1. The Impact of Managed Long Term Care for Residents and Service Coordinators New York State Association of Resident Service Coordinators June 5, 2014 Embassy Suites 6646 Old Collamer Rd E. Syracuse NY 10357 Ken Harris Senior Policy Analyst LeadingAge New York

2. Agenda  HUD Update  Federal and State Initiatives  New Landscape for New York Seniors  Impact on Senior Housing  MLTC  FIDA  DSRIP  Senior Supportive Housing Program  What’s Next? 2

3. Acronyms  THUD  MLTC  MAP  FIDA  BIP  DSRIP  SSHSP 3

4. The Future of Senior Housing 4

5. HUD Update New HUD Multifamily Program Administration Office (PAO) Five Goals: 1.Producing and preserving affordable housing for those most in need and in locations where it’s most needed; 2.Preserving affordable housing by improving risk management practices and expanding or enhancing preservation programs; 3.Strategically controlling program costs by taking innovative approaches to managing our portfolio; 4.Making the business case for increased investments in our programs to provide the tools we need to do our work; and 5.Continuing to provide quality customer service while transforming the way we work to 21 st century best practices. 5

6. HUD 2014 Priorities On March 5, 2014, Benjamin Metcalf, Deputy Assistant Secretary for Multifamily Housing Programs, issued 25 priorities for 2014: Selected few with senior housing impact: Inclusionary Requirements: Review the implications of Thompson v. HUD with respect to implementing Multifamily Housing programs. Thompson v. HUD found that HUD violated the Fair Housing Act of 1968 by unfairly concentrating African-American public housing residents in the most impoverished, segregated areas of the city of Baltimore, MD. 6

7. HUD 2014 Priorities RAD: Lift the RAD cap from 60,000 units of public housing and Section 8 Mod Rehab, and extend the demonstration timeframe for Rent Supplement and RAP. Work to encourage the use of RAD to achieve the neighborhood revitalization goals of the new Promise Zone Program. Issue the 4350.1 Handbook: Provide clear and current guidelines to industry partners and field staff to improve risk management practices, enhance portfolio oversight and ensure the availability of high quality assisted and insured housing opportunities. 202 Demonstration NOFA: The FY 2014 Omnibus Appropriations bill authorizes sweeping of residual receipts and using other available Section 202 funds to fund demonstration programs testing housing with services model to avoid or delay nursing home services. The bill also made changes to Section 202 Statute to eliminate capital advance requirements and authorize operating assistance-only grants. Multifamily will utilize these new authorities to issue a 202 Demonstration NOFA. 7

8. HUD 2014 Priorities Enhance Service Coordinator Program: Promote an outcomes oriented approach to services coordination for our elderly residents. This may include standardizing the work that service coordinators perform, mandating best practices and facilitating training on best practices, different tracking of outcomes by updating the semi-annual performance report, and by promoting the use of service coordinators in certain PRAC properties. HUD Section 202 22015 THUD Budget Administration (HUD): $440 million Senate: $440 million U.S. House of Representatives Appropriations Committee: $420 million. $20 million less eliminates the Rental Assistance Demonstration program. 8

9. New “Section 202” Program Elderly Project Rental Assistance (Section 202 PRA Demo) New Model for Section 202 Program:  Allows properties to set-aside housing for elderly population that is older, poorer, and frailer than those who normally access housing subsidized through LIHTC and/or HOME.  Strong emphasis on Service Coordination linked to community- based services.  Conduct rigorous evaluation of the impact of 202 housing plus service model and demonstrate outcome. 9

10. New “Section 202” Program Elderly Project Rental Assistance (Section 202 PRA Demo) Notice of Funding Availability (NOFA); Summer 2014 Will require that applicants have an agreement for the provision of services and the summary of the bill suggests that the new Section 202 program demonstration will be operated in accordance with and determined by state healthcare priorities. HUD intends to provide $4 million for a research assessment of the new demonstration program. 10

11. New “Section 202” Program Elderly Project Rental Assistance (Section 202 PRA Demo) Evidence-based housing with services models can significantly reduce Medicare expenditures on hospitalization and Emergency Room visits for people who:  Have chronic conditions  Need support with Activities of Daily Living and/or Instrumental Activities of Daily Living (IADL)  Eligible for Home and Community Based Services Housing with service model can reduce these high health costs by allowing residents to age in place and facilitating the provision of supportive services. 11

