Letters in the Medicaid Alphabet:

Letters in the Medicaid Alphabet: OPTIONS FOR FINANCING HOME AND COMMUNITY- BASED SERVICES P R E S E N T E D B Y : R O B I N E. C O O P E R D I R E C T O R O F T E C H N I C A L A S S I S T A N C E N A S D D D S, O C T O B E R 2 0 1 3

Today s Presentation Will: Cover 1915(c), (i) and (k) with some depth Cover 1915(j) very briefly Touch on other authorities such as Money Follows the Person and the Balancing Incentives Program Leave any real discussion of 1115 waivers, b/c combos and other managed care authorities for another day 3

HCBS options we know and love 1915(c) Home and Community-base waiver program initiated in 1981 4 1115 Research and Demonstration waivers, available since 1962 (before Medicaid existed!) State plan home and community-based services such as personal care, home health, homemaker/chore

New(ish) HCBS options we re learning to love... Since 2005, CMS made multiple new options available under Medicaid to encourage and fund home and community-based services 5 These options also include incentives for funding and increasing the use of HCBS such as: Money Follows the Person and the Balancing Incentive Program Optional State plan amendment programs: 1915(i), (j) and (k)

Short Primer on HCBS options Money Follows the Person: Grants to state to incentivize moving individuals from institutional to community setting, providing increased federal funds for services to individuals moving to the community For information see: http://www.medicaid.gov/medicaid-chip- Program-Information/By-Topics/Long-Term-Services-and- Support/Balancing/Money-Follows-the-Person.html 6 Balancing Incentive Program: Provides a time limited 2-5% increase in Federal Financial Participation for HCBS expenditures for states that reduce reliance on institutional services For information see: http://www.medicaid.gov/medicaid-chip- Program-Information/By-Topics/Long-Term-Services-and- Support/Balancing/Balancing-Incentive-Program.html

Short Primer Waivers: HHS waives (sets aside) certain regulations to allow Medicaid funds to be used differently than usual: 7 Optional State plan amendments under the regular State Medicaid plan 1915 (c): The Home and Community-based Services (HCBS) waiver 1115 research and demonstration waiver 1915(i):State plan HCBS 1915(j): Self-directed personal care 1915(k): Community First Choice-attendant care services

Overarching Requirements 8 Home and Community-based character Conflict of interest standards Quality Management Data and reporting requirements Interaction among the authorities

Overarching Requirements for All HCBS Options: Home and Community-based Character 9 A definition of what constitutes community for Medicaid funded HCBS as proposed in 1915(i) State plan NPRM applies to all Medicaid HCBS authorities* The setting is integrated in, and facilitates the individual s full access to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, in the same manner as individuals without disabilities. The setting is selected by the individual from among all available alternatives and is identified in the person-centered service plan. An individual s essential personal rights of privacy, dignity and respect, and freedom from coercion and restraint are protected. *1915(a), 1915(c), 1915(i), 1915(j), 1915(k), and 1115 waivers

Overarching Requirement: Home and Community-based Character 10 In a provider-owned or controlled residential setting, the following additional conditions must be met: The unit or room is a specific physical place that can be owned, rented or occupied under another legally enforceable agreement by the individual receiving services Each individual has privacy in their sleeping or living unit Units have lockable entrance doors, with appropriate staff having keys to doors; Individuals share units only at the individual s choice; and Individuals have the freedom to furnish and decorate their sleeping or living units.

Overarching Requirement: Home and Community-based Character 11 Home and community-based settings do not include the following: A nursing facility; An institution for mental diseases; An intermediate care facility for the intellectually disabled; A hospital providing long-term care services; or Any other locations that have qualities of an institutional setting, as determined by the Secretary.

Overarching Requirement: Home and Community-based Character 12 The Secretary will apply a rebuttable presumption that a setting is not a home and community-based setting, and engage in heightened scrutiny, for any setting that is located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment, or in a building on the grounds of, or immediately adjacent to, a public institution, or disability-specific housing complex.

