Transcript Medicaid’s Role in Supporting Olmstead Implementation

The Olmstead Decision and Community
Integration: Medicaid’s Role
New York State Association of Community and Residential Agencies
Annual Leadership Conference
December 5, 2014
Figure 1
The Olmstead Plaintiffs and Their Claim
• Olmstead was brought by two women with cognitive
and mental health disabilities who remained
institutionalized in Georgia, despite the fact that
their treatment teams had determined that their
needs could be met in the community
• The Olmstead plaintiffs argued that their
circumstances violated of the Americans with
Disabilities Act’s community integration mandate:
Photo credit: Atlanta Legal Aid Society
– State and local governments are prohibited from disability-based discrimination and
must provide services “in the most integrated setting appropriate to the needs of
people with disabilities”
– State and local governments must make “reasonable modifications” to policies,
practices, and programs to avoid disability-based discrimination, unless doing so
would constitute a “fundamental alteration” the nature of the service, program, or
activity
Figure 2
The Supreme Court’s Decision in Olmstead
• Unjustified institutional isolation of people with disabilities is a form of
discrimination under the ADA
– in order to receive needed medical services, people with disabilities must, because of
those disabilities, relinquish participation in community life that they could enjoy
given reasonable accommodations, while people without disabilities can receive
needed medical services without similar sacrifice
• Community-based services must be offered, if appropriate, if a person with a
disability does not oppose moving from an institution to the community, and if
the community placement can be reasonably accommodated, considering the
state’s resources and the needs of other people with disabilities
• The reasonable modification standard would be met if a state demonstrates that
it has a comprehensive, effectively working plan for placing qualified people with
disabilities in less restrictive settings and a waiting list that moves at a reasonable
pace
Figure 3
As the Primary Payer for Long-Term Services and Supports,
Medicaid Plays a Key Role in Community Integration
Private
Insurance, 8%
Other Public
and Private,
22%
Medicaid, 50%
Out-ofPocket,
19%
Total National LTSS Spending in 2012
= $294 billion
NOTE: Total LTSS expenditures include spending on residential care facilities, nursing homes, home health
services, and home and community-based waiver services. Expenditures also include spending on
ambulance providers and some post-acute care. This chart does not include Medicare spending on postacute care ($73.3 billion in 2012). All home and community-based waiver services are attributed to
Medicaid.
SOURCE: KCMU estimates based on CMS National Health Expenditure Accounts data for 2012.
Figure 4
Most Medicaid Home and Community-Based Services Are
Provided at State Option, 2010
807,659
11%
$5.7 billion
19%
$10.2 billion
26%
Mandatory Home Health
State Plan Services
Optional Personal Care
State Plan Services
951,853
30%
70%
$36.8 billion
Optional § 1915(c) HCBS
Waiver Services
1,403,736
Total:
44%
Participants
Expenditures
3.2 million
$52.7 billion
SOURCE: Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and CommunityBased Service Programs: 2010 Data Update (March 2014), http://kff.org/other/report/medicaidhome-and-community-based-services-programs-2010-data-update.
Figure 5
Medicaid § 1915(c) HCBS Waivers Can Be Capped,
Resulting in Waiting Lists, 2002-2012
Other
Aged/Disabled
6%
Intellectual/Developmental Disability
6%
6%
3%
43%
53%
1%
51%
1%
41%
5%
10%
30%
26%
10%
29%
32%
62%
58%
28%
28%
29%
42%
53%
53%
9%
8%
68%
64%
63%
61%
64%
53%
47%
45%
2002 53%2003
47%
2004
200545% 2006
2007
2008
2009
2010
2011
2012
206,427
260,916
331,689
393,096
365,553
428,571
511,174
523,710
Total: 192,447
180,347
280,176
NOTE: “Aged/Disabled” comprises the following enrollment groups: aged, aged/disabled, and physically disabled.
“Other” comprises the following enrollment groups: children, individuals with HIV/AIDS, individuals with mental
health needs, and individuals with traumatic brain and spinal cord injuries. Percentages may not sum to 100 due to
rounding. SOURCE: Kaiser Commission on Medicaid and the Uninsured, Medicaid Home and Community-Based
Service Programs: 2010 Data Update (March 2014), http://kff.org/other/report/medicaid-home-and-communitybased-services-programs-2010-data-update.
