Transcript HCBS Alternative to Psychiatric Residential Treatment

Money Follows the Person
Rebalancing Demonstration
Section 6071 of the
Deficit Reduction Act 2005
Richard C. Allen
Centers for Medicare & Medicaid Services
Presentation to
2007 Annual Conference of Assistive Technology
ACT Programs
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Expenditures in Billions
Medicaid Institutional and Community-Based Expenditures
in 2005 Dollars: FFY 1980-2005
$100
$90
$80
$70
$60
$50
$40
$30
$20
$10
$0
$35
$22
$13
$6
$3
$1
$27
1980
$34
1985
$42
1990
Institutional
$55
$59
$59
1995
2000
2005
Community
Source: Thomson/Medstat: CMS Form 64 Reports, adjusted for price increases based on the
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Skilled Nursing Facility Input Price Index.
Medicaid LTC Expenditures for Older Adults and People
with Physical Disabilities, in 1995 and 2005
2005
1995
Personal
Care,
8%
E/D
HCBS
waivers,
3%
Home
Health,
5%
Personal
Care
14%
E/D
HCBS
waivers
6%
Home
Health
6%
Nursing
Facility,
84%
Source: Thomson/Medstat: CMS Form 64 Reports
Nursing
Facility
75%
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Medicaid LTC Expenditures for Individuals with MR/DD, in
1995 and 2005
2005
1995
DD
HCBS
Waiver,
30%
ICF/MR
42%
ICF/MR,
70%
DD
HCBS
Waiver
58%
Source: Thomson/Medstat: CMS Form 64 Reports
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Quest for a “Balanced” LTC System

The organization, financing, and delivery of Medicaid-funded LTC services is
biased towards institutional care.
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Almost two-thirds of Medicaid LTC expenditures are devoted to “institutional” care.
13% of NH residents are under age 65.
40.9% of NH residents have no ADLs.
80% of NH residents have no, or only mild, or moderate cognitive impairments.
MDS Q1A:
For residents with a LOS of +30 days, 11% of the nearly2.8 million discharges from NFs
were to the consumer’s home with no additional services and 28% went home with only
home health services.
Reasons for the Bias:
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Mandatory NF benefit.
Funding follows the setting, not the individual.
The use of separate line-item budgets to pay for institutional services and HCBS.
Overcoming the effects of historically high NF occupancy rates and waiting lists.
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Quest for a “Balanced” LTC System

Passage of the Americans with Disabilities Act

Olmstead v. L.C. and E.W

President’s New Freedom Initiative and Executive Order
13217
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With HHS and CMS funded grants to states to foster:
 choice of quality options for where to receive their care;
and
 greater control over the types of services and supports they
need to live their lives.

Proportion of Medicaid LTC devoted to HCBS has grown
significantly.
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Objectives of the MFP program
1.
2.
3.
4.
A nursing facility transition program that identifies
consumers in institutions who wish to transition and
assists them in doing so.
A financial system the allows Medicaid funds budgeted
for institutional services to be spent on HCBS when
individuals move the community.
Quality management system that ensures the provision
of, and improvement of services in both HCBS and
institutional settings.
Broader rebalancing efforts to support and foster
facilitate transition and diversion.
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States Awarded MFP Grants

First Round: Arkansas, California, Connecticut,
Indiana, Iowa, Maryland, Michigan, Missouri,
Nebraska, New Hampshire, New York, Ohio,
Oklahoma, South Carolina, Texas, Washington,
& Wisconsin

Second Round: Delaware, District of Columbia,
Georgia, Hawaii, Illinois, Kansas, Kentucky,
Louisiana, New Jersey, North Carolina, North
Dakota, Oregon, Pennsylvania, and Virginia
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MFP Fundamentals
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$1.75 billion over five years (January 1, 2007September 30, 2011)
Participating states receive an enhanced FMAP
for 12 months for qualified home and community
based services for each person transitioned
from an institution to the community.
Self-direction encouraged.
“Rebalancing” Benchmarks required.
States must participate in CMS’ national
evaluation.
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Qualified Individuals

Reside in an institution (6months – 2 year minimum
period).
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Institutions include: hospital, nursing facility, or ICF/MR.
An IMD is also included to the extent that medical
assistance is available under the State plan for service in
the IMD.
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Is receiving Medicaid benefits for inpatient services
furnished by such inpatient facility.
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Would need HCBS services in order to successfully
reside in community based settings.
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Qualified Residence
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Where eligible individuals can move to.
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A home owned or leased by the individual or the
individual’s family member.
An apartment with an individual lease, with lockable
access and egress, and which includes living,
sleeping, bathing, and cooking areas over which the
individual or the individual’s family has domain and
control; or
A residence, in a community based residential setting,
in which no more than 4 unrelated individuals reside.
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Transition

How to Target Consumers for Transition?
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Potential discrimination.
Can it be done at a reasonable cost? Conserve
limited resources for those that are likely to benefit.
Developing NFT Infrastructure
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Inform all residents about HCBS options.
Identification process.
Assessment and care planning.
Transition case management services.
One-time transition expenses (security deposits,
household items, etc);
Monitoring of those transitioned.
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MFP Quality Management System

Grantees must develop and submit for approval
a quality management system (QMS) for
demonstration participants during the
demonstration year and a description of what
system they will be transitioned to after the 12month demonstration period.

QMS must meet or exceed the guidance for a
QMS set forth under Appendix H of the 1915(c)
HCBS waiver program.
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Website
See the following website for all information:
www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp
http://www.amda.com/advocacy/regulations.cfm
For any questions, send to:
[email protected]
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