Long-Term Care PolicySummit
Suzanne Crisp
Director of Program Design &Implementation
Boston College
Today’s Discussion
Balancing Incentive Program
Community First Choice Option
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Balancing Incentive Program
Purpose – Encourage States to rebalance budgets
Shift Medicaid dollars from institutions to thecommunity
Enhanced FMAP to increase diversions and accessto HCBS
5% if less than 25% LTSS spending in non-institutional settings
2% if less than 50% LTSS spending in non-institutional settings
Enhancement ends after two years
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Requirements
Aging and Disability Resource Centers (ADRC)Single point entry or no wrong door -
Uniform assessments process
Eliminate conflict of interest
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Conflict Free Case Management
Desire of CMS for years
Eliminate:
Incentives for over or under utilization
Retain as clients through failure to promoteindependence
Focus on agent or provider convenience rather thanperson-centered practices
Independent agent should not be influenced byvariations in local or State funding
Service plan based on needs-based criteria
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Conflict Free Case Management
Independent assessments and service plandevelopment may not be performed by a providerthat will then provide services
Payment to the provider of services for evaluationand assessment cannot be based on the cost of theresulting plan of care
In rare instances, service providers may evaluateand assess but firewalls must be present
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Section 1915(k) Community FirstOption
Section 6078 of the Affordable Care Act 2010
Provides vehicle to use consumer control toprovide personal assistance services
Consumer control
Individual exercises as much control as desired to select,train, supervise, schedule, determine duties, and dismissthe attendant care provider
Community First Choice Option
Attendant services & supports to assist inaccomplishing activities of daily living (ADLs),instrument ADLs, and health-related tasks throughhands-on assistance, supervision, or curing
Back-up System must be in place
Transitions costs required
Allows for the provision of services that increaseindependence or substitute for human assistance tothe extent that expenditures would have been madefor human assistance
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1915(k) Recognizes Three Models
Agency-provider model
Entity contracts to provide services directly through employeesor arranges for the services under the direction of the individual
Agency acts as the employer of record
Individual must have significant and meaningful role inmanagement of services
Self-directed model with service budget
FMS must be available
Reimbursed at service or administrative FMAP rate
Cash or vouchers permitted
Participant is employer of record
Other service delivery model
States may propose other models
Support Services Required
Operate with person-centeredness
Provide support system
Assesses and counsels
Provides information
Includes information on risks and responsibilitiesincluding tools
Develops a backup plan
Assessors are free from conflict
Data collection
Section 1915(k)
May offer goods and services
Home modification excluded unless tied toincreased independence or sub for human asst.
Targeting not permitted
Must offer statewide
Current activity – CA, MN, AK, NY, AZ
Differences between the (j) and (k)
Enhanced funding (k)
Level of Care (k)
Section 1915(k) Continued
Allows a cash benefit
Prospective payments allowed
Target population must meet level of care
FMS reimbursed at service or admin rate
Requires creation of a Development andImplementation Council
Enhanced FMAP at 6%
Requires a face-to-face assessment (telemedicine)annually
Person-centered planning required
The Possibilities
Include all participant directed program under oneauthority that offers enhanced match
Replace State Plan Personal Care and WaiverAttendant Care with Community First Choice andreceive Enhanced Match (6%)
Section 1915(i) Targets those not meeting LoC
Use FMS Support Structure to Manage all PD
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Challenges of Community FirstChoice
Create sufficient supports to ensure programintegrity
Case Management, care coordination and self-directed counseling –YIKES!
Establish and maintain a comprehensive continuousquality assurance system
Collect and report information for Federaloversight and the completion of a Federalevaluation
Serves a LoC population only
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Challenges of Community FirstChoice Option
Must receive one waiver service to maintainfinancial eligibility
Consumer Control – how broad, how narrow
Coordinating assessment and service planning withother authorities
Who has final say in care coordination?
Waiver case manager
Targeted case management
Health Home coordinator
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Majority of States have more than oneParticipant-Directed LTSS Program
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States with less than 1,000 PD articipants
States with 1,000 but less than 5, 000 PD articipants
States with 5,000 but less than 10, 000 PD articipants
States with more than 10, 000 PD articipants
Majority of States have 1000 – 5000 Self-Direction LTSS Participants
Hawaii
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Participant
Workersrecruitedand reportto agency
Programandagency settasks
Agencyspecifiessalary andbenefits
Normalwork hourschedule
Workertrainingrequiredby agency
Casemanagersdetermineneeds &services
Participant
Recruitsandmanagesworkers
Sets tasks
Specifiessalary andbenefits(optional)
Assignsflexiblework hourschedule
Trains/arrangesworkertraining
Makesdecisionsabout needsand services
Traditional Services
Participant-Directed Services
Positive Impact of Life
Cash & Counseling participants were up to 90% morelikely to be very satisfied with how they led their lives.
Assessed Needs Met
Cash & Counseling significantlyreduced participants’ unmet personal care needs.
Caregivers Better Satisfied
Primary caregivers were significantlymore satisfied with their lives in general.
Virtually No Fraud or Abuse
Cash & Counseling did not result in the increasedmisuse of Medicaid funds or abuse of participants
Essential Elements of ParticipantDirection
Person-Centered Practices
Individual budget
Information, Assistance and Supports
Financial Management Services
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Commonly Used Terms
Participant-Directed Counselor: Individual whoworks with the participant in designing their plan.The person the participant goes to with questions.
McInnis-Dittrich, Simone, and Mahoney (April, 2006)
consultant
skills trainer
supportbroker
counselor
case manager
participant-directedcounselor
Understand Federal EmploymentObligations
Internal Revenue Services – uniform across states
Payroll for participant-directed services is different
Separate Employer Identification Number required?
Are guidelines clear for completing forms, filing, withholding,and depositing
If reconciliation is necessary – can you perform this?
A few forms: IRS Forms – 940, 941, 2678, W-3, W-4, 1099,1096
When are numbers retired?
How do you calculate Federal unemployment taxes? When doyou deposit?
How do you manage overpayments of SSA and Medicare Taxes
Common Findings – Self DirectionRebalances Service Dollars
Acute care and high costs services are lower forthose self-directing, however, basic service costsincrease
Per capita Medicaid costs are less for self-directedparticipants than traditionally served participants
Costs per hour are lower for those using self-direction than for agency services
If the cost of counseling and FMS are considered inthe design of the program, these are at least neutral
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Tangible Costs Considerations
Hiring family members – reduce unemployment orpublic assistance
Income tax implications
Service costs – Participants receive services
Case management – add on – PD in addition to CMtasks
Financial Management Services
Admin staff to run a PD program – cost vsefficiency
Intangible Considerations
Satisfaction/Safety with PD
QOL impacts health – health impacts $
Responsibility and authority can lead to goodstewardship
Caregiver satisfaction
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