Overarching Requirement: Quality Management Although the intensity and details differ for each of the HCBS authorities, they all require (at a minimum): Collection and analysis of data on regulatory compliance and system performance Standards for providers A overall quality improvement strategy Methods to continuously monitor the health and welfare of each individual including mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports Assurances that individuals have appeal rights for any denials 13

Overarching Requirement: Data Collection and Reporting Each of the HCBS authorities come with reporting requirements Typically states have to report on expenditures and utilization patterns Suffice to say that each authority has statutorily defined different, specific, and detailed reporting requirements 14

Interaction among the options 15 An individual may be enrolled in multiple options at the same time For example, could get personal care through CFC and get supported employment though a HCBS waiver Key concerns is duplication of service-cannot get the same services at the same time from multiple sources, and, The amount of service is based on assessed need, so if someone is getting personal care needs met through one option, would not personal care from another option this is clearly a support planning issue though, that states will need to be aware of

1915 (i) State Plan HCBS 16 Effective January 1, 2007, Revised October 1, 2010 States can amend their state plans to offer HCBS as a state plan optional benefit. May have multiple 1915(i) State plan amendments (ispas) Breaks the eligibility link between HCBS and institutional care-enrollees do not have to meet an institutional level of care

1915(i) HCBS State Plan Option Similarities Between 1915(c) and 1915(i) May target services to specific groups (waives comparability) Evaluation to determine program eligibility Assessment of need for services Plan of care Health and Welfare and Quality Requirements Self Direction Same allowable services Both use a preprinted application format 17

Differences Between 1915(c) and 1915(i) 18 Financial Eligibility Criteria Program Eligibility Institutional care requirements Length of time for operation Financial estimates Waiver of statewideness

Financial Eligibility Criteria 1915(i) 19 1915(c) Any eligibility group included in State plan at state chooses to include Post eligibility treatment of income for those eligible using institutional rules (e.g., special income level group up to 300% Federal Poverty Level -FPL). 1915(i) 150% of FPL Can choose to serve medically needy Can use institutional deeming rules for individuals who meet institutional LOC Post eligibility for those eligible using institutional rules (e.g., special income level group).

Post-Eligibility Treatment of Income?? All this means is that states have the option of allowing individuals who qualify for institutional care with income that is higher than the regular Medicaid to qualify for Medicaid 20 This options allows states to collect excess income that is income above a personal needs amount (usually enough to cover room, board and incidentals) to offset the cost of HCBS

Program Eligibility 1915(c) Must meet institutional LOC eligible for a nursing facility, ICF-DD or hospital Must target by LOC May additionally target by participant characteristics Disease or condition Diagnosis Age 21 1915(i) Can target by diagnosis, age, disease or condition Can include multiple groups Entrance eligibility must be less stringent than institutional LOC However, state establishes functional needs-based criteria specific to the general program eligibility and/or to individual services if desired

1915(i) Needs-based criteria?? 22 Not diagnosis or condition or demographic situation Cannot target by living arrangement Needs-based criteria mean, the individual s particular need for support, regardless of the conditions and diagnoses that may cause the need. May take into account the inability of the individual to perform two or more activities of daily living (ADLs) May also assess other risk factors (such as risk of homelessness, risk of falls) May include Instrumental ADLs (ex.: meal prep, housework, financial management)

ADLs/IADLs Activities of Daily Living (ADLs) means: basic personal everyday activities including, but not limited to, tasks such as eating, toileting, grooming, dressing, bathing, and transferring Instrumental Activities of Daily Living (IADLs) means: 23 activities related to living independently in the community, including but not limited to, meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community

Independent Evaluation and Assessment 24 Eligibility is established through an independent evaluation Must be free of conflict of interest with providers, the consumer or the budget Assessment for services planning must also be free of conflicts of interest

Conflict of interest 25 Conflict of Interest Standards. The State assures the independence of persons performing evaluations, assessments, and plans of care. Written conflict of interest standards ensure, at a minimum, that persons performing these functions are not: related by blood or marriage to the individual, or any paid caregiver of the individual financially responsible for the individual empowered to make financial or health-related decisions on behalf of the individual providers of State plan HCBS for the individual, or those who have interest in or are employed by a provider of State plan HCBS; except, at the option of the State, when such individuals are the only willing and qualified provider in a geographic area, and the State devises conflict of interest protections. (If the State chooses this option, specify the conflict of interest protections the State will implement):

Institutional Care Requirements or not! 26 1915(c) 1915(i) Must have eligibility criteria at least as stringent as the institutions. LOC must be: equal to or greater than institution but not less than institution Needs based, not tied to institutional criteria But, institutional criteria must be more stringent than 1915(i) needs-based criteria, therefore: Needs-based eligibility criteria must be: less than institution

Program Eligibility 1915(i) 1915(c) 27 1915(i) Can cap the numbers served May have a waiting list Can cap individual expenditures Cannot cap the numbers served or individual expenditure All eligibles are entitled to the program May NOT have a waiting list Eligibility assessment must be independent

1915(c) Financial Estimates 1915(i) 29 1915(i) Reasonable estimates of cost and utilization. Program must be cost neutral compared to institutional care Reveal payment methodology on Attachment 4.19-B of the State Plan.

