1. Mary Sowers NASDDDS July 14, 2014 NASDDDS National Association of State Directors of Developmental Disabilities Services 113 Oronoco Street, Alexandria, VA 22314 Tel: 703·683·4202; Fax: 703·684·1395 Web: www.nasddds.org

2.  Medicaid Basics  Medicaid HCBS Basics  Medicaid Authorities: Opportunities for Assistive Technology Coverage  New HCBS Regulations  Questions 2 NASDDDS National Association of State Directors of Developmental Disabilities Services

3.  Medicaid can be an important source of public financing for assistive technology  In addition to medical and rehabilitative uses, AT can also play a key role in assisting individuals return to or remain in their homes and communities and avoid institutional utilization  To understand how AT is covered in Medicaid, it is important to understand some Medicaid basics NASDDDS National Association of State Directors of Developmental Disabilities Services

4.  Established in 1965 as a companion program to Medicare  “Grants to States for Medical Assistance Programs” – Medicaid  Federal/State entitlement partnership program  Medicaid mandates some eligibility groups and services, States may elect to include other groups and benefits 4 NASDDDS National Association of State Directors of Developmental Disabilities Services

5.  Medicaid State Plan has, historically, referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute  With additions to the SSA, a state’s Medicaid State Plan can include more services and benefits than those in 1905(a).  There are now HCBS state plan benefits, described more fully below, at 1915(i) and 1915(k) of the SSA. NASDDDS National Association of State Directors of Developmental Disabilities Services

6.  Under the traditional Medicaid State Plan, states often cover some AT through Home Health Services and/or Durable Medical Equipment  Coverage and payment for items varies by state  Medically-necessary DME for use in the home or to function in the community. States may have a list of preapproved items with established process for modifications or exceptions.  Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid. NASDDDS National Association of State Directors of Developmental Disabilities Services

7.  States may offer HCBS through a number of statutory authorities, as well as some time- limited grant programs  Increased demand from individuals and families, the Olmstead decision, other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade.  The two primary HCBS sources for AT include: 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option NASDDDS National Association of State Directors of Developmental Disabilities Services

8.  Section 1915(c) of the Social Security Act, originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS ◦ More than 300 waivers serving more than 1 million people ◦ In federal fiscal year (FFY) 2011, total state and federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion 1 1 CMS, Truven Health Analytics, Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011, Steve Eiken, Brian Burwell, Lisa Gold, Kate Sredl, Paul Saucier, October 2013 8 NASDDDS National Association of State Directors of Developmental Disabilities Services

9.  Title XIX permits the Secretary of Health & Human Servicesto waive certain provisions required through the regular State Plan process: ◦ For 1915(c) HCBS waivers, the provisions that can be waived are related to:  Comparability (amount, duration, and scope) – provides ability to target benefit  Statewideness  Income and resource requirements 9 NASDDDS National Association of State Directors of Developmental Disabilities Services

10.  Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF), Intermediate Care Facilities for the Mentally Retarded (ICFs/MR), or hospital Level of Care (LOC)  Serves diverse target groups – including individuals with intellectual and developmental disabilities, individuals with physical disabilities, individual who are aging and those with mental health support needs  Services can be provided on a less than Statewide basis  Allows for participant-direction of services 10 NASDDDS National Association of State Directors of Developmental Disabilities Services

11.  Costs: HCBS must be “cost neutral” as compared to institutional services, on average for the individuals enrolled in the waiver  LOC: Institutional levels of care define waiver LOC and the populations that may be targeted  Choice: HCBS participants must have the choice of all willing and qualified providers 11 NASDDDS National Association of State Directors of Developmental Disabilities Services

12.  Home Health Aide  Personal Care  Case Management  Adult Day Health  Habilitation  Homemaker  Respite Care For chronic mental illness:  Day Treatment/Partial Hospitalization  Psychosocial Rehabilitation  Clinic Services  AND, Other Services – can be State-proposed service specifications 12 NASDDDS National Association of State Directors of Developmental Disabilities Services

13.  AT is commonly covered in 1915(c) waivers  States cover a wide array of technology, including commercially available technology when it is addressing an identified need in an individual’s plan of care.  States frequently include annual, multi-year and/or lifetime dollar limits on AT  Prior authorization is also common for technology costing over certain amounts. NASDDDS National Association of State Directors of Developmental Disabilities Services

