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Colleen Horton Hogg Foundation for Mental Health The University of Texas at Austin July, 2010 MEDICAID FUNDED LONG-TERM SERVICES AND SUPPORTS FOR PEOPLE.

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Presentation on theme: "Colleen Horton Hogg Foundation for Mental Health The University of Texas at Austin July, 2010 MEDICAID FUNDED LONG-TERM SERVICES AND SUPPORTS FOR PEOPLE."— Presentation transcript:

1 Colleen Horton Hogg Foundation for Mental Health The University of Texas at Austin July, 2010 MEDICAID FUNDED LONG-TERM SERVICES AND SUPPORTS FOR PEOPLE WITH DISABILITIES

2  Explain Medicaid funding for long term services and support.  Talk about all the waiver programs offered through DADS and DSHS including:  Eligibility requirements (eligibility)  How to sign up  Services available  Funding amounts  Where to get information  Include information about the consumer directed services options.  Provide information on other long term services and supports  Talk about the waiting lists.  Talk about how folks can impact change during the session. WHAT I WAS ASKED TO DO…

3  History  Entitlement program established in Texas in 1967 to provide health care to certain low income individuals; Title XIX of Social Security Act (1965)  Purpose – to provide health coverage to:  Low-income families, children & related caretakers  Pregnant women  Elderly  People with disabilities  Eligibility  Individuals receiving TANF and SSI  Individuals receiving waiver services  Individuals meeting income and disability criteria  Emergency Medicaid Services MEDICAID ( MUCH OF THE INFORMATION IN THIS PRESENTATION TAKEN DIRECTLY FROM THE DADS WEBSITE)

4 30 % or the Medicaid Population 58% of Medicaid Costs PEOPLE WITH DISABILITIES

5  Entitlement (no waiting list)  Mandatory Services  Optional Services  Mandatory populations  Optional Populations  Texas Medicaid and CHIP in Perspective TOC.html TOC.html MEDICAID STATE PLAN THE STATE’S CONTRACT WITH THE FEDS

6  EPSDT-Texas Health Steps  Inpatient/Outpatient hospital care  Physician services  Nurse midwife services  Nurse practitioner  FQHCs  Lab & xrays  Prenatal care  Family planning services  Skilled nursing  Children’s vaccines  Nursing facility care  Home health care  Rural Health Clinics  Nurse practitioners  Home health care  Rural health clinics MANDATORY SERVICES

7  Durable medical equip.  PT, OT, Speech  Personal care services  Dental services  ICFMR  IMDs (under 21, over 65)  Private duty nursing (under 21)  RX drugs (3 per mo.)  Unlimited RX in nursing facilities, ICFMR, managed care  Birthing center  Renal dialysis  Rehabilitation (chronic mental illness, physical, development)  Targeted case management  Medical transportation  Optometry  Podiatry  Emergency hospital services  Licensed professional counselor (LPC) OPTIONAL SERVICES

8  TANF recipients  Families based on age, income, and assets  Newborns up to 12 months whose mother is Medicaid certified at the time of child’s birth  The majority of children in foster care  Some adopted children  Non-disabled, non-pregnant adults over age 65 w/ income below the TANF limit  Children under 19 and pregnant women over the income limit but have significant medical bills (Medically needy/spend down)  SSI recipients (aged, blind and disabled) POPULATIONS COVERED

9  Individuals receiving Primary Home Care services (up to 300% of SSI income limit)  Individuals receiving waiver services  Childless adults (not covered in Texas) OPTIONAL POPULATIONS

10 Some things are different for kids:  All medically necessary services  Texas Health Steps – Early and Periodic Screening, Diagnosis, and Treatment  Comprehensive Care Program  Personal Care Services  Voluntary participation in managed care (Star+Plus) CHILDREN IN MEDICAID