Figure 6
Medicaid HCBS Waiver Services Play An Important Role in
Supporting Beneficiaries’ Community Integration
Curtis
Age 20
Topeka, KS
Margot
Age 38
Charlotte, NC
Carolyn
Age 25
Miami, FL
Residence
Lives with his mother
Lives with a friend
Lives with her mother
Time on
Waiting List
Recently started receiving
services after 12 year wait
Still waiting 18 months after interstate move to be near family
Received services after waiting for 9
years
Health
Mental retardation, autism, and
sensory integration issues
Cerebral palsy with spastic
quadriplegia
Chromosomal condition affecting
growth, mobility, behavior, and
intellectual functioning
Situation
Attendant services help with
basic living skills at home and in
the community; will eventually
need group home residential
placement
Has master’s degree in social work
but unable to work due to health;
has had 6 inpatient hospitalizations
since her move, which she believes
were preventable with sufficient
home health aide hours
Needs behavioral therapist and job
coach to succeed at sheltered
workshop and attendant services and
wheelchair ramp to facilitate
community access
SOURCE: Kaiser Commission on Medicaid and the Uninsured, Faces of People on HCBS Waiver Waiting Lists (March 2014),
http://kff.org/medicaid/report/medicaid-beneficiaries-who-need-home-and-community-based-services-supportingindependent-living-and-community-integration/.
Figure 7
Medicaid LTSS Spending is Increasingly Devoted to HCBS as
Opposed to Institutional Care
(in billions)
$121
$109
$93
32%
$123
$123
45%
46%
$113
$100
37%
41%
42%
45%
Home and Community-Based LTSS
Institution-Based LTSS
68%
63%
59%
58%
55%
55%
54%
2002
2004
2006
2008
2010
2012
2013
NOTES: Home and community-based care includes state plan home health, state plan personal care
services and § 1915(c) HCBS waivers. Institutional care includes intermediate care facilities for individuals
with intellectual/developmental disabilities, nursing facilities, and mental health facilities.
SOURCE: KCMU and Urban Institute analysis of CMS-64 data.
Figure 8
Among Beneficiaries Who Use LTSS, a Larger Share of Non-Elderly
People with Disabilities Live in the Community Than Seniors
1.9 million
1.6 million
49%
79%
Predominantly CommunityBased Care
Predominantly Institutional
Care
51%
21%
Seniors
Non-Elderly People with
Disabilities
NOTE: Individuals who used both institutional and community-based services in the same year are
classified as using institutional services in this figure.
SOURCE: KCMU and Urban Institute estimates based on MSIS and CMS-64 FY 2010 data.
Figure 9
Olmstead Implementation 15 Years After the Supreme
Court’s Decision
• Recent case themes, highlighting Medicaid’s key role in Olmstead
implementation, include:
– providing community-based services instead of institutionalization;
– providing services in the most integrated setting to enable people with
disabilities to interact with non-disabled peers to the fullest extent possible;
– providing community-based services to prevent institutionalization for
people at risk;
– replacing sheltered workshops with supported employment; and
– eliminating disability-based discrimination within the Medicaid program
SOURCE: Kaiser Commission on Medicaid and the Uninsured, Olmstead’s Role in Community Integration for People
with Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision (June 2014), available at
http://kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-undermedicaid-15-years-after-the-supreme-courts-olmstead-decision/.
Figure 10
Medicaid Offers A Number of Options for States to Increase
Beneficiary Access to HCBS
45
21
16
15
12
4
Money Follows
the Person
Demonstration
Balancing Incentive
Program
Health Homes
State Plan
Option
HCBS State Plan
Option
NOTE: Total counts equal the number of states that are approved by CMS to participate in the option as
of Nov. 2014. States with pending state plan amendments or demonstration proposals are not captured
in this figure. Washington is approved for both capitated and managed fee-for-service financial alignment
demonstrations. SOURCES: CMS, Medicaid.gov, and state websites.
