New Delivery Systems for Long Term Services and Supports: How States are Diving into Affordable Care Act Opportunities

New Delivery Systems for Long Term Services and Supports: How States are Diving into Affordable Care Act Opportunities September 2013 Sarah Barth, JD, Director of Coverage and Access Michelle Herman Soper, MHS, Senior Program Officer www.chcs.org

Agenda I. Welcome and Introductions II. III. IV. High Level Overview of the Duals Demonstration Improving Care for Medicare-Medicaid Enrollees: Virginia Financial Alignment Demonstration LTSS-related ACA Initiatives V. Maryland s Long Term Care Reform VI. Questions 2

Welcome and Introductions Sarah Barth, JD Director, Long-Term Services CHCS Michelle Herman Soper, MHS Senior Program Officer CHCS Suzanne Gore, JD, MSW Director, Policy and Research Virginia Department of Medical Assistance Services Lorraine Nawara, MS Deputy Director for Community Integration, State of Maryland, Department of Health and Mental Hygiene 3

A non-profit health policy resource center dedicated to improving services for Americans receiving publicly financed care Priorities: (1) enhancing access to coverage and services; (2) advancing quality and delivery system reform; (3) integrating care for people with complex needs; and (4) building Medicaid leadership and capacity. Provides: technical assistance for stakeholders of publicly financed care, including states, health plans, providers, and consumer groups; and informs federal and state policymakers regarding payment and delivery system improvement. Funding: philanthropy and the U.S. Department of Health and Human Services. 4

Long-Term Services and Supports: Person-Centered Care I decide where and with whom I live. I make decisions regarding my supports and services. I work or do other activities that are important to me. I have relationships with family and friends I care about. I decide how I spend my day. I am involved in my community. My life is stable. I am respected and treated fairly. I have privacy. I have the best possible health. I feel safe. I am free from abuse and neglect. 5 5

Agenda I. Welcome and Introductions II. III. IV. High Level Overview of the Dual Demonstration Improving Care for Medicare-Medicaid Enrollees: Virginia Financial Alignment Demonstration LTSS-related ACA Initiatives V. Maryland s Long Term Care Reform VI. Questions 6

What are the Goals of Integrated Care? Creates one accountable entity that delivers primary/ preventive, acute, behavioral, and long-term services and supports Aligns Medicaid & Medicare services and financing to streamline care, reduce inefficiencies, and eliminate cost shifting Promotes the use of home- and community-based services and improvements in quality of life and health outcomes Provides high-quality, person-centered care Section 2602 of the Affordable Care Act created the Medicare-Medicaid Coordination Office and new opportunities to advance integration 7 7

Testing Innovative Integrated Financing and Delivery Models* 15 states awarded demonstration design contracts, April 2011 26 states submitted financial alignment proposals, May 2012** 6 states exploring alternative approaches to improve integration MOU signed? No Yes 7 states move to readiness reviews and contracting 14 states continue to work toward an MOU*** * As of September 2013 ** Includes all 15 states awarded a demonstration design contract ***WA is counted twice: signed MFFS MOU; pending capitated MOU 8

Financial Alignment Demonstration Models Capitated CA, ID, IL, MA, MI, NY, OH, RI, SC, TX, VT, VA, WA* Joint procurement of highperforming health plans Three-way contract: CMS, state, health plan Single set of rules for marketing, appeals, etc. Blended payment, built-in savings Voluntary, passive enrollment with opt-out provisions Managed Fee-for- Service (MFFS) CO, CT, IA, MO, NC, OK, WA* FFS providers, including Medicaid health homes or accountable care organizations Seamless access to necessary services Quality thresholds and savings targets * As of September 2013 9

Examples of State Innovation Approach Developing nuanced payment and financing methodologies Designing targeted interventions to identify high-risk individuals through linked data systems Offer additional Medicaid benefits Requires plans to contract with community supports Actively engage key stakeholders throughout design and implementation processes Developed readiness review standards that address a continuum of acute, BH and LTSS needs State* All WA MA MA, OH CA, VA CA, MA *NOTE: Several states have developed many approaches listed above; this list provides examples of a few in each. 10

Next Steps for Demonstration States Seven states have signed a Memorandum of Understanding (MOU) with CMS: MA, WA, OH, IL, CA, VA, NY Key decision points in MOU development: Rates, benefits, performance measures, enrollment Procurement and readiness reviews Final step before going live Capitated: CMS/state/plan 3-way contract (MA: July 11, 2013) MFFS: CMS/state final agreement (WA: June 28, 2013) Enrollment of Medicare-Medicaid beneficiaries Late 2013 and 2014 Generally phased in Voluntary opt-in period Passive enrollment with monthly opt-out option 11