11  How do I apply for Medicaid?  By phone – call 211 (connects callers with information on health and human services)  On-line  In person  Texas Medicaid and Healthcare Partnership (TMHP) contracts with state to provide Medicaid administration, reimbursement services, claims, prior authorization  Texas Medicaid and CHIP in Perspective  Frew v. Hawkins (1996) – Texas HealthSteps  Alberto, N. – Private duty nursing and personal care services NUTS AND BOLTS

12  Eligibility  Under 19 years of age  Children in families with low incomes and assets  Services  12 months of health care coverage  Cost Sharing  Enrollment fees are $50 or less per family  co-pays typically $3 -$5 CHIP CHILDREN’S HEALTH INSURANCE PLAN

13  If you would like to request an application or check the status of your application, call  You may also go online to and print an application.www.chipmedicaid.com  Fax or mail completed applications to the Texas ACCESS Alliance at: P.O. Box Midland, TX FAX: HOW TO ENROLL IN CHIP

14 MAXIMUM MONTHLY INCOME LIMITS FOR HEALTH CARE COVERAGE PROGRAMS FOR CHILDREN Family Size Medicaid for Children Under Age 1 Medicaid for Children Ages 1 to 5 Medicaid for Children Ages 6 through 18 CHIP Medicaid for Youth Transitioning out of Foster Care 1 $1,670$1,201$903$1,805$3,610 2 $2,247$1,615$1,215$2,429$4,857 3 $2,823$2,030$1,526$3,052$6,104 4 $3,400$2,444$1,838$3,675$7,350 5 $3,976$2,859$2,150$4,299$8,597 6 $4,553$3,273$2,461$4,922$9,844 7 $5,130$3,688$2,773$5,545$11,090 8 $5,706$4,102$3,085$6,169$12,337 For each additional person, add: $577$415$312$624$1,247 Source: HHSC Financial Services, 2007 Medicaid Expenditures,

15  STAR  Managed care – acute care  STAR+Plus  Managed care – acute care and long term services and supports  PCCM (Primary Care Case Mgt.)  Primarily in rural areas  Northstar  Behavioral health managed care  Dallas/Ft. Worth  IDD Pilot – current study MANAGED CARE

16  MRA  Service coordination  Respite  Employment services  Flexible services  LMHA  Children’s mental health services  Adult mental health services  Crisis services  State hospitals COMMUNITY SAFETY NET SERVICES 39 MHMR COMMUNITY CENTERS

17  Will allow parents of children with disabilities in families with income up to 300% of federal poverty limit, to buy into the state Medicaid Program  SB Authorizing legislation/SB 1 – appropriation (Senator Deuell and Rep. Lucio)  Development - underway  Implementation ??? A program at risk. MEDICAID BUY-IN FOR CHILDREN

18  State/Federally funded  Community-based long term services and supports  State must submit a waiver application to CMS  Texas has too many waivers! Nine different (1915(c) waivers with different administrative units and rules, service arrays, rates, monitoring requirements, billing guidelines, etc.  Developed to provide alternatives to institutionalization  Waive certain Medicaid rules (e.g. state-wideness)  1915(c) waivers “waive off” of some institutional setting (e.g. nursing facility, state school, ICFMR) MEDICAID 1915(C) WAIVERS

19  Community Living Assistance and Support Services (CLASS)  Home and Community-based Services (HCS)  Medically Dependent Children’s Program (MDCP)  Deaf-Blind with Multiple Disabilities (DBMD)  Community Based Alternatives (CBA)  Consolidated waiver (CWP)  Youth Empowerment Services (YES)  Texas Home Living (TxHmL)  STAR+PLUS Federal requirement – waiver programs must be cost neutral in the aggregate. TEXAS 1915(C) WAIVER PROGRAMS

20 August, 2009 CLASSHCSMDCPDBMDCBA Managed Care Total # on interest list 27,67442,36014, ,0505,633124,143 March, 2010 # on interest list 30,36343,38517, ,2785, ,083* (Unduplicated 102,647) WAIVER INTEREST LISTS