12. Federal & State Priorities Priorities & Goals & Funding: Federal and State Senior Housing The Good News and The Bad News  Reduce Medicaid costs  Involve housing and health agencies (F&S)  Prevent institutionalizations  Reduce hospitalizations (Medicare)  Increased health care and service coordination  Higher health needs for senior housing residents  Reduced (eliminated) funding for senior housing and service coordination 12

13. Medicaid Redesign MRT #90 Mandatory Enrollment in MLTC: Approval was granted by the Centers for Medicare and Medicaid Services (CMS) to fully implement the transition and enrollment of individuals requiring community-based long term care into Managed Long Term Care (MLTC) Plans or Care Coordination Models. Expands MLTC for Medicaid members who are also eligible for Medicare (dual eligibles) and currently receiving community-based long term care services. Benefit package includes home care, personal care, social supports, and transportation services. The costs of skilled nursing facility services are included in the capitation payment, providing a financial incentive for the Plans to keep their members healthy and living in the community. 13

14. Managed Long Term Care (MLTC) Mandatory Population:  Dual eligible, aged 21 and over, receiving community-based long term care services for over 120 days.  Duals between 18 and 20 remain voluntary. MLTC initially excluded the following:  Nursing Home Transition and Diversion waiver participants;  Traumatic Brain Injury waiver participants;  Nursing Home residents  Assisted Living Programs; and  Dual eligible that do not require community-based long term care services. 14

15. Managed Long Term Care Enrollees have a choice of three MLTC Plans Partially Cap (Medicaid) Benefit package is long term care and ancillary services including home care and unlimited nursing home care. Program of All-Inclusive Care for the Elderly (PACE) (Medicare and Medicaid) Benefit package includes all medically necessary services – primary, acute, and long term care. Medicaid Advantage Plus (MAP) (Medicare and Medicaid Benefit package includes primary, acute, and long term care services (excludes specialized mental health services). 15

16. MLTC Enrollment  Phase 1: the five counties of New York City: New York, Kings, Bronx, Queens, and Richmond counties.  Phase II: Nassau, Suffolk, and Westchester Counties.  Phase III: Rockland and Orange Counties.  Phase IV: Albany, Erie, Onondaga, and Monroe Counties.  Phase V: Other counties with capacity.  Phase VI: Previously excluded dual eligible groups contingent upon development of appropriate programs. 16

17. MLTC Enrollment  In December 2013, enrollment started in Albany, Erie, Onondaga, and Monroe counties.  As of March 1, 2014, enrollment in these counties include:  Albany = 199  Onondaga = 691  Monroe = 832  Erie = 476  NYSDOH did not seeing any major concerns with access in these counties. There were some coding problems with some LTHHCP cases which were resolved. 17

18. MLTC Enrollment Preparations are underway for next phase of the transition, as Plan capacity is established, the Department proposes to roll out Mandatory Managed Long Term Care in the remaining counties as follows: May: Rensselaer, Cayuga, Herkimer and Oneida June: Greene, Schenectady, Washington and Saratoga July: Dutchess, Montgomery, Broome, Fulton, Madison, Schoharie and Oswego 18

19. MLTC Enrollment August: Warren, Delaware, Niagara, Otsego and Chenango September: Essex, Clinton, Franklin and Hamilton October: Jefferson, Lewis, St. Lawrence, Steuben, Chautauqua, Cattaraugus and Alleghany November: Yates, Seneca, Schuyler, Tioga, Cortland and Chemung December: Genesee, Livingston, Ontario, Orleans, Tompkins, Wayne and Wyoming 19

20. MLTC Anticipated start dates of the previously excluded dual eligible groups begin enrollment upon development of appropriate programs: Nursing Home Transition and Diversion waiver participants in 2015; Traumatic Brain Injury waiver participants in 2015; Nursing Home residents, new to custodial status only, in September 2014; Assisted Living Program participants date to be determined; and Dual eligibles that do not require community-based long term case services date to be determined. 20