States and CMS are Working Together to: Engage stakeholders at every level in design and implementation Build on existing relationships between state Medicaid agencies, providers, and beneficiaries Ensure beneficiary protections under Medicare Include quality standards and rigorous evaluations Establish payment strategies that encourage provider participation and create potential state and federal savings The Integrated Care Resource Center (ICRC): Established by CMS to help states advance integrated care delivery for dual eligibles. CHCS, with Mathematica Policy Research, coordinates state technical assistance and online resources. Visit www.integratedcareresourcecenter.com 12

Department of Medical Assistance Services Improving Care for Medicare-Medicaid Enrollees: Virginia Financial Alignment Demonstration Suzanne S. Gore, JD, MSW, Director, Policy and Research Virginia Department of Medical Assistance Services Suzanne.gore@dmas.virginia.gov NASUAD September 10, 2013 http://dmasva.dmas.virginia.gov 14

Overview A little background We ve Been at this a Long Time The Big Disappointment Silos and Stressed Out Staff Shaking Things Up Full Steam Ahead 15

Virginia is Ready to Improve Care One program to coordinate primary, preventive, acute, behavioral, and long-term services and supports. Blend Medicare and Medicaid services to improve access and streamline care. Offer high quality, person centered services. 16

Quick Overview: Financial Alignment Models Opportunity to create one accountable entity to coordinate delivery of primary/preventive, acute, behavioral, and longterm services and supports CMS provided states with two paths (aka Financial Alignment Models ) Financial Alignment Models CAPITATED MANAGED FEE-FOR-SERVICE 23 states are pursuing financial alignment or alternative demonstration models to improve integration between Medicare and Medicaid 17

We Have Been at This a Long Time Long history of PACE Mandatory Uniform Assessment Instrument since 1994 Explored integrated care in the mid-1990 s Published the Blueprint for Improving Long- Term Care Services in 2006 Developed plan for Virginia Acute and Long- Term Care (VALTC) in 2008 and completed Phase I 18

The Big Disappointment In 2011, Virginia applied for CMS State Demonstrations to Integrate Care for Dual Eligible Individuals Virginia did not receive a design contract 19

Silos and Stressed Out Staff Staff with other responsibilities pulled to work on the demonstration Limited support between divisions Staff morale was abysmal 20

Shaking Things Up Created a new Deputy Director of Complex Care and Services Created a new Division for Behavioral Health and Integrated Care Hired Director for the Office of Coordinated Care and Outreach Specialist Shaken, not stirred: Time for a Reorg! 21

Full Steam Ahead! Medicaid Programs are NOT Nimble and neither is Medicare Amazing staff working on the program now Top Priority for the Secretariat and Agency You are Here

ACA Vehicles to Rebalance LTC Settings Historically, programs not designed to support individual choice of settings: Facility-based care is an entitlement HCBS often has waiting lists Limited coordination for HCBS participants across all service areas The ACA provides states with opportunities to move individuals to or support them in the community through: Money Follows the Person Demonstration Balancing Incentive Payment Program Community First Choice Options Program With the support of The SCAN Foundation, CHCS provided technical assistance to 10 states in their efforts to rebalance LTSS and migrate to MLTSS delivery systems. 24

Money Follows the Person Supporting Transitions Assists states to rebalance their long-term care systems by providing enhanced federal funds for services needed to transition Medicaid enrollees from institutions to the community Goals: increase the use of HCBS decrease the use of institutional care eliminate barriers that restrict flexible use of Medicaid funds ensure quality assurance and quality improvement 45 states and DC currently have MFP programs 25

Balancing Incentive Program Supporting Community Living Provides enhanced federal financing to states to rebalance LTSS expenditures toward HCBS services Must establish three structural changes No wrong door/single entry point system Conflict-free case management A core standardized assessment instrument There are currently 16 states with approved programs 26

Community First Choice Options (CFCO) Supporting Community Living New state plan option for providing communitybased attendant services and supports 6 percent enhanced FMAP for an indefinite period Limitations: Must be statewide No waiting lists As of July 2013, California and Oregon have approved CFCO programs 27