21 Interest List CBAICMSTAR+CLASSDBMD**MDCPHCS 0-1 years18,9791,3584,2746, ,4649, Years14, ,268344,6627, years1, ,45863,9176, yearsN/A2174,241N/A3,0095, yearsN/A 2,607N/A 3, yearsN/A 2,561N/A 3, yearsN/A 2,320N/A 3, yearsN/A 2, yearsN/A 1, yearsN/A TIME ON THE INTEREST LIST/MARCH 2010

22  CLASS provides home- and community-based services to people with related conditions as a cost- effective alternative to placement in an intermediate care facility for persons with intellectual disabilities or a related condition (ICF-MR/RC). Community Living Assistance supports and Services CLASS

23  Disability/functional  Related conditions (not primary diagnosis of intellectual disabilities)  Must meet level of care needed for ICFMR eligibility  Must have a need for habilitation  Assessment conducted by direct service agency nursing staff  Must be diagnosed before the age of 21 years  Financial  300% for the federal poverty level; $2,000 countable assets  Based on child’s income, not family income  Determined by HHSC Medicaid enrollment division, not DADS  Service plan may not exceed 200% of cost of care in ICFMR CLASS ELIGIBILITY REQUIREMENTS

24  Adaptive aids  Case management  Habilitation  Minor home modifications  Nursing services  OT, PT, Speech  Psychological Services  Behavioral supports  Respite care  Specialized therapies  Medical supplies  Support family services SERVICES AVAILABLE IN CLASS

25  Call toll-free to have a person placed on the interest list.  Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.  Need to confirm annually that you want to remain on the waiting list.  Assessment to determine eligibility is not done until services are offered (slot is available). HOW TO APPLY FOR CLASS WAIVER SERVICES

26  Amount of services/budget based on plan of care.  CLASS waiver costs have increased 25% since  Cost cap for CLASS is approximately $57,000  DADS utilization review unit looking closely at those plans of care that exceed a certain threshold ;  Children - ($43,000) (3/2010)  Adults - $57,368 UTILIZATION REVIEW/INCREASED COSTS

27  HCS provides individualized services and supports to persons with intellectual disabilities who are living with their family, in their own home or in other community settings, such as small group homes. Home and Community -based Services HCS

28  Disability  Must have an intellectual disability with IQ of 70 or below, or  Have a related condition with an IQ of 75 or less  Must meet the level of care criteria for an ICFMR  Assessment and service coordination done by local MHMR Center staff  Financial  300% of the SSI income limits; no more than $2000 in countable assets  Based on child’s income, not family income  Determined by HHSC Medicaid enrollment division, not DADS  Service plan may not exceed 200% of cost of care in an ICFMR HCS ELIGIBILITY

29  Service Coordination  Adaptive aids  Minor home modifications  Counseling and therapies  Speech, OT, PT  Audiology  Dietary  psychological  Nursing  Dental treatment  Respite  Supported employment  Day habilitation  Residential Services  Supported home living  Foster/companion care  Supervised home living SERVICES AVAILABLE IN HCS

30  Apply for services by  Contacting you local mental retardation authority (MRA)  MRA website: or call 211.http://www.dads.state.tx.us/contract/mra.cfm or call 211  Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.  Need to confirm annually that you want to remain on the waiting list. If your local MRA doesn’t contact you, call them! HOW TO APPLY FOR HCS WAIVER SERVICES

31  Amount of services based on assessed Level of Need (LON)  Number of individuals waiting for HCS services = 43,385 (3/2010)  Current waiting time = about 9 years (3/2010)  Service coordination now conducted by local MRA (MHMR community center)  Cost caps vary by level of need. UTILIZATION REVIEW/INCREASED COSTS/WAITING LIST

32  MDCP provides services to support families caring for children and young adults who are medically dependent and to encourage de- institutionalization of children in nursing facilities. Medically Dependent Children’s Program MDCP

33  Disability  Must meet medical criteria for nursing facility admission  Must be under the age of 21 years  Must meet disability criteria for social security or Medicaid benefits  Financial Eligibility  300% SSI income limits; no more than $2,000 in countable assets  Based on child’s income, not family’s MDCP ELIGIBILITY