14. CMS offers the following Core Service Definition for Assistive Technology, but states may amend/change as needed: Assistive technology device means an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants. Assistive technology service means a service that directly assists a participant in the selection, acquisition, or use of an assistive technology device. Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant; (B) services consisting of purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices for participants; (C) services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (D) coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the service plan; (E) training or technical assistance for the participant, or, where appropriate, the family members, guardians, advocates, or authorized representatives of the participant; and (F) training or technical assistance for professionals or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of participants. NASDDDS National Association of State Directors of Developmental Disabilities Services

15.  CMS Review/Approval Process: ◦ CMS approves a new waiver for a period of 3 years (possible 5 years for programs serving Medicare/Medicaid eligible individuals) ◦ States may request amendments at any time ◦ States may request that waivers be renewed; CMS considers whether the State has met statutory/regulatory assurances in determining whether to renew ◦ Renewals are granted for a period of 5 years Each of these opportunities for change or renewal offers an opportunity to add or improve AT coverage 15 NASDDDS National Association of State Directors of Developmental Disabilities Services

16.  Originally authorized under the Deficit Reduction Act of 2005 (effective 2007), 1915(i) permits states to offer HCBS as a state plan option.  The Affordable Care Act of 2010 amended 1915(i), providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c) NASDDDS National Association of State Directors of Developmental Disabilities Services

17. ◦ May target services to specific groups (waives comparability) ◦ Evaluation to determine program eligibility ◦ Assessment of need for services ◦ Plan of care ◦ Health and Welfare and Quality Requirements ◦ Self Direction ◦ Same allowable services ◦ Both use a preprinted application format 17 NASDDDS National Association of State Directors of Developmental Disabilities Services

18. ◦ Financial Eligibility Criteria ◦ Program Eligibility ◦ Institutional care requirements ◦ Length of time for operation ◦ Financial estimates ◦ Waiver of statewideness 18 NASDDDS National Association of State Directors of Developmental Disabilities Services

19. 1915(c)  Must have eligibility criteria at least as stringent as the institutions.  LOC must be: equal to or greater than institution but not less than institution 1915(i)  Needs based, not tied to institutional criteria  But, institutional criteria must be more stringent than 1915(i) needs-based criteria, therefore:  Needs-based eligibility criteria must be: less than institution 19 NASDDDS National Association of State Directors of Developmental Disabilities Services

20. 1915(c)  Can cap the numbers served  May have a waiting list  Can cap individual expenditures 1915(i)  Cannot cap the numbers served or individual expenditure  All eligibles are entitled to the program  May NOT have a waiting list  Eligibility assessment must be independent 20 NASDDDS National Association of State Directors of Developmental Disabilities Services

21. 1915(c)  3 years initial  5 years upon renewal 1915(i)  If state targets, 5 years until renewal  Indefinite if state does not target 21 NASDDDS National Association of State Directors of Developmental Disabilities Services

22. 1915(c)  Reasonable estimates of cost and utilization.  Program must be cost neutral compared to institutional care 1915(i)  Reveal payment methodology on Attachment 4.19- B of the State Plan. 22 NASDDDS National Association of State Directors of Developmental Disabilities Services

23.  1915(i) permits all statutory and “other” 1915(c) services  Under 1915(i) and (c) states can “target” services to specific populations ◦ Example: autism services, recovery services  May have multiple iSPAs or HCBS waivers  Same prohibitions on covering services that otherwise would be covered through IDEA or the Rehabilitation Act 23 NASDDDS National Association of State Directors of Developmental Disabilities Services

24. 1915(c)  May waive statewideness  1915(i)  May not waive statewideness  24 NASDDDS National Association of State Directors of Developmental Disabilities Services

25.  As of June 2014, 14 states have approved 1915(i) SPAs:  California  Colorado  Connecticut  Florida  Idaho  Indiana  Iowa  Louisiana  Michigan  Mississippi  Montana  Nevada  Oregon  Wisconsin NASDDDS National Association of State Directors of Developmental Disabilities Services

26.  Many states are considering moving HCBS and other LTSS into a managed care environment  Assistive technology may be included in services covered by managed care entities  States may also allow managed care entities to provide cost effective alternatives to covered services – Assistive technology may play a key role in those alternatives

27.  States may have a set array of technology they will pay for in their standard fee-for- service arrangements  In some states, self-direction, through the management of an individual budget may afford even greater opportunity for individualized AT.  Self-direction is an option in both 1915(c) and 1915(i) HCBS programs.

