Transcript Elderly Waiver and Alternative Care – Programs Supporting

Elderly Waiver and Alternative
Care – Programs Supporting
Older Adults at Home
2013 Age and Disabilities Odyssey
Libby Rossett-Brown - Elderly Waiver/Alternative
Care Program Administrator
Gail Carlson – Alternative Care Operations
June 18, 2013
Session Goals
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Understand the basic concepts and
policies of the Elderly Waiver (EW) and
Alternative Care (AC) programs
Comparison of EW and AC Service sets
Become knowledgeable of each programs
financial eligibility
AC fees and cost sharing
Acronyms
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CMS
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SRU
MA
EW
MCO
MSHO
MSC+
SIS-EW
LTCC
NF
MNA
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Centers for Medicare and Medicaid
Services
Special Recovery Unit
Medical Assistance
Elderly Waiver
Managed Care Organization
Minnesota Senior Health Option
Minnesota Senior Care Plus
Special Income Standard-Elderly Waiver
Long Term Care Consultation
Nursing Facility
Maintenance Needs Allowance
Acronyms
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DHS
LOC
CL
AC
CDCS
FFP
HCBS
PNA
PCA
Department of Human Services
Level of Care
Customized Living
Alternative Care
Consumer Directed Community Supports
Federal Financial Participation
Home and Community Based Services
Personal Needs Allowance
Personal Care Attendant
Purpose of Elderly Waiver (EW)
and Alternative Care (AC)
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Maintain people in their own homes –
person chooses to live in the community
Connect people with services that they
need
Support Caregivers
Support choice and informed decision
making
Prevent or delay NF admissions
Move people out of institutions
Elderly Waiver
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The Elderly Waiver program funds home
and community based services for people
age 65 and older who are eligible for
Medical Assistance and require the level
of care provided in a nursing home, but
choose to reside in the community.
Authority found in MN Statute, Section
256B.0915
Federal and State funding
Alternative Care
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Contain MA expenditures by funding care
in the home and community
Prevent impoverishment of older adults by
assisting them to access services at an
earlier point of need and prevent more
costly levels of care
Authority found in MN Statute, Section
256B.0913
State funded only
EW – Who is Eligible?
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Age 65 or older
Eligible for Medical Assistance
A Minnesota Resident
Need nursing home level of care as
determined by the Long term care
consultation process (LTCC)
Requires a waiver service to remain in the
community
EW-Who is Eligible?
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The EW service cost for an individual
cannot be greater than the estimated
nursing home cost for that individual and is
limited by the case mix classification
The person’s plan of care assures health
and safety
AC-Who is Eligible?
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Age 65 and older
Have chronic care needs
Chooses to reside in the community
Have financial resources to meet their own
health related needs and independent
living needs
At risk of NF placement as determined by
the LTCC
May be eligible for Medicare Savings
Programs
EW and AC Program Models
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Voluntary Enrollment
Payer of Last Resort
Cost sharing by participants
Program and service is appropriate to
need
Most cost effective way to meet the need
Enhance self sufficiency
Support and extend informal caregiving
EW client Characteristics FY13
Average Age:
 80 years old
 198 are 100+ years
 Oldest is 107
 Total Eligible EW Clients
FY13 27,798
Gender:
 73% female
 27% male
Marital Status:
 48% are widowed 19%married
Case Mix:
 17% A; 17% B;
22% L; 12% D, 13% E, 2%K
Living Arrangements:
2/3 live alone
Ave Cost (State):
 $10,675 per client/per yr or
$890/month
EW Total Cost:
 Approx. $266 million (FY2013)
Managed Care
FFS 1,664 6%
MSHO-EW 19,554 70%
MSC+ -EW 6,580 24%
Minnesota Elderly Waiver
Clients by County FY2013
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Total EW Clients
27,798
AC client Characteristics FY13
Average Age:
 82 years old
 27 are 100+ years
 Oldest is 103
 Total Eligible AC Clients
FY13 4,037
Gender:
 76% female
 24% male
Marital Status:
 Nearly 2/3 are widowed
Case Mix:
 29% A; 24% B;
20% L;9% D, 8% E
Living Arrangements:
2/3 live alone
Service Months:
 30 months average
Ave Cost (State):
 $6,096 per client/per yr or
$797/month
AC Total Cost:
 Approx. $28.2 million
(FY2013)
Minnesota Alternative Care
Clients by County FY2013
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Total Eligible AC
Recipients FY13
4,037
Enrollment Process for EW/AC
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Community Assessment determines service
needs –
County Social Service Department
Tribal Entity
Public Health Nurse/Social Worker
Managed Care Organization (EW)
Medical Assistance Eligibility (EW) – county
financial worker
AC financial eligibility determined by the Case
Manager
EW Financial Eligibility
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Special Income Standard (SIS-EW) –
income is equal to or below $2,130/month
(300% SSI)
Clients can keep $971(as of 7/1/13) –
Maintenance Needs Allowance (MNA)
If income exceeds $971 the client must
pay for part all waiver service costs –
Waiver Obligation.