Services 1915(i) and 1915(i) are the same 30 1915(i) permits all statutory and other 1915(c) services Under 1915(i) and (c) states can target services to specific populations Example: autism services, recovery services May have multiple ispas or HCBS waivers Same prohibitions on covering services that otherwise would be covered through IDEA or the Rehabilitation Act

To recap a lot is similar with 1915(i) and (c) 32 Can target specific individuals Individualized assessment and planning Self-directed services permitted Allowable services are the same (statutory and other) Can waive comparability May have multiple programs Must address conflict of interest Quality management requirements

And some things under 1915(i) are quite different Cannot cap the numbers served-1915(i) is an entitlement to all eligible Cannot cap the individual costs-but can use individual budgets Do not have to meet institutional LOC Cannot waive statewideness Approval not time limited (unless targeting) No cost neutrality Requires an independent evaluation for needsbased eligibility Requires independent assessment for service planning 33

1916(j):State plan participant-directed personal assistant services (PAS) Provides a new State Plan participant-directed option to individuals who must be Medicaid eligible for and receiving services under either state plan requirements or eligible for and receiving services under a 1915(c) HCBS waiver To participate in 1915(j) the state must either operate a HCBS waiver covering PAS or have an approved state plan amendment for traditional PAS. State may define and limit the target group(s) served. 34

1915(j): Covered Services Personal care or related services. Home and community-based services otherwise available to the participant under the state plan or an approved 1915(c) waiver. At state s discretion, items that increase an individual s independence or substitute for human assistance. Must be a participant-directed model Direct cash payments are permitted 35

1915(k): Community First Choice Incentivizing Home and Community-Based Services 36 CFC, Section 1915(k) of the Social Security Act establishes a new State plan option to provide home and community-based attendant care services and supports CFC provides for a perpetual 6 percentage point increase in Federal medical assistance percentage (FMAP) for these services Final rule issued May 7, 2012

1915(k): CFC 37 CFC is a State plan amendment, NOT a waiver California has an approved CFC State plan amendment (SPA) and at least two other states are in progress States apply using a draft preprint obtained from CMS Regional Offices Because CFC is a State plan amendment, it is an entitlement to all those eligible Services must be provided on a statewide basis Cannot cap the number served

Special CFC Requirement: Development and Implementation Council 38 The state must create a Development and Implementation Council that includes a majority of members with disabilities, elderly individuals, and their representatives State must consult and collaborate with the Council when developing and implementing a State Plan amendment to provide HCBS attendant services

Special CFC Requirement: Maintenance of Effort 39 Maintenance of effort (MOE) For the first full 12 month period in which the State plan amendment is implemented, the State must maintain or exceed the level of State expenditures for home and community-based attendant services and supports that the States has provided for the previous 12 months under sections 1115, 1905(a), under other subsections of 1915, or otherwise under the Act.

Special CFC Requirement: Self-direction CFC requires that states allow for the provision of services to be self-directed under either : 40 An agency- provider model, A self-directed model with service budget, or Other service delivery model defined by the State and approved by the Secretary

Program Eligibility Criteria 41 Like the HCBS waiver, CFC requires that any individual served under the option must meet an institutional level of care (LOC) The individual of course must have an assessed need for the covered services, as with any of these HCBS options

Allowable Medicaid Eligibility Groups Under CFC Individuals eligible for Medicaid under the State plan up to 150% of Federal Poverty Level(FPL) Individuals with who are eligible using the institutional deeming rules must be enrolled in a 1915(c) HCBS waiver and receive at least one service per month 42 At State discretion as to whether CFC will be provided to individuals who meet Medicaid eligibility under the medically needy provisions

Other Eligibility Criteria Under CFC states cannot target the benefit CFC, unlike 1915(i) and 1915(c), does not allow a state to limit the benefit to a particular group defined by age, diagnosis or condition CFC must be available to all individuals who have an assessed need for the services thus it is an entitlement if the individual meets all other criteria Individuals are NOT precluded from receiving other Medicaid services including State plan, waiver, demonstration and grant services 43

Supports and Services under CFC: Overarching Requirements Services must be provided: In the most integrated setting appropriate to the individual s needs, and 44 Without regard to the individual s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual requires in order to lead an independent life

Allowable Services: MUST Cover Assistance w/ ADLs, IADLs, & health related tasks. Acquisition, maintenance and enhancement of skills necessary for individual to accomplish ADLs, IADLs, and health-related tasks. Back-up systems or mechanisms to ensure continuity of services and supports. Some type of self-directed option including voluntary training on how to select, manage and dismiss staff (support for self-directed services). 45

Allowable Services: MAY Cover 46 Financial management entity that performs payroll and tax functions for self-directed options Transition costs such as: Rent and utility deposits 1 st month s rental and utilities Bedding Basic kitchen supplies, and Other necessities linked to an assessed need for an individual to transition from an institution

Allowable Services: MAY Cover 47 May cover supports on a 24/7 basis May occur in provider controlled settings Expenditures relating to a need identified in an individual s person-centered plan that increases his/her independence or substitutes for human assistance to the extent the expenditures would otherwise be made for the human assistance

Excluded Services 48 Room and board (except as a part of transition services such as rent and utility deposits or 1 st month rent or utilities) Special education and related services provided under the Individuals with Disabilities Education Act that are related to education only, and vocational rehabilitation services provided under the Rehabilitation Act of 1973.