28.  To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c)*, 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate  To enhance the quality of HCBS and provide protections to participants 28 NASDDDS National Association of State Directors of Developmental Disabilities Services

29.  States can now combine multiple target populations within one 1915(c) waiver  Gives CMS with new compliance options for 1915(c) waiver programs, not just approve/deny  Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible  Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example) 29 NASDDDS National Association of State Directors of Developmental Disabilities Services

30.  Conflict-free case management ◦ Was just in guidance, now it is in rule  Implements the final rule for 1915(i) State plan HCBS— same requirements on HCB settings character, person- centered planning  Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option  Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements 30 NASDDDS National Association of State Directors of Developmental Disabilities Services

31.  HCB Settings Character ◦ What is NOT community ◦ What is likely not community ◦ What is community  Person-centered planning ◦ Codifies requirements  Transition planning-coming into compliance with the HCB settings requirements 31NASDDDS 4/17/14

32. 42CFR441.310(C)(4)  Is integrated in and supports access to the greater community  Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources  Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services 32 NASDDDS National Association of State Directors of Developmental Disabilities Services

33.  As states identify strategies to meet the obligations of the new regulations, they may look to technology to assist individuals to more effectively engage in their community, get and maintain employment, develop social networks, and communicate with friends, family and co-workers. NASDDDS National Association of State Directors of Developmental Disabilities Services

34.  Determining whether, what and how your state covers AT can be daunting  Building relationships, becoming informed and educating others are key to having a voice in future AT coverage strategies NASDDDS National Association of State Directors of Developmental Disabilities Services

35.  A key message to policy-makers….AT may be the necessary difference for individuals to live, work and meaningfully engage in community NASDDDS National Association of State Directors of Developmental Disabilities Services

36.  A number of states, such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation.  To learn more about state activity and options: ◦ www.medicaid.gov www.medicaid.gov ◦ Coleman Institute http://www.colemaninstitute.org/ http://www.colemaninstitute.org/

37. www.nasuad.org 2014: State of Aging and Disabilities Assistive Technology and Medicaid July 14, 2014

38. NASUAD Overview Founded in 1964 to represent state agencies on aging. In 2010, changed name in recognition of the fact that most state agencies served aging and disability populations. 56 members Represents State and Territorial Agencies on Aging and Disabilities. Board of Directors – Executive Officers, 10 regional representatives and 10 regional alternate reps.

39. Our mission To design, improve, and sustain state systems delivering home and community based services and supports for the elderly and individuals with disabilities and their caregivers Page 39

40. Key Resources NASUAD.org HCBS.org NASUADiQ.org Friday Update Integration Tracker Expansion Tracker Page 40

41. Join us at the 30 th annual HCBS conference September 15-18, 2014, Crystal City, VA 5 pre-conference intensives 130 sessions covering all populations receiving LTSS 1,000 attendees representing state policymakers, federal officials, staff, academics, businesses, etc. For more information: www.nasuad.orgwww.nasuad.org Page 41

42. State Aging & Disability Agencies Page 42

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45. Page 45 Managing relationships identified as key job responsibility

46. State Medicaid HCBS Options Page 46

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48. Page 48 Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers Compared to SFY 2012, in SFY 2013, the Waiver Caseload: IncreasedDecreased Stayed the SameNot Applicable % of States Alzheimer's Disease25.8%0.0%16.1%58.1% Autism13.8%0.0%13.8%72.4% Intellectual/Developmental Disabilities33.3%0.0%16.7%50.0% Older Adults62.9%0.0%14.3%22.9% Older Adults and Adults with Disabilities54.5%9.1%21.2%15.2% Adults with Physical Disabilities56.7%0.0%20.0%23.3% Severe Emotional Disturbance17.9%0.0%10.7%71.4% Traumatic Brain Injury21.4%3.6%25.0%50.0%