34  Respite  Adjunct support services  Adaptive aids  Minor home modifications  Transition services SERVICES AVAILABLE IN MDCP

35  Call to have the child's or young adult's name placed on the MDCP interest list.  Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.  Need to confirm annually that you want to remain on the waiting list. If your local MRA doesn’t contact you, call them! HOW TO APPLY FOR MDCP SERVICES

36  Service coordination/case management is performed by DADS regional MDCP staff (nurse and/or social worker)  Cost cap is 50% of cost of nursing facility care (wrap-around Comprehensive Care Program services)  Number of children waiting = 17,052 (3/2010)  Current waiting time = 3-4 years (3/2010) UTILIZATION REVIEW/WAITING LIST

37 DB/MD waiver provides home and community-based services to people who are deaf-blind with multiple disabilities as a cost-effective alternative to institutional placement. The program focuses on increasing opportunities for consumers to communicate and interact with their environment. Deaf/Blind Multiple Disabilities DBMD

38 Disability/Functional  Meet ICFMR or related conditions care criteria. Have deaf- blindness with a third disability resulting in a need for one or more services. Financial  Must meet Medicaid eligibility.  Have an individual plan of care that does not exceed specific limits. ELIGIBILITY FOR DBMD

39  Adaptive aids  Medical supplies  Assisted living *  Behavior support  Case managements  Chore Provider  Employment assistance  Minor home mods  Habilitation  Intervener  Nursing services  OT, PT, Speech  Orientation & mobility  RX  Respite care  Supported employment  Transition assitance SERVICES AVAILABLE IN DBMD

40  Call and ask for the DB-MD waiver representative. HOW TO APPLY FOR DBMD WAIVER SERVICES

41  Fewer “slots” and number served than other waivers  Provides services similar to other waivers and some services specific to those experiencing multiple disabilities.  Number on waiting list = 262 (3/2010)  Current wait = 2-3 years (3/2010) UTILIZATION REVIEW/WAITING LIST

42 Community Based Alternatives CBA  This program provides home-and community- based services to people who are elderly and to adults with disabilities as a cost-effective alternative to living in a nursing home.

43 Disability/functional  be at risk of entering a nursing facility,  be 21 or older  Must meet medical necessity for Medicaid nursing home care Financial  Meet Medicaid income eligibility requirements (300% SSI) and have no more than $2,000 in countable assets  Cost of plan of care may not exceed 200% of the cost of care in a nursing facility ELIGIBILITY FOR CBA

44  Adaptive aids  Medical supplies  Adult foster care  Assisted living  Emergency response services  Home delivered meals  Minor home mods  Nursing services  OT, PT, Speech  Personal assistance services  Respite care services  Dental services  Unlimited RX  Transition assistance services SERVICES AVAILABLE IN CBA

45  Call your local Department of Aging and Disability Services Office.  DADS local offices can be found at:  Call 211 HOW TO APPLY FOR CBA SERVICES

46  Case management performed by DADS regional staff.  Eligible individuals living in STAR+Plus areas must receive their services through STAR+Plus and are not able to obtain services on fee-for-service basis.  Number on waiting list = 35,278 (3/2010)  Current anticipated wait = 2-3 years (3/2010) UTILIZATION REVIEW/WAITING LIST

47  The Consolidated Waiver Program provides home and community-based services to people who are eligible for care in a nursing facility or intermediate care facility for persons with intellectual disabilities or a related condition (ICF/MR-RC). Consolidated waiver program CWP

48  No age limit  Must currently be on an interest list in Bexar County for one of the following programs:  Community Based Alternatives  Community Living Assistance and Support Services  Deaf-Blind with Multiple Disabilities  Medically Dependent Children  Home and Community-based Services  Must have a service plan developed by a DADS and the participant using the person-directed planning process.  Must meet specific institutional level of care criteria for an ICF-MR/RC, or  Must meet medical necessity determination for nursing facility services. CWP ELIGIBILITY

