Presentation on theme: "Colleen Horton Hogg Foundation for Mental Health"— Presentation transcript:
1Medicaid funded long-term services and supports for people with disabilities Colleen HortonHogg Foundation for Mental HealthThe University of Texas at AustinJuly, 2010
2What I was asked to do…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 upServices availableFunding amountsWhere to get informationInclude information about the consumer directed services options.Provide information on other long term services and supportsTalk about the waiting lists.Talk about how folks can impact change during the session.
3Medicaid (Much of the Information in this presentation taken directly from the DADS website) HistoryEntitlement 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 caretakersPregnant womenElderlyPeople with disabilitiesEligibilityIndividuals receiving TANF and SSIIndividuals receiving waiver servicesIndividuals meeting income and disability criteriaEmergency Medicaid Services
4People with disabilities 30 % or the Medicaid Population58% of Medicaid Costs
5Medicaid State Plan The State’s contract with the feds Entitlement (no waiting list)Mandatory ServicesOptional ServicesMandatory populationsOptional PopulationsTexas Medicaid and CHIP in Perspective
6Mandatory services EPSDT-Texas Health Steps Family planning services Inpatient/Outpatient hospital carePhysician servicesNurse midwife servicesNurse practitionerFQHCsLab & xraysPrenatal careFamily planning servicesSkilled nursingChildren’s vaccinesNursing facility careHome health careRural Health ClinicsNurse practitionersRural health clinics
7Optional Services Durable medical equip. PT, OT, Speech Personal care servicesDental servicesICFMRIMDs (under 21, over 65)Private duty nursing (under 21)RX drugs (3 per mo.)Unlimited RX in nursing facilities, ICFMR, managed careBirthing centerRenal dialysisRehabilitation (chronic mental illness, physical, development)Targeted case managementMedical transportationOptometryPodiatryEmergency hospital servicesLicensed professional counselor (LPC)
8Populations Covered TANF recipients Families based on age, income, and assetsNewborns up to 12 months whose mother is Medicaid certified at the time of child’s birthThe majority of children in foster careSome adopted childrenNon-disabled, non-pregnant adults over age 65 w/ income below the TANF limitChildren under 19 and pregnant women over the income limit but have significant medical bills (Medically needy/spend down)SSI recipients (aged, blind and disabled)
9Optional populationsIndividuals receiving Primary Home Care services (up to 300% of SSI income limit)Individuals receiving waiver servicesChildless adults (not covered in Texas)
10Children in medicaid Some things are different for kids: All medically necessary servicesTexas Health Steps – Early and Periodic Screening, Diagnosis, and TreatmentComprehensive Care ProgramPersonal Care ServicesVoluntary participation in managed care (Star+Plus)
11Nuts and Bolts How do I apply for Medicaid? By phone – call 211 (connects callers with information on health and human services)On-lineIn personTexas Medicaid and Healthcare Partnership (TMHP) contracts with state to provide Medicaid administration, reimbursement services, claims, prior authorizationTexas Medicaid and CHIP in PerspectiveFrew v. Hawkins (1996) – Texas HealthStepsAlberto, N. – Private duty nursing and personal care services
12CHIP Children’s Health Insurance Plan EligibilityUnder 19 years of ageChildren in families with low incomes and assetsServices12 months of health care coverageCost SharingEnrollment fees are $50 or less per familyco-pays typically $3 -$5
13how to enroll in CHIPIf you would like to request an application or check the statusof your application, call You may also go online to and print an application.Fax or mail completed applications to the Texas ACCESS Alliance at: P.O. Box Midland, TX FAX:
14MAXIMUM MONTHLY INCOME LIMITS FOR HEALTH CARE COVERAGE PROGRAMS FOR CHILDREN Source: HHSC Financial Services, 2007 Medicaid Expenditures,Family SizeMedicaid for Children Under Age 1Medicaid for Children Ages 1 to 5Medicaid for Children Ages 6 through 18CHIPMedicaid for Youth Transitioning out of Foster Care1$1,670$1,201$903$1,805$3,6102$2,247$1,615$1,215$2,429$4,8573$2,823$2,030$1,526$3,052$6,1044$3,400$2,444$1,838$3,675$7,3505$3,976$2,859$2,150$4,299$8,5976$4,553$3,273$2,461$4,922$9,8447$5,130$3,688$2,773$5,545$11,0908$5,706$4,102$3,085$6,169$12,337For each additional person, add:$577$415$312$624$1,247
15Managed Care STAR STAR+Plus PCCM (Primary Care Case Mgt.) Northstar Managed care – acute careSTAR+PlusManaged care – acute care and long term services and supportsPCCM (Primary Care Case Mgt.)Primarily in rural areasNorthstarBehavioral health managed careDallas/Ft. WorthIDD Pilot – current studyManaged Care
16Community Safety Net Services 39 MHMR Community Centers MRAService coordinationRespiteEmployment servicesFlexible servicesLMHAChildren’s mental health servicesAdult mental health servicesCrisis servicesState hospitals
17Medicaid Buy-IN for Children Will allow parents of children with disabilities in families with income up to 300% of federal poverty limit, to buy into the state Medicaid ProgramSB Authorizing legislation/SB 1 – appropriation (Senator Deuell and Rep. Lucio)Development - underwayImplementation ???A program at risk.Medicaid Buy-IN for Children
18Medicaid 1915(c) Waivers State/Federally funded Community-based long term services and supportsState must submit a waiver application to CMSTexas 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 institutionalizationWaive certain Medicaid rules (e.g. state-wideness)1915(c) waivers “waive off” of some institutional setting (e.g. nursing facility, state school, ICFMR)
19Texas 1915(c) Waiver Programs 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+PLUSFederal requirement – waiver programs must be cost neutral in the aggregate.