21. MLTC Participant Ombudsman (PO):  The PO will act as a resource and advocate for Participants and their families/caregivers who transition to MLTC Plans.  The PO will be an independent, conflict-free entity that provides Participants in MLTC, FIDA, and Mainstream free assistance in accessing care, understanding and exercising rights and responsibilities, and appealing adverse decisions.  The RFA was released on February 28, 2014.  Application were due April 11, 2014, and are under review. 21

22. MLTC What’s The Impact? Three populations in senior housing: 1.Not on Medicaid 2.Qualify for Medicaid. Not receiving LTC services 3.On Medicaid – receiving LTC services for 120+ days LTC Medicaid residents need to choose a plan MLTC residents will have care coordination. Residents may lose, change, or add LTC services 22

23. MLTC and Senior Housing What’s The Impact to Service Coordinators? Understand the new senior housing: MLTC will strive to reduce costs Service coordinators need to work with MLTCs Determine “job roles” of SC and MLTC Some nursing homes may close…. Higher health needs of residents in senior housing 23

24. FIDA Fully Integrated Dual Advantage (FIDA)  A key component of “care management for all” is the Fully Integrated Dual Advantage (FIDA) demonstration project, a partnership between CMS and NYSDOH.  Through this effort certain dual eligible individuals residing in the FIDA demonstration region will be enrolled into fully-integrated managed care products.  The Memorandum of Understanding between CMS and NYSDOH was signed on August 26, 2013.  Demonstration period is from October 2014 through December 2017. 24

25. FIDA FIDA Eligible Populations:  Age 21 or older;  Entitled to benefits under Medicare Part A and enrolled under Parts B and D, and receiving full Medicaid benefits; and  Reside in a FIDA Demonstration County: Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk or Westchester. Must also meet one the following three criteria:  Are Nursing Facility Clinically Eligible and receiving facility- based LTSS;  Are eligible for the Nursing Home Transition and Diversion Waiver; or  Require community-based LTSS for more than 120 days. 25

26. Balancing Incentive Program (BIP) The Balancing Incentive Program (BIP) is a funding opportunity offered under section 10202 of the Patient Protection and Affordable Care Act of 2010  Provides enhanced FMAP (+2%) to participating states to rebalance Medicaid Long Term Services and Supports (LTSS) by increasing access and expanding community services as an alternative to institutional care. Requires 3 structural changes: No Wrong Door/Single Entry Point network Core Standardized Assessment Instruments Conflict-Free Case Management 26

27. BIP Balancing Incentive Program NYS’ BIP application was approved in March 2013, and the State was awarded $598.7 million. The BIP period is April 1, 2013 – September 30, 2015. BIP will reinforce New York’s ongoing efforts to improve access to home and community-based long term care services for those with physical, behavioral health, and/or intellectual and developmental disabilities throughout the State. When BIP ends, the State must show an increase in the community- based LTSS percentage from the baseline percentage by the end of the BIP period. 27

28. BIP No Wrong Door/Single Entry Point Network: Delivers consistent information about LTSS options whether an individual seeks information from a 1-800 number, a website, or a local office that is part of the State’s NWD/SEP network. Provides individuals with assistance in accessing Medicaid or non-Medicaid services. The State plans to:  Expand NY Connects statewide;  Add an interactive web-based screening tool to allow individuals to help identify their LTSS needs; and  Develop tools and training to ensure consistent information about the LTSS available in communities across New York. 28

29. DSRIP Delivery System Reform Incentive Payment (DSRIP) On April 14, 2014 New York has finalized terms and conditions with the federal government for a waiver that will allow the state to reinvest $8 billion in federal savings generated by Medicaid Redesign Team (MRT) reforms. The waiver amendment dollars will address critical issues throughout the state and allow for comprehensive reform through a Delivery System Reform Incentive Payment (DSRIP) program. The DSRIP program will promote community-level collaborations and focus on system reform, specifically a goal to achieve a 25 percent reduction in avoidable hospital use over five years. 29

30. DSRIP The $8 billion reinvestment will be allocated in the following ways: $500 Million for the Interim Access Assurance Fund – temporary, time limited funding to ensure current trusted and viable Medicaid safety net providers can fully participate in the DSRIP transformation without disruption $6.42 Billion for Delivery System Reform Incentive Payments(DSRIP) – including DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs $1.08 Billion for other Medicaid Redesign purposes – this funding will support Health Home development, and investments in long term care, workforce and enhanced behavioral health services 30