49  Adaptive aids  Medical supplies  Assisted living /residential care  Audiology  Behavior communications specialist  Dental  Dietary  Nursing services  Orientation and mobility  Personal assistance svcs.  RX  Psychological services  Respite care  Emergency response system  Family surrogate svcs.  Habilitation  Home delivered meals  Independent advocate  Minor home modifications  Social work  OT, PT, speech/language  Transportation  Transition assistance svcs. SERVICES AVAILABLE IN CWP

50  Contact local Department of Aging and Disability Services office.  DADS local offices can be found at:  When names “comes up” on one of the other waiting lists in Bexar County, and there is an open slot in CWP, individuals have the option to choose between the standard waiver or the consolidated waiver program HOW TO APPLY FOR CWP SERVICES

51  Waiver services should not be considered an “all you can eat menu.”  Every child should have access to the services they truly need, but those children and families fortunate enough to be receiving waiver services also have a responsibility. It’s not a contest of whoever gets the most, wins.  With tens of thousands waiting for services, every extra dollar used affects how long all the children on the waiting list will have to wait. FOOD FOR THOUGHT…

52  Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families. Youth Empowerment Services YES

53 Pilot Project approved by CMS  Achieves cost neutrality by waiving off of state hospitals  Access through MHMR centers in Bexar and Travis counties  Intended to expand to other parts of Texas if successful  Provides intensive mental/behavioral health services in the community  Intended to prevent hospitalization/residential treatment  Pilot in Travis and Bexar counties only  Administered by DSHS YES WAIVER PILOT

54 Disability/Functional  Be between the ages of 3-18 years;  Reside in Travis or Bexar County;  Reside in a non-institutional setting with the child or adolescent’s Legally Authorized Representative (LAR); or in the child or adolescent’s own home or apartment, if legally emancipated;  Choose, or have the LAR choose, the waiver program services as an alternative to care in an inpatient psychiatric facility;  Meet Department State Health Services (DSHS) clinical criteria (including, but not limited to risk of self-harm, risk of severe disruptive or aggressive behavior, family resources, and risk of challenging school behavior); and  There must be a reasonable expectation that, without Waiver services, the child or adolescent would qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines YES WAIVER ELIGIBILITY

55 Financial  Must be eligible for Medicaid, under a Medicaid Eligibility Group included in the approved waiver; parental income is not counted in financial eligibility; YES WAIVER ELIGIBILITY CONT’D.

56  Respite  Community living supports  Family supports  Transitional services  Adaptive aids  Minor home mods  Professional services  Supportive family- based alternatives  Non-medical transportation  Paraprofessional services SERVICES AVAILABLE IN YES WAIVER

57  Travis County --  ATCIC’s YES Waiver Interest List Message Line at ,or  ATCIC maintains an interest list for individuals interested in receiving YES waiver  Bexar County – Center for Health Care Services, (210) HOW TO APPLY FOR SERVICES

58  Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families.  The waiver is designed to reduce Medicaid psychiatric hospital expenses for children with SED by providing community-based services. YES

59  Waiver “lite”  This program provides selected essential services and supports to people with mental retardation who live in their family homes or their own homes. Texas Home Living TXHML

60 Disability/Functional  No age limit.  Have a determination of mental retardation made in accordance with state law or have been diagnosed by a physician as having a related condition.  Not be assigned a pervasive plus level of need (LON 9).  Live in their own home or with their family. Financial  Must meet Medicaid eligibility  Only waiver that considers the family income instead of only the child’s income; many children eligible for HCS are not eligible for TxHmL  Have a plan of care that does not exceed the specific program annual cost limit of $12,000 TXHML WAIVER ELIGIBILITY

61  Adaptive aids  Minor home mods  Specialized therapies  Behavioral support  Dental treatment  Nursing  Respite  Day Habilitation  Employment assistance  Supported employment  Community support TXHML WAIVER SERVICES