EW Financial Eligibility
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Clients do not have to meet the waiver
obligation in full each month to remain
eligible.
Waiver obligations cannot be collected
until services are delivered
SIS-EW Example
Mr Is it summer – not married and income is
$1000/month
 Special income standard is 2130 – He is below
the standard
Maintenance needs allowance (MNA) is $971
Calculation: Income minus the MNA = difference of
$29
He will have a $29 waiver obligation
This amount is paid towards waiver services used
in a month
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Financial Eligibility non SIS-EW
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Income is greater than $2130/month
Keep $719/month income (medically
needy income standard 7/1/13)
Will have a medical spenddown – must
pay a portion of medical costs and waiver
costs.
Non SIS-EW example
Mrs Flowers has income of $3000/month
 Special income standard is $2130
She will need to spend down to 75%FPG ($719)
because she is already over 100%FPG ($958)
There are other disregards and deductions
 Client will need to meet a medical spendown of
$2281 and will pay a portion of medical costs
and waiver costs
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EW Asset Limit
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MA method B: $3000 for a household of 1
Married couples: The community spouse
is entitled to an asset allowance and an
asset assessment needs to be completed
An asset assessment protects a specified
amount of assets for the community
spouse.
Asset assessments are completed by the
financial worker
AC Financial Eligibility
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Financial resources are within 4.5 months
of Medical Assistance Eligibility ($25,881
7/1/13) and
Capable of meeting own remaining health
needs and
Capable of meeting a monthly fee
requirement
Spousal Impoverishment rules apply
AC Financial Eligibility
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Monthly income is >$1149 (7/1/13) or
Assets are >$3000 (MA Asset limit) and
Total combined adjusted monthly income
and assets are less than the projected
nursing facility care cost for 135 days
(+MA asset limit of $3000)
7/1/13 this is $25,881
AC Financial Eligibility
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Income is ≤$1149 and assets are ≤$3000
applicant is ineligible for AC
Can be temporary served under AC up to
60 days during their application to Medical
Assistance/Elderly Waiver
If income and assets available are greater
than the projected nursing facility care cost
for 135 days(+MA asset limit of 3000)
client is ineligible for AC and cannot be
temporarily served
AC Financial Worksheets
Alternative Care Program Eligibility Worksheets:
DHS 2630A Married person with a community
spouse
DHS 2630 Unmarried individuals, or Married
couples when both may choose AC or a married
person whose spouse is an EW recipient or is
living in a nursing facility
Case Manager determines financial eligibility
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Estate Claim Recovery
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Effective 7/1/2003, DHS and the county pursue
estate claims for people that use the AC
program
An estate claim is a method of recovering AC
payments from the estate of a deceased person
It is only payable from the assets in the estate of
the recipient of AC services.
The estate will pay a portion of the claim before
it will give heirs any inheritance
The estate may include a life estate or any joint
tenancy interests in real estate that is owned at
the time of death.
Lead agency role to inform clients concerning
estate recovery - Use form 5186
Estate Claims
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Estate claims are imposed for recipients over the
age of 55 who receive Medical Assistance. The
law has changed recently concerning QMB,
SLMB , QI1.
Dates of service before 1/1/2010 » subject to
recovery
Dates of service after 1/1/2010 » Exempt from
recovery
Liens are only imposed if stay in a nursing
facility or hospital is greater than 30 days (paid
for by MA)
AC Monthly Fees – Cost
Sharing
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Fees are used to help fund the program
Fees are based on income and assets; sliding
fee scale-0%, 5%,15% or 30% of the cost of
AC services
Dollar amounts and effective date of fees are
entered into the service agreement MMIS
screen when a client enters the AC Program,
even if the amount due is $0;
All Alternative Care services shall be
included in the estimated costs for the
purpose of determining the fee.