Financial and/or Community First
Administrative
Choice State Plan
Alignment Demos
Option
for Dually Eligible
Beneficiaries
Figure 11
Medicaid Plays a Key Role in Community Integration
Wanda
Age 78
Tulsa, OK
Virginia
Age 72
Oklahoma City, OK
Don
Age 41
Owossa, MI
Residence
Lives in subsidized senior housing
Lives alone at home
Lives in an apartment
Health
Muscular and skeletal problems,
degenerative joint disease in
lower back, hip replacement, and
poor circulation in legs
Uterine cancer, hypertension, acid
reflux, hernia, poor circulation in
legs
Developmental disabilities, impulse
control disorder, neuroleptic
malignant syndrome
Medicaid’s
Role in LTSS
Helped her transition from
nursing home to community after
two year stay post-surgery; case
manager coordinates in-home
aide and transportation services
Provides regular home visits by
nurse and personal care aide
Enables him to self-directs his LTSS by
hiring his own in-home caregivers
and move from group home to his
own apartment
SOURCE: Kaiser Family Foundation, Faces of Dual Eligible Beneficiaries (July 2013).
Figure 12
State Interest in Delivering LTSS Through Capitated
Managed Care Waivers Is Increasing
VT
WA
MT
ME
ND
NH
MN
OR
ID
MI*
WY
UT
CA
PA
IA
NE
NV
IL
CO
IN
OH
WV
KS
MO
KY
OK
NM
TX
AL
DC
SC
AR
MS
VA
CT RI
NJ
DE
MD
NC
TN
AZ
MA
NY
WI
SD
GA
LA
AK
FL
HI
MLTSS waiver includes seniors and people with physical disabilities (13 states)
MLTSS waiver includes seniors, people with physical disabilities, and people with I/DD (5 states)
No MLTSS waiver** (31 states plus DC)
NOTES: *MI has 1 waiver for seniors and people with physical disabilities and another waiver for
people with I/DD. **Analysis includes states with § 1115 or § 1915(b)/(c) capitated MLTSS waivers.
Other states may have capitated MLTSS programs through § 1932 state plan or § 1915(a) waiver
authority.
SOURCE: KCMU analysis of approved waiver terms and conditions, available at www.medicaid.gov.
Figure 13
Some Managed LTSS Waiver Provisions Are Aimed at
Increasing Beneficiary Access to HCBS
• Expanding Medicaid financial eligibility criteria (NJ, NY, RI, VT)
• Providing HCBS to people at risk of institutionalization (AZ, DE, HI,
NY, RI, TN, VT)
• Allowing spouses as paid caregivers (AZ, VT)
• Including financial incentives for health plans to provide increased
HCBS (HI, IL*, OH, TN) or provisions that increase state funding of
HCBS (KS, VT)
• Requiring health plans to have strategies for NF to community
transitions or NF diversion (KS, NJ, NM)
NOTE: *IL’s provision is in concurrent § 1115A authority.
SOURCE: KCMU analysis of approved MLSS §1115 and §1915(b)/(c) waiver
terms and conditions, available at www.medicaid.gov.
Figure 14
Some LTSS Rebalancing Measures Exist, But Further
Development is Needed
•
Some existing quality measures, such as the National Core Indicators, ask beneficiaries to
rate aspects of their services, such as:
– The extent of community integration where they live, work, and spend leisure time
– Opportunities to exercise choice and self-determination
•
Some of the financial alignment demonstrations for dual eligible beneficiaries require
states to report on measures related to LTSS rebalancing, such as:
– The number or percent of beneficiaries living in institutional or community-based settings
– The number or percent of beneficiaries transitioning between institutional and community-based
settings
– The number or percent of beneficiaries experiencing a decrease in authorized personal care
hours.
•
LTSS rebalancing measures remain a gap in evaluating HCBS quality, and additional work is
needed and underway in this area.
Figure 15
Looking Ahead, Medicaid Will Continue to Offer States
Options to Facilitate Community Integration
• The ACA’s new and expanded options to rebalance LTSS spending toward HCBS
can be incorporated into states’ Olmstead plans
- Money Follows the Person and Community First Choice include enhanced federal
funding
- The Balancing Incentive Program includes reforms such as the development and
expansion of no wrong door/single entry point systems and core standardized
assessments to achieve greater equity among different populations receiving Medicaid
HCBS
• CMS’s new definition of “home and community-based setting” seeks to ensure
the fullest integration for people with disabilities
• CMS’s 2013 guidance on Medicaid managed LTSS waivers specifies that these
delivery systems reforms must be administered consistent with Olmstead and
the ADA’s community integration mandate
Figure 16
For more information on Medicaid and health reform,
visit…
www.kff.org