Excluded Services Assistive devices and assistive technology services Medical supplies and medical equipment, other than those that meet the requirements, and, Home modifications 49 ***UNLESS these services/items increase independence, substitute for human assistance or are back-up systems to ensure continuity of services***

Support System States must assure that individuals have the information, training, skills and supports they need to participate in CFC and must provide for: 50 Person-centered planning Information on the range of options and choices Information on grievance process and appeal rights Freedom of choice of providers and service models

Key Considerations in Choosing HCBS Options WHAT MAKES SENSE FOR WHAT PURPOSE

Key Considerations: 1915(c) Since every state has more than one 1915(c) HCBS waiver you all pretty much know when and how they make sense but 52 Good for specific target group(s) Can cap the individual benefit Can peg the number served to available financing (can have waiting list) Not an entitlement to all eligibles (due to the cap on numbers and prioritization) Participants must meet LOC

Key Considerations: 1915(i) 53 1915(i), (j) and (k) are entitlements thus all eligible individuals must be served no caps no waiting lists For states with entitlements to certain services, 1915(i) can work well 1915(i) does allow states to narrow the populations served through targeting, risk factors and needs-based criteria 1915(i) could be useful in serving a specific group or opening new services to groups for whom Medicaid HCBS was previously not available, for example: Serving people who do not meet LOC Serving a very specific target group with a limited service menu such as children with autism ages 3-10 Providing supported employment and supportive housing to individuals with mental health needs

Key Considerations: 1915(k) 54 1915(k) with the increased FMAP may be very attractive to states that already have an entitlement to personal care under their State plan Moving these services to 1915(k) will permanently increase the state s federal funding It is important that 1915(k) comes with many additional requirements when compared to regular State plan personal care But it also offers additional options such as goods and services that increase independence But 1915(k) is an entitlement with NO targeting open to all who can demonstrate need But only serves people who meet LOC

Addendum

Example of needs-based criteria -Iowa (Read at your leisure!) The individual meets at least one of the following risk factors: Has undergone or is currently undergoing psychiatric treatment more intensive than outpatient care, more than once in a lifetime (e.g., emergency services, alternative home care, partial hospitalization or inpatient hospitalization). Has a history of psychiatric illness resulting in at least one episode of continuous, professional supportive care other than hospitalization, AND, Has a need for assistance typically demonstrated by meeting at least two of the following criteria on a continuing or intermittent basis for at least two years: 56 Is unemployed, or employed in a sheltered setting, or have markedly limited skills and a poor work history. Requires financial assistance for out-of-hospital maintenance and may be unable to procure this assistance without help. Shows severe inability to establish or maintain a personal social support system. Requires help in basic living skills such as self-care, money management, housekeeping, cooking, or medication management. Exhibits inappropriate social behavior that results in demand for intervention.

Some Approved ispas 57 Idaho: Children with developmental disabilities Iowa: Adult mental health population Michigan: Services to children with autism Washington: Acute or Chronic health needs; ADL and/or IADL deficits Colorado: Health risk or Chronic condition; assistance with one ADL Nevada: ADL deficits and risk of harm; the need for supervision; functional deficits secondary to cognitive and /or behavioral impairments Wisconsin: Mental health Oregon: Mental health Louisiana: Mental health population over 21 Florida: Children in juvenile justice system

Secret Acronym Key ADL/IADL Activities of daily living/instrumental activities of daily living BIP Balancing Incentives Program CFC Community First Choice (1915(k)) FPL Federal Poverty Level FFP Federal Financial Participation FMAP Federal Medical Assistance Percentage HCBS Home & community based services HHS Health and Human Services (Federal agency where Medicaid resides) ICF-DD Intermediate care facility for the developmentally disabled LOC Level of care MFP Money Follows the Person NPRM Notice of Proposed Rulemaking PAS Personal Assistance Services SPA State plan amendment 1915(c) Home and community-based services waiver 1915(i) State plan home and community-based services 1915(j) State plan self-directed personal care 1915(k) CFC-state plan attendant care--6% increase in FMAP 58