State LTC programs > State Protection and Advocacy Assistance System to enter into agreements with HHS to help CLASS participants (January 1, 2012) > States assess providers capacity to serve as fiscal agents and provide employment-related benefits to personal care attendants or designate or create entities to serve as fiscal agents (March 23, 2012) > States establish links between enrollment and payment systems to identify individuals receiving benefits under CLASS and Medicaid and comply with primary payor rules AARP 45
CLASS: SC State Decisions SC can choose to participate as employer May wish to assess how CLASS will intersect with other programs Can offer tax incentives to employers/ individuals Establish links between enrollment and payment systems to identify joint beneficiaries AARP 46
Action Steps > Nail down MFP current status in SC > Prioritize and focus advocacy plans > Map picture of the future to help agencies and individuals see what an improved LTC system could look like > Serve as the brain trust for state agencies > Keep hope alive for older and disabled persons and their families by leading reform efforts AARP 47