20Waiver interest lists August, 2009 CLASS HCS MDCP DBMD CBA Managed CareTotal# on interest list27,67442,36014,3477934,0505,633124,143March, 201030,36343,38517,05226235,2785,743132,083*(Unduplicated102,647)
21Time on the interest list/March 2010 http://www. dads. state. tx CBAICMSTAR+CLASSDBMD**MDCPHCS0-1 years18,9791,3584,2746,9092225,4649,2961-2 Years14,84712486,268344,6627,9342-3 years1,4522305,45863,9176,4443-4 yearsN/A174,2413,0095,0974-5 years2,6073,8995-6 years2,5613,2686-7 years2,3203,2227-8 years2,9358-9 years1,2909+ years
22CLASS 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).ClassCommunity Living Assistance supports and Services
23CLASS Eligibility requirements Disability/functionalRelated conditions (not primary diagnosis of intellectual disabilities)Must meet level of care needed for ICFMR eligibilityMust have a need for habilitationAssessment conducted by direct service agency nursing staffMust be diagnosed before the age of 21 yearsFinancial300% for the federal poverty level; $2,000 countable assetsBased on child’s income, not family incomeDetermined by HHSC Medicaid enrollment division, not DADSService plan may not exceed 200% of cost of care in ICFMR
24Services available in CLAss Adaptive aidsCase managementHabilitationMinor home modificationsNursing servicesOT, PT, SpeechPsychological ServicesBehavioral supportsRespite careSpecialized therapiesMedical suppliesSupport family servicesWhat’s missing?Adaptive aids - Reimbursement: Actual cost of item plus requisition fee. The annual allocation is $10,000 per service plan year.Habilitation attendant/training services: CLASSThis service helps individuals living in their own or their families' homes learn, retain, or improve their skills related to activities of daily living. Services include teaching:personal grooming and cleanliness, bed making and household chores, preparing and eating food, and the social and adaptive skills necessary to reside in their own home in the community.Minor home modifications: CLASSThis service is used to assess the need for, arrange for, and modify or improve individuals' living quarters to allow community living and ensure safety, security, and accessibility.Reimbursement: Actual cost of modifications. The lifetime maximum amount for modifications is $10,000, with an annual maintenance and repair allotment of $300 per service plan year once the lifetime limit is reached.Nursing services: CLASSThis service, which is provided by a licensed nurse, include: monitoring health conditions, administering and monitoring medication, providing referrals for medical services, and training individuals, their family members, and support personnel.Psychology: CLASSThis service provides a licensed psychologist to perform services that are directed toward modifying and improving cognitive and affective skills. Services include: counseling individuals and assessing and training direct service providers or family members with regard to a specific individual treatment plan.Specialized therapies: CLASSThis service includes therapeutic intervention to decrease inappropriate behaviors, provide opportunities for socialization, and improve physical and medical status. Services include:musical therapy,recreational therapy,massage therapy,hippotherapy,hydrotherapy,therapeutic horseback riding,auditory integration therapy,nutritional services; andaquatic therapy.
25How to apply for class waiver services 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).