See Bulletin 12-25-05 for detailed information
on AC Fees
Payment Options Include
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DHS Form 4639 describes payment options
Personal checks, money orders, or cashiers checks
made out to DHS-AC Fees and mailed to:
DHS-AC Premiums
PO Box 64835
St. Paul, MN 55164-0835
Credit card payments and bank withdrawals (including
recurring payments) made at:
http://payments.dhs.state.mn.us
Payment plan (including partial payments)
Representative Payee or greater family involvement
Automatic withdrawal of AC fees from a checking or
savings account is no longer a payment option
Do not send cash
AC Monthly Fees - Contacts
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MAXIS email at [email protected]
– For current or past month fee changes
– Refunds
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Special Recovery Unit at (651-431-3205)
or
1-800-657-3762
– For client billing questions
AC Monthly Fees – Cost
Sharing
Case Managers can change fees on the
service agreement for the following month:
 If there is a change in condition which
results in a change in the cost of services;
 If there is a change in the adjusted income
or assets;
 A client enters a nursing facility as an
admission for more than 30 days
AC Monthly Fees
Client Income*
Gross
Assets
Monthly Fee
Income<100% FPG
($958)
and
Income>=100% ($958)
and <150% FPG
($1437)
and
Income>=150%($1437)
and <200% FPG
($1915)
and
Income >=200% FPG
($1915)
OR
<$10,000
$0
<$10,000
5% cost of AC
Services
<$10,000
15% cost of
AC Services
>=$10,000
30% cost of
AC Services
*Income minus recurring and predictable medical expenses
Over Due Fees
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Case managers are responsible for
notifying AC clients if they are behind in
paying their fees. This information can be
found on Infopac report RN190. This
report is organized by county of service.
Clients are identified as open (O), closed
(C) or deceased (D).
Clients continue to receive overdue fee
notices until they are current in payment of
their fees, or for one year after they have
been closed or deceased.
Over Due Fees
Case managers need to work with clients
and their families to make arrangements to
pay overdue fees (including a partial
payment plan); however clients be
ineligible for the AC Program after 60 days
of nonpayment of fees.
 Eligibility may be extended while making
arrangements to pay outstanding fees
256B.0913 Subdivision 4
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Overdue Fees
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When clients move to a new county, the new lead
agency is responsible for collecting the fees,
including past due fees incurred prior to the move.
The current county of service must update the
county fields on the screening document before the
client will show up on the RI90 report under the new
county.
Clients who are dis-enrolled for non payment of fees
are not eligible to re-open to AC for 30 days
The client must be mailed the Notice of Action Home
and Community-Based Waiver Programs and AC
(DHS-2828) form and be closed to the AC Program
with 10 day notice per instructions in bulletin #1225-05
AC Infopac Reports RN-190
and RN-193 are available
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AC RN-190 is a bi-monthly report that
provides information on AC clients with
over due fees by county of service and
case manager. It provides the clients
name, due date, balance due by due date,
PMI and Swift ID and status (O-open, Cclosed or D-Deceased).
RN-193 provides client name, address,
pmi, swift Id and case manager name by
county of service.
Fees may be waived if:
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A person is residing in a NF and receiving case
management only
A married couple is requesting an asset assessment
under the spousal impoverishment provision
A person is eligible for AC but has not received any
services
A person has chosen CDCS for which the cost of
services is not greater than the cost of services minus the
monthly fee that would otherwise be assessed
Income and assets determine that the fee can be waived
The client is on temporary AC
The AC waiver reason is identified on the screening
document
EW/AC Benefit Set
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AC services are generally the same as
those offered under the EW program
AC is a state funded program so it has
some unique differences from EW which is
a federally funded program
AC does not have residential services
such as: Foster Care or Customized Living
Both programs are payers of last resort
EW/AC Benefit Set
Services on both programs:
Adult Day Service/ADS bath
Caregiver Training/Education
Case Management
Chore Services
Companion Services
Home Delivered Meals
Home Health Aide
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EW/AC Benefit Set
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Homemaker services
Environmental Accessibility Adaptations
Personal Care Assistant
Respite Care
Nursing
Specialized Supplies and Equipment
Transportation
Consumer Directed Community Supports
EW Only Services
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Foster Care
Residential Care
Customized Living/24 hour Customized
Living
Transitional Supports
AC Only Services
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Conversion Case management
Nutritional Service
Discretionary Services
Specialized Supplies and
Equipment
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Includes durable and non durable medical
supplies and equipment which are
provided as necessary to the direct
treatment of the recipients condition and
which medical assistance does not fund.
Medical Assistance equipment and
supplies are defined in Minnesota Rules,
parts 9505.0310. Also a section of the
MHCP Provider Manual
Specialized Supplies and
Equipment
Devices, controls or medical appliances or
supplies specified in the community support
plan that enable a person to increase their
ability to:
 Perform activities of daily living
 Perceive, control or interact with their
environment or communicate with others
 The most cost effective way
Specialized Supplies and
Equipment
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Items necessary for life support or to
address physical conditions along with
ancillary supplies and equipment
necessary to the proper functioning of
such items
Once an item is purchased it becomes the
property of the person it was purchased
for
Specialized Supplies and
Equipment
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Items, equipment and supplies that exceed the
scope or limits in the state plan may be covered.
May cover evaluation of the need for equipment
and/or device and, if appropriate, subsequent
selection and acquisition.