List of States Participating in these Initiatives States participating in MFP are: AL, AR, CA CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, VA, VT, WA, WI, WV and the District of Columbia. States Participating in the Balancing Incentive Program are: AK, CT, GA, IA, ID, IL, LA, ME, MD, MI, MS, NH, NJ, NY, OH, TX States Participating in Community First Choice Option are: CA and OR 28

Opportunities for States ACA contains numerous program opportunities for states to support individuals with disabilities and intense medical needs in the community Innovative states look to use the enhanced federal financial funding to strengthen HCBS delivery systems MD is an example of a state using all of these initiatives to reform LTSS systems of care 29

Maryland Department of Health and Mental Hygiene

Maryland s population is changing. An aging population and increased demand from younger adults with disabilities means Maryland will see a dramatic increase in people needing LTSS in the near future. We need to find more effective ways of providing services. People making their own decisions about when, where and how to receive those services restores dignity to a very personal process. We need to simplify the process both administratively and functionally. Clear pathways to find services and enter programs. Clear expectations and responsibilities of all of our partners and providers. 32

Aging and Disability Resource Centers (ADRCs) Maryland launched its ADRC effort in 2003 Now have statewide coverage by 20 Maryland Access Point (MAP) sites Money Follows The Person (MFP) Demonstration Maryland has participated since 2007 with over 1,500 transitions Key initiatives include peer outreach and mentoring, options counseling, funding for ADRC expansion, and enhanced transition assistance Balancing Incentive Program (BIP) Maryland was the second state to be awarded in February of 2012 with a projected award of $106 million Current procurement for pilot projects Implementing the interrai-hc tool as the standardized assessment Utilizing MAP sites as the single-entry point/no Wrong Door Community First Choice Maryland submitted a SPA on September 6, 2013 Merging 2 existing 1915(c) waivers, moving allowable services to the State Plan 33

Maryland Access Point (MAP) Sites MAP initiative led by Maryland Department of Aging Formalized partnerships between Area Agencies on Aging, Local Health Departments, and Departments of Social Services BIP/MFP Expansion of MAP sites MAP Partnership Development accelerated with MFP funding Required partnerships with the Brain injury Association of Maryland, local mental health authorities, and Centers for Independent Living (CILs) Funded expansion of the MAP resource website and development of the1-800 number MAP sites will: Complete the Medicaid interrai phone screen prior to referrals for a full assessment Maintain the Medicaid registry for waiver services 34

The MFP/BIP-funded expansion of the Maryland Access Point (MAP) sites creates a No Wrong Door system of entry into streamlined service system. 1800 Number MAP Site Information and referral Level 1 screening Waiver registry Options counseling www.marylandaccesspoint.info 35

DHMH conducted a review of instruments with stakeholder participation Chose the interrai-hc for the nursing facility level of care population Has been tested for reliability and validity Meets the BIP requirements with little modification DDA is exploring the Supports Intensity Scale with modifications for individuals with IDD MHA is exploring the Daily Living Activities (DLA-20) Assessment for individuals with mental illness Pilot of instruments Main purpose is to ensure Level of Care/medical eligibility determinations are consistent with current regulations 36

Create new or expanded community supports identified through an RFP process Enhanced technology and home modifications Remote monitoring Emergency back-up services Shared attendant care Blended somatic and behavioral health services Start-up costs and pilot projects Rate increases Additional waiver slots Expansion related to implementation of Community First Choice 37

The In-Home Supports and Assurance System will track personal care time, and improve quality and efficiency It will ensure services are delivered to beneficiaries and support the transition to incremental (15 minute or hourly) rates Implementation to begin in 2013 The new LTSSMaryland client-centered tracking system will help coordinate services, eliminate duplicate work and unnecessary paperwork All assessments and nurse monitoring forms will be automated and accessible on a laptop or tablet Maryland has grant money through the Balancing Incentive Program to pay for tablets and/or laptops purchased for use within the tracking system 38

8 HCBS waivers: 2 IDD Waivers: Community Pathways and New Directions Model Waiver for children with complex medical needs Autism Waiver The Traumatic Brain Injury (TBI) waiver Medical Day Care The Older Adults Waiver (OAW) serves adults age 50 and older who meet NF LOC The Living at Home (LAH) waiver serves adults with physical disabilities between 18 and 64 who meet NF LOC State Plan Personal Care option called Medical Assistance Personal Care (MAPC) 39