31. DSRIP The $8 billion reinvestment will be allocated in the following ways: $500 Million for the Interim Access Assurance Fund – temporary, time limited funding to ensure current trusted and viable Medicaid safety net providers can fully participate in the DSRIP transformation without disruption $6.42 Billion for Delivery System Reform Incentive Payments(DSRIP) – including DSRIP Planning Grants, DSRIP Provider Incentive Payments, and DSRIP Administrative costs $1.08 Billion for other Medicaid Redesign purposes – this funding will support Health Home development, and investments in long term care, workforce and enhanced behavioral health services 31

32. Senior Supportive Housing Services Program (SSHSP) Department of Health (DOH) Request for Applications (RFA) to establish Senior Supportive Housing Services Projects to serve low- income, Medicaid-eligible seniors who are at risk of nursing home placement or are homeless, or seniors who are transitioning out of nursing homes into community living and require long term care services. Senior supportive housing services project is defined as the pairing of capital assistance and supportive services within existing senior housing communities. 32

33. Senior Supportive Housing Services Program (SSHSP) 1. Develop an innovative, high quality model to increase accessibility within existing U.S. Department of Housing and Urban Development (HUD) senior housing units as well as other senior housing units. Features will include universal design modifications, renovation and reconfiguration. 2. Conduct needs assessment with current residents of senior housing to identify the types of supportive services necessary to assist residents to remain in their current housing units. Develop supportive services which will assist residents’ ability to live independently in the community. 33

34. Senior Supportive Housing Services Program (SSHSP) 3. Develop an in-reach mechanism within existing senior housing community to identify current residents who are Medicaid-eligible, and at risk of nursing home placement. Develop a plan to determine if current resident(s) may safely remain in their housing unit with the addition of increased accessibility features and/or available supportive services. Modify housing units and provide support services to current residents. 4. Develop an outreach mechanism to identify low-income Medicaid- eligible seniors who currently are homeless or reside in the community (not currently in low income senior housing), and who are at risk of nursing home placement and seniors who wish to transition out of nursing homes into community living who require long term care services. Develop and implement a plan to assist these eligible seniors to obtain low income senior housing with increased accessibility features and supportive services. 34

35. Senior Supportive Housing Services Program (SSHSP) 5. Develop outcome measures and evaluation criteria which will assist DOH in determining the value of the pilot project and senior supportive housing services best practices for the target population. 6. Develop a process for data collection and reporting, including completing the Supportive Housing Data Collection Tool and submitting such data to the Department on a monthly basis.  Develop new model of housing with services  Will assist in defining line between housing and assisted living  Applications were due May 30, 2014 35

36. What’s Next? Opportunities Greater cooperation between Homes and Community Renewal (HCR), HUD, DOH, NYSOFA… Federal service coordination funding through Medicare / Medicaid? DOH or NYSOFA funding for service coordination and support services? Funding for service coordination through MLTC? 36

37. What’s Next? Service Coordinators in New York State NYSARSC: Keep on top of federal and state issues Advocacy and education needed by service coordinators about service coordinators Advocate for funding – service coordination, resident services with MLTC, construction, support services….. Get to know the MLTC plan options in your area Educate MLTCs on the role of service coordinators and how can benefit residents. 37

38. The Squeaky Wheel… Advocacy! 38

39. MLTC Resources LeadingAge New York: http://www.leadingageny.org Senior Supportive Housing Services: http://www.health.ny.gov/funding/rfa/1212230202/ MRT Website: http://www.health.ny.gov/health_care/medicaid/redesign/ MRT Listserv: http://www.health.ny.gov/health_care/medicaid/redesign/listserv.htm DSRIP Website: http://www.health.ny.gov/health_care/medicaid/redesign/delivery_sys tem_reform_incentive_payment_program.htm 39

40. Contact Information Ken Harris Senior Policy Analyst LeadingAge New York 13 British American Blvd Latham, New York 12110 518.867.8383 kharris@leadingageny.org www.leadingageny.org 40