49. Page 49 Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities 2012 - 2013 Percent Change in Waiver Expenditures Less than 5%5%-8%8%-15%More than 15%Not Applicable % of States Alzheimer's Disease12.5%0.0% 87.5% Autism8.0%0.0%4.0%0.0%88.0% Intellectual/Developmental Disabilities20.0%8.0%12.0%0.0%60.0% Older Adults17.9%14.3% 7.1%46.4% Older Adults and Adults with Physical Disabilities29.6%3.7%14.8%18.5%33.3% Adults with Physical Disabilities12.5%8.3%4.2%8.3%66.7% Severe Emotional Disturbance8.3%4.2%0.0% 87.5% Traumatic Brain Injury4.2%12.5%0.0%4.2%79.2%

50. State Assistive Technology Coverage Page 50

51. 2012 Survey of Assistive Technology and State Agencies Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities: –Seventeen states fund some type of personal emergency response system (PERS). –Six states fund technology to support home and/or vehicle modifications. –Three states (Colorado, Iowa, and Minnesota) use telehealth/telemedicine. –Three states (Colorado, Maine, and Minnesota) use telemonitoring or wander locating. –Two states (Minnesota and Texas) use remote medication management / automated medication dispensing. Page 51

52. Page 52 State Services Available to Specified Populations through Medicaid HCBS Waivers Older Adults Individuals with Physical DisabilitiesIndividuals with I/DDIndividuals with TBI # of States Adult Day Health (includes health component)28231412 Adult Day Social (does not include health component)26161511 Adult Foster Care1415125 Assisted Living282557 Assistive Technology27 19 Behavioral Supports10122612 Environmental Modifications31322716 Home-Delivered Meals3123108 Personal Assistance Services32 2717 Personal Emergency Response Systems34282111 Physical Therapy1213188 Recreation Therapy2340 Residential Habilitation34259 Respite35302714 Specialized Equipment and Supplies28302316 Speech Therapy1011156 Supported Employment462810 Transportation32282716 Extended State Plan Waiver Benefit: Personal Care9964 Extended State Plan Waiver Benefit: Nursing81084 Extended State Plan Waiver Benefit: Home Health7744 Extended State Plan Waiver Benefit: Other4363 N=40

53. State Examples: Oklahoma (ID/DD) Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems: –live video feed; –live audio feed; –motion sensing system; –radio frequency identification; –web-based monitoring system; or –other device approved by OKDHS/DDSD. The system shall include devices to engage in live two-way communication with the member being monitored as described in the member’s Plan. Page 53

54. State Examples: Oklahoma (ID/DD) Assistive devices for members who are deaf or hard of hearing: –visual alarms; –telecommunication devices (TDD's), telephone amplifying devices; and –other devices for protection of health and safety. Assistive devices for members who are blind or visually impaired: –tape recorders; –talking calculators; –lamps, magnifiers; –Braille writers, paper and talking computerized devices; and –other devices for protection of health and safety. Augmentative/alternative communication and learning aids such as language boards, electronic communication devices and competence based cause and effect systems. Mobility positioning devices such as wheelchairs, travel chairs, walkers, positioning systems, ramps, seating systems, lifts, bathing equipment, specialized beds and specialized chairs. Orthotic and prosthetic devices such as braces and prescribed modified shoes. Environmental controls such as devices to operate appliances, use telephones or open doors. Page 54

55. State Examples: Pennsylvania (Seniors) TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence, quality of life and reduce the need for nursing home placement. By utilizing in-home technology, more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization. TeleCare services are specified by the service plan, as necessary to enable the participant to promote independence and to ensure the health, welfare and safety of the participant and are provided pursuant to consumer choice. TeleCare includes: –1) Health Status Measuring and Monitoring TeleCare Service; –2) Activity and Sensor Monitoring TeleCare Service; and –3) Medication Dispensing and Monitoring TeleCare Services. Page 55

56. State Example: New York (Aged and Physical Disabilities) Assistive Technology Supports are specialized equipment and supplies that enable a client to increase, maintain, or improve his/her functional capabilities. It includes the evaluation and purchasing (not leasing) of the assistive technology. It includes selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing the assistive technology device, and any training or technical assistance for the client and family members, guardians, etc. Page 56

57. State Example: South Carolina (TBI or Spinal Cord Injuries) Supplies, Equipment and Assistive Technology means medical supplies and equipment and specialized appliances, devices, or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others. It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items. Excluded are items not of direct medical or remedial benefit to the participant. Page 57