The service includes equipment rental during a
trial period, customization, training and technical
assistance to enrollees
Maintenance and repair of devices
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EW/AC Section of MHCP
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Oral and Enteral Nutritional
Products
MA may pay for nutritional products whether or
not they are oral or tube fed
 EW/AC may pay for nutritional products with the
following requirements:
- There is a physicians orders, medical
documentation and a physical reason why the
person cannot obtain their caloric intake without
the supplements
- The Doctor has established that the person
needs the product to maintain body weight and
strength in the community
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Personal Emergency Response
Services (PERS)
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Includes more traditional systems which
require the individual to press an alert or
panic button worn on a pendant or
bracelet in the event of a fall or an
emergency.
Payment can include installation and
testing, the monthly service fee and the
system/equipment purchase.
Environmental Accessibility
Adaptations
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Minor physical adaptations to the home, required by the
individuals care plan that are :
Necessary to ensure the health, welfare and safety of
the individual with mobility problems, sensory deficits or
behavior problems.
Enabling the individual to function with greater
independence in the home, and without which, the
individual would require institutionalization.
The annual limit is $10,000 – per waiver year
May be funded in any setting which can be defined as
the person’s primary place of residence and the
modification is of direct and specific benefit to the
recipient. EW should be the payer of last resort
Environmental Accessibility
Adaptations
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Can include: installation of grab bars and ramps,
widening of bathroom facilities, widening of doorways,
installation of specialized electrical or plumbing systems
which are necessary to the medical equipment and
supplies which are necessary for the welfare of the
individual.
Environmental modifications also include modifications
to vehicles
Environmental modifications also include modifications
to adaptive equipment –such as furniture or utensils
required by an individual.
Excluded Modifications: general utility and that do not
have a direct medical or remedial benefit to the individual
such as carpeting, roof repair, central AC or adaptations
that add to the square footage of the home
Tribal EW and AC
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Legislation allows tribes to behave as a
county and administers EW and AC –
perform screenings, approve payment for
services including PCA
White Earth and Leech Lake tribes
currently participating
Expansion to other tribes
Service Delivery Systems for
EW Recipients
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Fee for Service: The provider bills MN Dept of
Human Services for each service
Minnesota Senior Care Plus (MSC+): 2003
State Legislation adds LTC to basic Medicaid
Managed Care package. Includes basic
services plus LTC services (EW and 180 days
NF) It is now being implemented in 87 counties.
This is mandatory for all clients 65+ Who
are not excluded from
Managed care.
Service Delivery Systems for
EW Recipients
Minnesota Senior Health Options
(MSHO)
CMS payment demo since 1997, includes
full risk for Medicare/Medicaid primary,
acute, LTC (NF and community services)
through a Special Needs Plan
All Medicare and Medicaid drugs and other
services in one coordinated plan.
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Includes EW and 180 days if NF
Expanded statewide
Special Needs Plans
EW/Managed Care
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All MSHO/MSC+ seniors get initial risk
assessment and follow up regardless of
setting of care or eligibility for waiver
services.
98% of enrolled seniors get primary and
preventive physician visits
All seniors are reviewed for need for PCA
and LTC services
Coordinates with Medicare
Adds a focus on improvement of
management for chronic conditions
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The project creates and implements a
single comprehensive, and integrated
assessment and support planning
application for long term care services and
supports in Minnesota.
Person centered approach to ensure
services are tailored to the individual’s
strengths, goals, preferences, and
assessed needs.
HCBS Waiver Provider
Standards
Uniform, statewide standards for HCBS
providers and
- Statewide mechanisms for enrolling and
licensing HCBS providers and
- enhanced provider enrollment standards
with an emphasis on services that will
remain unlicensed
- define Lead Agency quality assurance
functions for waiver services.
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HCBS Waiver Provider
Standards
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All currently enrolled waiver service providers
have begun a provider record review with DHS
Minnesota Statute Chapter 245D establishes
foundation licensing standards to be effective
1/1/2014. These standards apply regardless of
the funding source for the service.
DHS will provide training to lead agencies and
providers
NF Level Of Care Changes
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In 2009, the MN Legislature passed legislation that
changes nursing facility level of care (NF LOC)
criteria for public payment of long term care.
The change was important to:
- Provide more consistent access to services
- Address MN aging demographics and manage
growth in public spending for long term care
- Support service sustainability
- Improve the ability of lead agencies to assess
individuals, monitor programs , evaluate outcomes
and assess the impact of public spending
Will be implemented 1/1/14
Resources
Libby Rossett-Brown
Elderly Waiver/Alternative Care Program Administrator
651-431-2569
[email protected]
County’s Social Service Department
County’s Income Maintenance Department
AC Operations Questions:
Gail Carlson
651-431-2586
[email protected]