CFC services currently offered under two 1915(c) waiver programs for individuals who meet NF level of care will no longer be offered as waiver services but offered through CFC Maximize the enhanced Federal match Offers a full menu of services to all waiver participants Resolve inconsistent rates and policies across programs Reduces duplicate applications Simplifies administration Other waivers may be phased in later if we can unbundle service packages so that the services are allowable under CFC (Medical Day Care, TBI services) The Medical Assistance Personal Care (MAPC) State Plan program will remain for individuals who do not meet nursing facility level of care 40

To implement CFC 1915(k) preprint 1915(b)(4) to limit providers of supports planning, transition services, and nurse monitoring To merge existing 1915(c) waivers Two amendments, 1 for the new merged waiver and 1 to terminate the other waiver 1915(b)(4) to limit providers of case management Formal transition plan to explain changes/impact in coverage for participants and providers To modify the State Plan personal care option to mirror CFC State Plan amendment and 1915(j) to add self-direction and 1915(b)(4) to limit providers of supports planning and nurse monitoring Additionally, State regulation changes are required for all 4 programs 41

Waiver Participants Community First Choice Participants Dietitian and Nutritionist Case Management Family Training Voluntary Self- Direction Training Personal Care Personal Emergency Response Systems MAPC Participants All other State Plan services Supports Planning Items that Substitute for Human Assistance Transition Services Home-delivered meals Senior Center Plus Assisted Living Behavioral Health Consultation 42

Personal Assistant Services Case Management Consumer Training Personal Emergency Back-up Systems Transition Services Home Delivered Meals Assistive Technology Accessibility Adaptations Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus MAPC LAH OAW 43

Personal Assistant Services Case Management/Supports Planning Consumer Training Personal Emergency Back-up Systems Transition Services Home Delivered Meals 1 Assistive Technology 1 Accessibility Adaptations 1 Environmental Assessments Medical Day Care Nutritionist/Dietician Family Training Behavioral Consultation Assisted Living Senior Center Plus MAPC CFC Waiver *CFC services will be available to all waiver participants 1 Items that Substitute for Human Assistance 44

Existing LAH and WOA providers of services that will covered under CFC will be automatically enrolled as CFC providers Waiver participants will have access to more providers: LAH providers + WOA providers + MAPC providers = CFC provider pool The Department is working with the Maryland Department of Aging (MDoA) to develop a provider registry on the MAP website The registry will be a searchable, online database where providers can enter their availability and qualifications. The registry will be in development in 2014 45

The separate waiver registry lists will need to be combined The registries will be prioritized based on risk for institutionalization rather than solely based on date of interest A validated tool developed in partnership with interrai will used to screen registry candidates This prioritization will assure that the individuals at highest risk for institutionalization have access to services first so that limited resources can be targeted to prevent institutionalization The timeline for implementation of the prioritizing of the registry is some time in 2014 46

All participants will have access to: increased self-direction opportunities, a larger provider pool, and choice of case management providers. LAH participants will gain access to increased services currently only offered through the WOA. MAPC will be improved by moving to an improved rate structure and increased self direction options. More people in the community will have access to waiver-like services. 47

ADRC Single Entry Point The Exchange MAP Sites Level I Screen Core Standardized Assessment BIP Conflict-free Case Management Services Self-Direction Provider Registry Community First Choice Consumer Surveys In-home Supports Assurance Quality Provider Training Emergency Back-up System MFP

Questions? Contact Information: Sarah Barth: sbarth@chcs.org Michelle Herman Soper: msoper@chcs.org Suzanne Gore: Suzanne.gore@dmas.virginia.gov Lorraine Nawara: dhmh.ltcreform@maryland.gov www.chcs.org 49

Resources Building State Capacity to Implement Integrated Care Programs for Medicare-Medicaid Enrollees. M. Herman Soper, Center for Health Care Strategies, July 2013. http://www.chcs.org/usr_doc/building_state_capacity.pdf Innovations in Integration: State Approaches to Improving Care for Medicare-Medicaid Enrollees. M. Herman Soper, B. Ensslin, Center for Health Care Strategies, February 2013. http://www.chcs.org/usr_doc/innovations_in_integration_022213_(2).pdf Long-Term Services and Supports: Opportunities in the Affordable Care Act. S. Barth, J. Klebonis, N. Archibald, Center for Health Care Strategies, December 2011. http://www.chcs.org/usr_doc/ltss_aca_paper_121311.pdf Balancing Incentive Program: Strengthening Medicaid Community-Based Long-Term Services and Supports. S. Barth, A. Lind, Center for Health Care Strategies, September 2012. http://www.chcs.org/publications3960/publications_show.htm?doc_id=1261422#.udxprp nd-uk 50