1. 1 Autism Commission Presentation January 24, 2011 Lisa McDowell, Director of Institutional, Residential & Day Services MassHealth Office of Long Term Care

2. 2 Overview  The MassHealth Office of Long Term Care is responsible for providing frail elders and individuals with disabilities of all ages with services and supports that best meet their needs; we do this by ensuring the availability of, and managing, a broad range of long term care services provided in a range of settings.  Our work supports the missions and goals of the Executive Offices of Health and Human Services and Elder Affairs, and requires collaboration with numerous departments and agencies involved in the administration of disability programs.

3. MassHealth OLTC Programs Nursing Facilities Chronic Disease & Rehabilitation Hospitals Adult Day Health Day Habilitation Adult Foster Care Group Adult Foster Care Targeted Case Management Coordinated Care Programs: –Program for All Inclusive Care for the Elderly (PACE) –Senior Care Options (SCO) Personal Care Attendant Early Intervention Therapies Durable Medical Equipment – Oxygen & Respiratory Orthotics & Prosthetics Home Health Independent Nurse Hospice

4. 4 Residential and Day Programs Adult Foster Care (AFC) Day Habilitation (DH)

5. Adult Foster Care (AFC) Services 130 CMR 408.000 Description Services provided in a qualified home setting by a qualified caregiver who resides with the individual. Services offered include assistance with Activities of Daily Living (ADL’s) and other personal care, Instrumental Activities of Daily Living (IADLs), delivered by the caregiver, nursing management, nursing oversight, and care management delivered by the AFC provider’s nursing and care management staff Levels of Care Level 1 is designed to provide services to individual with low to moderate needs. Individuals minimally requires daily assistance or cueing and supervision during the entire task in order to complete of at least 1 ADL; and Level 2 designed to meet the needs of more frail individuals. Individuals minimally require physical assistance with 3 ADLs or physical assistance with 2 ADLS and management of behaviors that require caregiver intervention Member Eligibility 16+ years of age and need assistance or cueing & supervision with at least 1 of the following: bathing, dressing, toileting, eating, transfers and ambulation. Requires MD Approval

6. 6 Adult Foster Care (AFC) Services Continued Population Served Disabled Adults <65; increase in number of elders since implementation of regulations 2/1/07. Other Conditions/Limitations Requires pre-admission screening completed and submitted by the AFC provider to Coastline Elderly Services, an Aging Service Access Point (ASAP). Room and board fees are arranged between the Member and the Caregiver. Number of Programs 50 Primary Funding MassHealth Payment for Services’ Payment rates are set by the Division of Health Care Finance & Policy (DHCFP) and are based on cost report analysis submitted by AFC programs.

7. AFC: Spending & Utilization SFY 07-10 SpendingService UnitsUnduplicated Members SFY 07 $18,023,005439,1291507 SFY 08$ 28,602,695549,7851971 SFY 09$ 47,967,199761,7932822 SFY 10$ 74,079,9101,126,3344220

8. 8 Day Habilitation (DH) Services 130 CMR 419.000 Description Day Habilitation programs serve persons with intellectual disability or other developmental disabilities providing a structured day program designed to build skill development, improve level of functioning, and facilitate independent living and self-management skills. Services provided include: skilled nursing; developmental skills training; therapy (PT OT ST); and assistance with Activities of Daily Living (ADL). Services are offered primarily in the community Member Eligibility: Member must: have a diagnosis of ID (MR) or DD, need and benefit from DH services designed to improve independent functioning. DH services provided to Members residing in a nursing facility must be recommended for specialized services as a result of a preadmission screening conducted by the Department of Developmental Services. These Members are considered “Rolland” class Members.

9. 9 Day Habilitation (DH) Services Continued Population Served: Individuals of with either ID or DD. Developmental Disability (DD): A severe, chronic disability that meets all of the following conditions: –Is attributable to: a) cerebral palsy or epilepsy; or b) any other condition, other than mental illness, found to be closely related to MR because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with MR and requires treatment or services similar to those required for these persons; –Is manifested before the person reaches the age of 22; –Is likely to continue indefinitely; and –Results in substantial functional limitations in three or more of the following areas of major life activity: a) self-care; b) understanding and the use of language; c) learning; d) mobility; e) self-direction; f) capacity for independent living.

10. Day Habilitation (DH) Services Continued Intellectual Disability (ID)/Mental Retardation (MR): Significantly sub-average intellectual functioning existing concurrently and related to significant limitations in adaptive functioning. ID (MR) manifests before age 18. A person with MR may be considered to be mentally ill as defined in 42 USC § 1396r(e)(7)(G)(i), provided that no person with MR shall be considered to be mentally ill solely by reason of his or her ID (MR). * MR is still a diagnosis and is referenced in federal law; however the Commonwealth has chosen to use “ID” as the common language. Number of Programs 166 sites Primary Funding MassHealth Payment for Services Payment rates are set by the DHCFP and are based on UFR analysis submitted by DH programs. There are 3 levels of payment based upon severity of need: Low, Moderate and High. Additional rates are paid for qualifying Members receiving DH services and residing in a NF.

11. DH: Spending & Utilization SFY 07 & 10 SpendingService UnitsUnduplicated Members SFY 07$ 106,604,2341,305,5367278 SFY 08$ 112,355,4871,360,7397693 SFY 09$ 121,942,3411,431,1928135 SFY 10$ 134,091,9681,585,7038713

12. 12 Resources MassHealth Information –www.mass.gov/masshealthwww.mass.gov/masshealth Division of Health Care Finance and Policy Information –www.mass.gov/dhcfpwww.mass.gov/dhcfp MassHealth Customer Service Center –1-800-841-2900

13. 13 MassHealth Regulations & Other Publications www.mass.gov/masshealth –MassHealth regulations and other publications MassHealth Regulations –Eligibility Regulations –Provider Regulations Provider Library –Provider regulations –Transmittal Letters –Bulletins –Service Codes and Descriptions (Subchapter 6) –Appendices, etc.