Long-Term Care Improvements under the Affordable Care Act (ACA)

Long-Term CareImprovements under theAffordable Care Act(ACA)South Carolina Health Care Implementation CoalitionSeptember 17, 2010JoAnn Lamphere, DrPHDirector, State Government RelationsHealth & Long-term Care IssuesAARP

Presentation Overview> Provisions Affecting Home and Community-Based Services(HCBS)o State Balancing Incentives Payments Programo Community First Choice Optiono HCBS State Plan Option Changeso Money Follows the Person Rebalancing Demonstrationo Spousal Impoverishment for HCBSo Aging and Disability Resource Centerso Co-Pays For Dualso Federal Coordinated Health Care Office> Provisions Affecting Nursing Home Residents and Consumerso Information and Disclosureo Oversight and Enforcement> Provisions to Improve Quality across all Settingso Criminal Background Checkso Elder Justice> CLASS ProgramAARP 2

Long Term Care (LTC)How the Law Changes LTC:> New Options and Incentives for Medicaid Home and CommunityBased Services (HCBS)> New Protections and Better Information for Consumers> New public, voluntary insurance program (CLASS) to help peopleplan/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 LTCAARP 3

LTC Provisions Affecting HCBS

South Carolina’s Distribution ofSpending on LTCICF-MR 13.6% $154,255,458Mental Health Facilities 3.4% $38,790,785Nursing Facilities 44.5% $503,057,848Home Health &Personal Care38.5% $435,629,669Total 100% $1,131,733,760Source: KFF State Health Facts, 2008AARP 5

Medicaid LTC Spending for OlderPeople and Adults with PhysicalDisabilities in SC and US, 2008South CarolinaUnited States73%Source: AARP Public Policy InstituteAARP 6

Medicaid HCBS:State Balancing IncentivesPayments 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 entrypoint; conflict-free case management; standardized assessment; datacollection> Grants through temporary (5 year) enhanced FMAP; $3 B federal cap> State maintenance of effort on eligibility> Begins Oct. 1, 2011AARP 7

State BalancingIncentives PaymentProgram (BIPP)Increase HCBSfrom < 25% to25%Increase HCBSto 50% (stateswith spendingbetween 25 and50%)5 percentage pointincrease in thefederal medicalassistancepercentage (FMAP)2 percentage pointFMAP increaseEnhanced FMAP available for non-institutional Long-term Services and SupportsExpenditures between 10/2011 and 9/2015AARP 8

State BalancingIncentives PaymentProgram (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 meettargeted percentage by October 1, 2015.> Not make eligibility requirements for non institutional LTSSmore restrictive than those on 12/31/2010> Have in place 3 structural components within 6 months ofapplicationAARP 9

Balancing IncentivesPayment Program –Will SC Participate?Attractivebutstringsattached• 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 restrictiverequirements than those in effect on December 31, 2010)Distanceto Goal• Those closer to a target (50% HCBS as a % of LTC $) maybe more likely to apply• Unknown whether CMS will split out populations (e.g.,elderly and physically disabled) to calculate targets10

BIPPRecommendations> Educate state policymakers and officials of funding> Work to lay groundwork for BIPP> Structural changes including conflict free casemanagement and statewide SPEAARP 11

Community FirstChoice Option (CFC)Consumer controlled community-based attendant care services andsupportsAssistance with activities of daily living (ADLs), instrumental activitiesof daily living (IADLs), and health-related tasksStatewide services; no cap or waiting list permittedFMAP increase on CFC services (no end date).MOE requirement but only for one year.AARP 12

Medicaid Community FirstChoice 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; assistancewith ADLs, IADLs, health-related tasks, etc.> Financial eligibility requirements for participation> Incentive: 6% enhanced FMAP (no end date)> Begins effective Oct. 1, 2011AARP 13

Medicaid Community FirstChoice Option (CFC)> States must:> Make services available regardless of age, disability, formof 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 andreporting data> Must have quality assurance and appeals systemAARP 14

Will SC Take Up theCFC Option?Is it Needed?• Many CFC features can be accomplished under priorlawThere is a fiscalincentive…• Enhanced FMAP (forever? No end date noted) could beattractive to a state that is “almost there”• Need to evaluate 1-year MOETargeted service packagefavored by consumersand advocates• Can be part of a states’ continued or new initiative torebalance care• Entitlement and prescriptive service “package” mayscare some statesEligible population maybe less expansive thanfor PCA services• Can eligibility be limited to persons with LOC? Currentlyunclear…Need for CMS guidance to evaluate feasibility for a particular state15