62  Does not have a separate waiting list  HCS waiting list used when slots are available  If TxHmL is accepted, individual’s name remains on HCS waiting list  Only waiver that allows all services to be consumer directed TEXAS HOME LIVING WAIVER

63  Early Childhood Intervention  School services  DARS employment services  In-Home and Family Support (DADS)  Children with Special Health Care Needs (DSHS)  Community MHMR services  Social Security OTHER NON- WAIVER SERVICES / PROGRAMS

64  Requires waiver from CMS  Provides all waiver services available in CBA with the option to offer more  Provider rates are negotiated with the health plan, not mandated by state STAR+ PLUS

65  Those who are SSI eligible in the STAR+Plus regions have an entitlement to long term services and supports (CBA services).  Those who have income between SSI and 300% of SSI do not have an entitlement and must be placed on the waiting list.  Number waiting for services = 5,743 (3/2010) STAR+PLUS ENTITLEMENT

66  Consumer directed services is not a service; it’s a way of delivering services  Three options for service delivery  CDS is one mechanism available to enhance opportunities for self- determination/direction  All waivers have some services that can be provided through the CDS options  Not all waiver services can be provided through CDS SERVICE DELIVERY OPTIONS

67  Agency Model  Agency is responsible for arranging for provision of services  Agency is responsible for recruitment, hiring, training, monitoring  Individual has little say with respect to who provides their care  Direct care workers are employees (or contractors ) of the agency  Service Responsibility Options Model (SRO)  Agency is the employer of record, but client participates in the hiring of attendants and respite providers  Consumer Directed Services Model (CDS)  Individual receiving the services is the employer of record  Client is responsible for recruitment, hiring, training, supervising attendants, respite providers, therapists, nurses THREE TYPES OF SERVICE DELIVERY

68  Habilitation  Respite  Intervener  Supported home living  Adjunct support services  Personal assistance services  Professional therapies  Nursing Note: not all services listed above can be consumer directed in all the waivers. Check with your case manager/service coordinator. TYPES OF SERVICES THAT CAN BE CONSUMER DIRECTED

69  Allows an individual residing in a nursing facility to transition to community services.  An attempt to end the institutional bias in the H&HS system.  Only available to individuals residing in nursing facilities.  Not available for individuals in ICFsMR or state schools (state supported living centers).  Voluntary closure is not the same as money-follows-the-person. MONEY FOLLOWS THE PERSON

70  13 facilities, 4,200 residents at $150,000 per year, per resident  Olmstead – least restrictive setting  Promoting Independence Advisory Committee  Community Living Options Information Process (CLOIP)  No MFP only target population slots  Children in State Schools Workgroup  DOJ Investigation Formerly called State Schools STATE SUPPORTED LIVING CENTERS

71  Projected $18 billion deficit  5% cuts being implemented  Additional 10% must be identified  Only two ways to cover the deficit – raise more revenue or cut spending  “Everything is on the table except raising taxes”  May provide opportunities for major changes  Items previously “off the table” are now on  Mental health services may be hit harder than others (limited federal match) THE 82 ND LEGISLATURE

72  $18 Billion deficit  Lots of competition for the limited resources  Possibility of major systems changes  Get connected with other parents and advocates  Become informed on the issues  Begin crafting your message(s)  Visit you legislators during the interim  Make a plan IF THERE EVER WAS A TIME OR NEED FOR ADVOCACY…IT IS NOW!

73  Write down three things you’ll do this summer to begin your advocacy efforts. (e.g., make an appointment to meet your legislators, contact advocacy organization, etc.)  Become familiar with this website”  Government was never meant to be a spectator sport. Barbara Jordon BEGIN YOUR ADVOCACY

74  Information about the Medicaid waivers  Texas Medicaid and CHIP in Perspective TOC.html TOC.html  Imagine Enterprises  Texas Legislature on Line RESOURCES

75 If you need more information feel free to contact me at: THE END


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