26Utilization review/increased costs Amount of services/budget based on plan of care.CLASS waiver costs have increased 25% since 2006.Cost cap for CLASS is approximately $57,000DADS utilization review unit looking closely at those plans of care that exceed a certain threshold ;Children - ($43,000) (3/2010)Adults - $57,368
27HCS 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.HCSHome and Community-based Services
28HCS Eligibility Disability Financial Must have an intellectual disability with IQ of 70 or below, orHave a related condition with an IQ of 75 or lessMust meet the level of care criteria for an ICFMRAssessment and service coordination done by local MHMR Center staffFinancial300% of the SSI income limits; no more than $2000 in countable assetsBased on child’s income, not family incomeDetermined by HHSC Medicaid enrollment division, not DADSService plan may not exceed 200% of cost of care in an ICFMR
29Services available in HCS Service CoordinationAdaptive aidsMinor home modificationsCounseling and therapiesSpeech, OT, PTAudiologyDietarypsychologicalNursingDental treatmentRespiteSupported employmentDay habilitationResidential ServicesSupported home livingFoster/companion careSupervised home living
30How to apply for HCS waiver services Apply for services byContacting you local mental retardation authority (MRA)MRA website: 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!
31Utilization review/increased costs/waiting list 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.
32MDCPMDCP 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.
33MDCP Eligibility Disability Financial Eligibility Must meet medical criteria for nursing facility admissionMust be under the age of 21 yearsMust meet disability criteria for social security or Medicaid benefitsFinancial Eligibility300% SSI income limits; no more than $2,000 in countable assetsBased on child’s income, not family’s
34Services Available in MDCP RespiteAdjunct support servicesAdaptive aidsMinor home modificationsTransition services
35How to apply for MDCP services 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!
36Utilization review/waiting list 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)
37DB/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.DBMDDeaf/Blind Multiple DisabilitiesDB-MD 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.
38Eligibility for DBMD 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.FinancialMust meet Medicaid eligibility.Have an individual plan of care that does not exceed specific limits.Additionally, the proposed rules implement requirements in Senate Bill (SB) 37 and SB 63, 81st Legislature, Regular Session, 2009, which affect the program and require new rules. SB 63 creates a career ladder for interveners, and SB 37 removes the minimum age requirement from the eligibility criteria. The program, prior to September 1, 2009, served only individuals who were 18 years of age or older.
39Services available in DBMD Adaptive aidsMedical suppliesAssisted living *Behavior supportCase managementsChore ProviderEmployment assistanceMinor home modsHabilitationIntervenerNursing servicesOT, PT, SpeechOrientation & mobilityRXRespite careSupported employmentTransition assitance*up to six beds
40How to apply for dbmd waiver services Call and ask for the DB-MD waiver representative.
41Utilization review/waiting list Fewer “slots” and number served than other waiversProvides 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)
42This 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.CBACommunity Based Alternatives
43Eligibility for cba Disability/functional be at risk of entering a nursing facility,be 21 or olderMust meet medical necessity for Medicaid nursing home careFinancialMeet Medicaid income eligibility requirements (300% SSI) and have no more than $2,000 in countable assetsCost of plan of care may not exceed 200% of the cost of care in a nursing facility
44Services available in cba Adaptive aidsMedical suppliesAdult foster careAssisted livingEmergency response servicesHome delivered mealsMinor home modsNursing servicesOT, PT, SpeechPersonal assistance servicesRespite care servicesDental servicesUnlimited RXTransition assistance services
45How to apply for cba services Call your local Department of Aging and Disability Services Office.DADS local offices can be found at:Call 211
46Utilization review/waiting list 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)
47The 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).CWPConsolidated waiver program
48CWP eligibility No age limit Must currently be on an interest list in Bexar County for one of the following programs:Community Based AlternativesCommunity Living Assistance and Support ServicesDeaf-Blind with Multiple DisabilitiesMedically Dependent ChildrenHome and Community-based ServicesMust 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, orMust meet medical necessity determination for nursing facility services.
49Services Available in CWP Adaptive aidsMedical suppliesAssisted living /residential careAudiologyBehavior communications specialistDentalDietaryNursing servicesOrientation and mobilityPersonal assistance svcs.RXPsychological servicesRespite careEmergency response systemFamily surrogate svcs.HabilitationHome delivered mealsIndependent advocateMinor home modificationsSocial workOT, PT, speech/languageTransportationTransition assistance svcs.
50How to apply for cwp services 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 programWhy it didn’t work – designed to fail.
51Food for thought…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.
52Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families.YEsYouth Empowerment Services
53Yes Waiver Pilot Pilot Project approved by CMS Achieves cost neutrality by waiving off of state hospitalsAccess through MHMR centers in Bexar and Travis countiesIntended to expand to other parts of Texas if successfulProvides intensive mental/behavioral health services in the communityIntended to prevent hospitalization/residential treatmentPilot in Travis and Bexar counties onlyAdministered by DSHS
54YES Waiver eligibility Disability/FunctionalBe 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); andThere 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
55YES Waiver eligibility cont’d. FinancialMust be eligible for Medicaid, under a Medicaid Eligibility Group included in the approved waiver; parental income is not counted in financial eligibility;
56Services available in YES waiver RespiteCommunity living supportsFamily supportsTransitional servicesAdaptive aidsMinor home modsProfessional servicesSupportive family-based alternativesNon-medical transportationParaprofessional services
57How to apply for services Travis County --ATCIC’s YES Waiver Interest List Message Line at ,orATCIC maintains an interest list for individuals interested in receiving YES waiver servicesBexar County – Center for Health Care Services, (210)
58yesAllows 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.
59Waiver “lite”This program provides selected essential services and supports to people with mental retardation who live in their family homes or their own homes.TxhmlTexas Home Living
60TxHmL waiver eligibility Disability/FunctionalNo 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.FinancialMust meet Medicaid eligibilityOnly waiver that considers the family income instead of only the child’s income; many children eligible for HCS are not eligible for TxHmLHave a plan of care that does not exceed the specific program annual cost limit of $12,000
61Txhml waiver services Adaptive aids Minor home mods Specialized therapiesBehavioral supportDental treatmentNursingRespiteDay HabilitationEmployment assistanceSupported employmentCommunity support
62Texas home living waiver Does not have a separate waiting listHCS waiting list used when slots are availableIf TxHmL is accepted, individual’s name remains on HCS waiting listOnly waiver that allows all services to be consumer directed
63Other non-waiver services / programs Early Childhood InterventionSchool servicesDARS employment servicesIn-Home and Family Support (DADS)Children with Special Health Care Needs (DSHS)Community MHMR servicesSocial SecurityOther non-waiver services / programs
64STAR+Plus Requires waiver from CMS Provides all waiver services available in CBA with the option to offer moreProvider rates are negotiated with the health plan, not mandated by stateSTAR+Plus
65Star+plus entitlement 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)
66Service Delivery Options Consumer directed services is not a service; it’s a way of delivering servicesThree options for service deliveryCDS is one mechanism available to enhance opportunities for self-determination/directionAll waivers have some services that can be provided through the CDS optionsNot all waiver services can be provided through CDSService Delivery Options
67Three types of service delivery Agency ModelAgency is responsible for arranging for provision of servicesAgency is responsible for recruitment, hiring, training, monitoringIndividual has little say with respect to who provides their careDirect care workers are employees (or contractors ) of the agencyService Responsibility Options Model (SRO)Agency is the employer of record, but client participates in the hiring of attendants and respite providersConsumer Directed Services Model (CDS)Individual receiving the services is the employer of recordClient is responsible for recruitment, hiring, training, supervising attendants, respite providers, therapists, nurses
68Types of services that can be consumer directed HabilitationRespiteIntervenerSupported home livingAdjunct support servicesPersonal assistance servicesProfessional therapiesNursingNote: not all services listed above can be consumer directed in all the waivers. Check with your case manager/service coordinator.
69Money follows the person 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
70state supported living centers 13 facilities, 4,200 residents at $150,000 per year, per residentOlmstead – least restrictive settingPromoting Independence Advisory CommitteeCommunity Living Options Information Process (CLOIP)No MFP only target population slotsChildren in State Schools WorkgroupDOJ Investigationstate supported living centersFormerly called State Schools
71Projected $18 billion deficit 5% cuts being implementedAdditional 10% must be identifiedOnly 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 changesItems previously “off the table” are now onMental health services may be hit harder than others (limited federal match)The 82nd Legislature
72If there ever was a time or need for advocacy…it is now! $18 Billion deficitLots of competition for the limited resourcesPossibility of major systems changesGet connected with other parents and advocatesBecome informed on the issuesBegin crafting your message(s)Visit you legislators during the interimMake a plan
73Begin your advocacyWrite 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
74Resources Information about the Medicaid waivers Texas Medicaid and CHIP in PerspectiveImagine EnterprisesTexas Legislature on Line
75If you need more information feel free to contact me at: colleen If you need more information feel free to contact me at:The End