58. Medicaid and Managed LTSS Page 58

59. Medicaid Managed Care Managed Care in Medicaid can mean different things, including: –Comprehensive contracts with health plans; –Contracts with limited benefit plans, such as: Prepaid Inpatient Health Plans (PIHPs); Prepaid Ambulatory Health Plans (PAHPs); –Primary Care Case Management and other “managed fee-for-service”; –Program for All-inclusive Care for the Elderly (PACE) Plans; and –Others. Page 59

60. Managed Care and MLTSS Growth Continues, but Slows Historically, Medicaid Managed Care was largely limited to Children, Parents, Pregnant Women, and other “less complex” populations; States began including primary and acute care for some seniors and individuals with disabilities, which could include DME and other medically-oriented AT; A growing number of States are expanding managed care to encompass comprehensive benefits, including LTSS. Page 60

61. Medicaid Managed Care Statistics (FY 2011) 41 percent of enrollees age 65+ were in some form of managed care; 87 percent of non-disabled children were in managed care; Comprehensive MCO enrollment: –14% of aged beneficiaries; –33% of individuals with disabilities; –48% of adults without disabilities; and –63% of children without disabilities. Page 61 Source: MACPAC, June 2014

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68. Medicaid MCOs Bring Challenges and Opportunities MCOs are frequently given latitude to: –Establish selective provider networks; –Negotiate rates and contractual requirements with providers and suppliers; –Develop prior authorization and utilization controls. Medicaid MCOs are given strong incentives to provide care in a cost-effective manner, creating a value-proposition dynamic: –AT providers can benefit when they demonstrate value by reducing other costs, such as hospitalization, post-acute, and nursing homes –However, this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and, in many cases, without performance standards Page 68

69. State AT Involvement and Medicaid Marty Exline Missouri Assistive Technology July 14, 2014 Missouri Assistive Technology Blue Springs, Missouri 64015 816-655-6700 Marty.exline@att.net

70. Challenges & Opportunities What AT is covered in my state’s HCBS waivers? State’s Waiver applications State annual 372 report to CMS Contact your state waiver manager

71. ASSISTIVE TECHNOLOGY in HCB WAIVERS CMS Technical Assistance Guide 3.5 Home Accessibility Adaptations Environmental Accessibility Adaptations Vehicle Modifications Specialized Medical Equipment & Supplies Personal Emergency Response Systems Assistive Technology

72. Source: FY12 372 Reports ComprehensiveSupportAutismMOCDDPartnershipTotal Total Waiver Expenditures $512,677,539$15,588,016$1,513,136$2,421,925$5,840,897$538,041,513 Total Unduplicated Participants8,1261,4061602071,31411,213 Total EAA Costs$238,037$85,277$0$79,516$90,612$493,442 Unduplicated Participants Receiving EAA692202320134 DD Waiver-Environmental Accessibility Adaptations (EAA)

73. OKLAHOMA Able TECH  Living Choice Advisory Committee  AT in my Life My Choice Waiver  Policy: to increase or maintain functional abilities  State plan coverage of iPads for communication  Provider for OK Medicaid  DME Re-use

74. VERMONT ASSISTIVE TECHNOLOGY PROGRAM Piloting an MFP “AT and Access Evaluation” 3 –Step Process VATP reviews Eval Report device loans for trials reuse project DD Technology Workgroup State plan coverage for iOS devices for communication

75. MISSOURI ASSISTIVE TECHNOLOGY AT in all DD HCB waivers Developed guidelines for coverage Provider of AT for DD waivers Training Money Follows the Person Stakeholder Group Training for MFP Contact Agencies MFP training for nursing facilities

76. ASSISTIVE TECHNOLOGY PROGRAM of COLORADO In regular meetings with Medicaid to reconfigure all HCBS waivers. Has hosted meetings at their facility AT Advisory Committee Co-chair serves on MFP advisory board

77. NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP Provider for NE Aged & Disabled Waiver Collaborated to develop referral process, guidelines, regulations, forms, etc. Provides assessments for home modifications and AT $5,000 cap on service, so provides funding coordination

78. State AT Considerations Broad terminology Watch exclusions Evaluations & training included? Waiver service cost maximums State plan services? Help suggest language for guidelines