Medicaid HCBS StatePlan Option› Since 2006, State Medicaid plan option (Section 1915(i)) available toexpand HCBS without a waiver to individuals who need less thaninstitutional level of care› Few states have taken up the optionAARP 16

1915(i) State PlanOption Changesthrough ACAPrior toReformAfterReformEnrollment capsallowedLOC: less stringentthan institutionalstandardLimited service arrayIncome standard:no more than 150% FPLNo caps/waiting list: Must serve any eligiblemeeting criteriaCan also serve persons meeting institutionalLOCSame service array as under a HCBS waiverallowedMay use special income std (up to 300% SSI);creates optional eligibility categoryMay offer different 1915(i) benefit package ortarget services within a single 1915(i) benefitMay phase-in target groups and servicesAARP 17

Considerations for NYon Implementation of1915(i)?Fixes some previouslimitations/ problems• Expands scope of services• Includes institutional LOC group• Expands income eligibilityBut eliminates somefeatures that wereattractive to states• Ability to cap enrollment/use a waiting list• Ability to limit geographically (but does allowphase-in)Other issues/observations• Difficult to project interest level among states• Might be appealing for behavioral health HCBS19

Medicaid HCBS:Money Follows the PersonRebalancing Demonstration(MFP)> Grants awarded to states to transition Medicaid enrollednursing home residents to homes or community settingsthrough FY 2016> Minimum Nursing Home residency requirement reduced from6 months to 90 days—Medicare rehab days excluded> Begins: April 22, 2010> Authorized and funded for additional 5 years at $450 millioneach year FY 2012-2016AARP 20

Money Follows the PersonDemonstrationNew MFP StatesExisting MFP StatesMFP DemoGrantPlanningGrant• Due January 7 fornew applicants• Grants up to$200,000 forcreatingoperationalprotocol for MFPdemo• Due September 7ModificationOfExistingGrantsStates can expandand modify grants toinclude additionalpopulations, increasenumber of transitions,geographic scope,etc.AARP 21

MFP: SC StateDecisions> 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 useof funding> Build relationships with key legislative committees overseeingagency where money is held> Work with aging/disability community allies to put pressure onagency to use fundsAARP 22

Medicaid HCBS:Spousal Impoverishment> Current law allows the spouse of a nursing home resident withMedicaid to keep a certain level of income and assets toprotect against impoverishment and allow him/her to live athome> New law requires state to extend same spousalimpoverishment protections to the spouses of individualsreceiving Medicaid HCBS for 5 years> Begins Jan. 1, 2014AARP 23

SpousalImpoverishment StateDecisionsExtend protections sooner thanrequired (2014)?Extend protections to medicallyneedy sooner than required?AARP 24

Aging and DisabilityResource Centers> $10 million per year for five years starting in 2010 for Agingand Disability Resource Centers – “one-stop shops” forinformation and other assistance regarding long-term servicesand supports> SC received one of first ADRC grants> New funds will help to expand current system statewide> RFP possible at end of 2010AARP 25

Other HCBS Related Provisions> No Medicare Part D cost sharing for full dual eligibles (personswith Medicare and Medicaid) receiving home and communitybasedservices (HCBS) who would otherwise receiveinstitutional care> Federal Coordinated Health Care Office – within CMS tocoordinate coverage and services for dual eligiblesAARP 26

LTC Provisions AffectingNursing Home Residents andConsumers

Nursing Homes:Information and DisclosureNew law provides better and easier access to information on:ooooooNursing Home Ownership/Organizational StructureStandardized Staffing Data based on Payroll RecordsComplaints and How to Make ComplaintsCrimesExpendituresSurvey Reports and InvestigationsStates must have/maintain comprehensive nursing home websitesCMS Nursing Home Compare Website will be modified to include:oooTimely updates of inspection informationLinks to state government nursing home websites and inspection formsConsumer rights page with state specific informationGAO to study Five Star Rating System and report to CongressAARP 28

Nursing Homes:Oversight and Enforcement> States must establish complaint resolution processes that meetspecified criteria> Some Medicare and Medicaid fines may be used to benefitresidents or support consumer involvement> New requirements (& penalties) in the event of facility closure> Two new demonstration projects on culture change andinformation technology authorizedAARP 29

State Actions –Nursing HomesStates must have/maintain comprehensive nursing homewebsite that includes timely posting of inspectionrecords, plans of correction, and other info TBD bySecretary to assist consumersStates must also develop complaint resolution processAARP 30

