Protecting the Rights of Low-Income Older Adults

Protecting the Rights of Low-Income Older Adults

November 17, 2014 Consumer Rights in Medicaid MLTSS Advocating for choice, protection and quality Gwen Orlowski, National Senior Citizens Law Center www.nsclc.org 2

The National Senior Citizens Law Center is a non-profit organization whose principal mission is to protect the rights of low-income older adults. Through advocacy, litigation, and the education and counseling of local advocates, we seek to ensure the health and economic security of those with limited income and resources, and access to the courts for all. For more information, visit our Web site at www.nsclc.org.

A List of Common Acronyms CMS HCBS Long Term Care LTSS MCO MLTSS NF SNF Centers for Medicare and Medicaid Services Home and Community-Based Services LTC Long Term Services & Supports Managed Care Organization Managed Long term Services & Supports Nursing Facility Skilled Nursing Facility www.nsclc.org 4

MLTSS Basics October 2014 28 states Managed Care = New Delivery System for long-term services and supports MLTSS = Institutional Services and HCBS

How Do State s Implement Medicaid Managed LTSS? Medicaid Waiver Authority (www.medicaid.gov) 1915(b)(c) waiver approval documents 1115 waiver Special Terms and Conditions MCO Contracts (NSCLC s Details Matter! Advocate s Library ) 6

An all too common story... 7

3 Major MLTSS Advocacy Goals Accessing Services The Service Plan Notice and Appeal Rights These are Protected by the U.S. Constitution Rebalancing HCBS v. Institutions 8

Consumer Advocacy #1: Accessing Services - The Service Plan or Plan of Care www.nsclc.org 9

What is Person-Centered Service Planning? Consumer leads the planning process Process includes people chosen by consumer Informed choice of services and providers Plan must address needs and preferences Authority? New CMS HCBS Rule 1115 Waiver Special Terms and Conditions Balancing Incentives Program 10

Caution: MLTSS Tug-of-War Service Plans v. Prior Authorization 11

Consumer Advocacy Tip: Client-Centered Service Plans Continuity of Care in Transition Uniform assessment Service Plans must be appealable 12

Consumer Advocacy #2: Notices, Appeals & Hearing Rights www.nsclc.org 13

Legal Basis of Right to: Notices, Appeals and Hearing Due Process Protections of the 14 th Amendment of the U.S. Constitution The Medicaid Act Federal Regulations 42 C.F.R. 431, Subpart E (Medicaid Fair Hearings) 42 C.F.R. 438, Subpart F (Managed Care) 14

MCO Grievance System Three Tracks??? An MCO Grievance Process An MCO Appeals Process Access to the State s fair hearing system Dependent on whether or not the MCO decision or behavior = Action 15

If the MCO decision = ACTION Then the MLTSS consumer should access: The internal MCO Appeal process and/or The State s fair hearing system* Any matter other than action Internal MCO Grievance 16

What is an MCO action? The Denial or Limited Authorization of a requested service, including type or level of service The Reduction, Suspension, or Termination of previously authorized service The failure to provide services in a timely manner, as defined by the State 17

What information must the MCO include in the Notice of Action? An explanation of the action the MCO has taken or intends to take The reasons for the action The specific regulations that support the action The right to an internal MCO appeal The right to request a state fair hearing, subject to possible exhaustion of MCO internal appeal rights The procedures for exercising these rights, including timeframes during which the consumer must take action The circumstances under which an expedited appeal is available The right to continuation of benefits, how to request continued benefits, and any potential obligation to re-pay - This slide has too many words on it Imagine if you were the consumer receiving the notice... 18

Continuation of Services: aka Aid-Paid-Pending Involve termination or reduction of previously authorized service If notice is mailed at least 10 days before action and consumer requests hearing before date of action Termination Appeal or hearing must be filed timely Request for extension of benefits MLTSS consumer may have to repay 19

Consumer Advocacy Tip: Standardized Form of Notice Important Issues: Reason for the action, including the regulatory support Understandable explanation of appeals and fair hearing tracks, including timeframes Language around continuation of service 20

Consumer Advocacy #3: Rebalancing- HCBS v. Institutions www.nsclc.org 21

How MCOs are encouraged to rebalance? Capitated Rates and Incentive Payments Money Follows the Person (MFP) Nursing Facility Diversions Nursing Home Short Stays 22

How are state s measuring rebalancing efforts? National Core Indicators-Aging & Disability Dual Demonstrations MOUs and contracts CMS 2013 Guidance comprehensive quality strategy 23

Consumer Advocacy Tip: Rebalancing Measures in Contracts Number of Members receiving HCBS and NF services just prior to implementation Members are offered choice between institutional and HCBS MLTSS Members transitioned from NF to Community MLTSS Members transitioned from the Community to the NF for greater than 180 days http://www.state.nj.us/humanservices/dmahs/info/resources/care/hmocontract.pdf 24

NSCLC resources www.nsclc.org: Conflict Free Case Management: Themes in States Working to Implement New Systems Can Reality Match Rhetoric? Person- Centered Planning in Managed LTSS Just Like Home: An Advocate s Guide for State Transitions Under the New Medicaid HCBS Rules What s in a Notice? 25

Contact: Gwen Orlowski, gorlowski@nsclc.org www.nsclc.org 26