Provisions to Improve QualityAcross All Settings

South Carolina Overall Health CareQuality Compared to All StatesSource: Agency for Health Care Research and QualityAARP 32

SC Ranks in the Lower Half of the USon Health System PerformanceAARP 33

Using Medicaid toTransform Health CareDelivery> 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 paymentAARP 34

HCR Grant for MedicalHomes> Planning grants are up to $25 million total for all states. Couldreceive enhanced federal matching payments during the firsttwo years of operation for state plan option.> SC State Action - Apply for planning grant and potentiallyamend Medicaid state plan option to establish medical homesto provide care coordination, chronic disease management,and community support for those with chronic conditions.AARP 35

Criminal Background Checks andElder Justice> National program for national and state criminal backgroundchecks on certain employees of long-term care providers –both home and community-based and institutional settingso Federal dollars to states to help fund the program> Elder Justice – elder abuse prevention, detection, response,and coordination of effortso Must be funded before programs can startAARP 36

Community Living andAssistance Supports andServices (CLASS) Program

CLASS Program> New public, voluntary insurance program to help individuals planand pay for long-term services and supports (LTSS)> New financing option that helps people live in the setting of theirchoice and potentially delay or avoid impoverishing themselvesto qualify for Medicaid LTSS.> One part of the solution to address the LTSS challenges facingindividuals and federal and state governments.> No medical underwriting to participateAARP 38

CLASS: Who CanParticipateIndividuals age 18 andolder who are working• Must earn enough to qualify for a quarter ofsocial security (About $1,100 a year in 2010)Individuals whoseemployers participatein program• Automatic payroll deduction of monthlypremiums• Employees can opt outIndividuals whoseemployers do notparticipate in program• Also self-employed or who have more thanone employer• Can participate through alternate mechanismAARP 39

CLASS: What are thePremiums?> TBD by Secretary of HHS at a level to insure program solvency for 75years.> Working full-time students and individuals with incomes below thefederal poverty line pay a nominal premium.> Varies by age -- younger enrollees pay lower premiums than olderenrollees.> CBO estimated an average monthly premium of $123.> Would generally remain level with a couple exceptions:• Program Solvency• Lapse in paymentAARP 40

CLASS BenefitsHow do you qualifyfor benefits?Vesting requirement of 5 yearsWork at least 3 of the first 5years enrolled in programFunctional limitation, certified by licensed HCpractitioner, expected to last for at least 90continuous daysMust continue payingpremiums to receive benefitsAARP 41Individuals with lapses in coverage of more than3 months must also pay premiums for at least24 months

CLASS – What are theBenefits?Minimum cashbenefit of $50(provided throughdebit card)Higher benefits forindividuals withhigher disabilitylevelParticipants can rollover benefits frommonth to month (forup to 12 months)No lifetime benefitlimitsBenefit can be usedto pay caregivers(family, neighbors,friends)*CBO assumed average daily benefit of $75/day*Benefits may not cover all LTSS needs; can be supplemented with personalsavings, care from family/friends, private LTC Insurance, and other public andprivate programsAARP 42

CLASS: Implementation Dates andIssues> CLASS effective date is January 1, 2011;> Statute does not specify when enrollment must begin> Secretary to establish a Personal Care Attendants WorkforceAdvisory Panel by June 21, 2010> Secretary of HHS is required to designate a CLASS benefitplan by October 1, 2012AARP 43

CLASS: Interactionwith Medicaid> CLASS enrollees who qualify for Medicaid may retain a portionof their CLASS benefits:> Nursing Home residents may retain 5 percent of benefit> HCBS recipients may retain 50 percent (States will berequired to meet certain Medicaid criteria in order toreceive 50 percent of CLASS benefit)> CLASS benefits do not affect eligibility for benefits underany federal, state or local assistance programAARP 44

CLASS: Interaction with StateLTC programs> State Protection and Advocacy Assistance System to enterinto agreements with HHS to help CLASS participants(January 1, 2012)> States assess providers’ capacity to serve as fiscal agents andprovide employment-related benefits to personal careattendants or designate or create entities to serve as fiscalagents (March 23, 2012)> States establish links between enrollment and paymentsystems to identify individuals receiving benefits under CLASSand Medicaid and comply with primary payor rulesAARP 45

CLASS: SC StateDecisionsSC can chooseto participate asemployerMay wish toassess howCLASS willintersect withother programsCan offer taxincentives toemployers/individualsEstablish linksbetweenenrollment andpaymentsystems toidentify jointbeneficiariesAARP 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 theirfamilies by leading reform effortsAARP 47