Medicaid funded long-term services and supports for people with disabilities Colleen Horton Hogg Foundation for Mental Health The University of Texas at Austin July, 2010

What 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 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.

Medicaid (Much of the Information in this presentation taken directly from the DADS website) 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

People with disabilities 30 % or the Medicaid Population 58% of Medicaid Costs

Medicaid State Plan The State’s contract with the feds Entitlement (no waiting list) Mandatory Services Optional Services Mandatory populations Optional Populations Texas Medicaid and CHIP in Perspective 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html

Mandatory services EPSDT-Texas Health Steps Family planning services 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 Rural health clinics

Optional Services 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)

Populations Covered 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)

Optional populations Individuals receiving Primary Home Care services (up to 300% of SSI income limit) Individuals receiving waiver services Childless adults (not covered in Texas)

Children in medicaid 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)

Nuts and Bolts 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 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html Frew v. Hawkins (1996) – Texas HealthSteps Alberto, N. – Private duty nursing and personal care services

CHIP Children’s Health Insurance Plan 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

how to enroll in CHIP If you would like to request an application or check the status of your application, call 1-877-543-7669.  You may also go online to www.chipmedicaid.com and print an application. Fax or mail completed applications to the Texas ACCESS Alliance at: P.O. Box 14200 Midland, TX  79711 FAX: 1-877-542-5951

MAXIMUM MONTHLY INCOME LIMITS FOR HEALTH CARE COVERAGE PROGRAMS FOR CHILDREN Source: HHSC Financial Services, 2007 Medicaid Expenditures, 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

Managed Care STAR STAR+Plus PCCM (Primary Care Case Mgt.) Northstar 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

Community Safety Net Services 39 MHMR Community Centers MRA Service coordination Respite Employment services Flexible services LMHA Children’s mental health services Adult mental health services Crisis services State hospitals

Medicaid 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 Program SB 187 - Authorizing legislation/SB 1 – appropriation (Senator Deuell and Rep. Lucio) Development - underway Implementation ??? A program at risk. Medicaid Buy-IN for Children

Medicaid 1915(c) Waivers 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)

Texas 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+PLUS Federal requirement – waiver programs must be cost neutral in the aggregate.

Waiver interest lists August, 2009 CLASS HCS MDCP DBMD CBA Managed Care Total # on interest list 27,674 42,360 14,347 79 34,050 5,633 124,143 March, 2010 30,363 43,385 17,052 262 35,278 5,743 132,083* (Unduplicated 102,647)

Time on the interest list/March 2010 http://www. dads. state. tx CBA ICM STAR+ CLASS DBMD** MDCP HCS 0-1 years 18,979 1,358 4,274 6,909 222 5,464 9,296 1-2 Years 14,847 12 48 6,268 34 4,662 7,934 2-3 years 1,452 2 30 5,458 6 3,917 6,444 3-4 years N/A 17 4,241 3,009 5,097 4-5 years 2,607 3,899 5-6 years 2,561 3,268 6-7 years 2,320 3,222 7-8 years 2,935 8-9 years 1,290 9+ years

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). Class Community Living Assistance supports and Services

CLASS Eligibility requirements 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

Services available in CLAss 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 What’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: CLASS This 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: CLASS This 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: CLASS This 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: CLASS This 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: CLASS This 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; and aquatic therapy.

How to apply for class waiver services Call toll-free - 1-877-438-5658 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).

Utilization 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 $57,000 DADS utilization review unit looking closely at those plans of care that exceed a certain threshold ; Children - ($43,000) (3/2010) Adults - $57,368

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. HCS Home and Community-based Services

HCS Eligibility Disability Financial 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

Services available in HCS 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

How to apply for HCS waiver services Apply for services by Contacting you local mental retardation authority (MRA) MRA website: 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!

Utilization 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.

MDCP 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 Eligibility Disability Financial Eligibility 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

Services Available in MDCP Respite Adjunct support services Adaptive aids Minor home modifications Transition services

How to apply for MDCP services Call 1-877-438-5658 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!

Utilization 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)

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. DBMD Deaf/Blind Multiple Disabilities DB-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.

Eligibility 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. Financial Must 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.

Services available in DBMD 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 *up to six beds

How to apply for dbmd waiver services Call 1-877-438-5658 and ask for the DB-MD waiver representative.

Utilization review/waiting list 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)

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. CBA Community Based Alternatives

Eligibility for cba 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

Services available in cba 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

How to apply for cba services Call your local Department of Aging and Disability Services Office. DADS local offices can be found at: http://dads.state.tx.us/contact/combined/cfm Call 211

Utilization 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)

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). CWP Consolidated waiver program

CWP eligibility 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.

Services Available in CWP 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.

How to apply for cwp services Contact local Department of Aging and Disability Services office. DADS local offices can be found at: http://dads.state.tx.us/contact/combined/cfm 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 Why it didn’t work – designed to fail.

Food 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.

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

Yes Waiver Pilot 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 eligibility 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 cont’d. Financial Must be eligible for Medicaid, under a Medicaid Eligibility Group included in the approved waiver; parental income is not counted in financial eligibility;

Services available in YES waiver Respite Community living supports Family supports Transitional services Adaptive aids Minor home mods Professional services Supportive family-based alternatives Non-medical transportation Paraprofessional services

How to apply for services Travis County -- ATCIC’s YES Waiver Interest List Message Line at 512-804-3191 ,or e-mail YES@atcic.org. ATCIC maintains an interest list for individuals interested in receiving YES waiver services Bexar County – Center for Health Care Services, (210) 731-1300

yes 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.

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. Txhml Texas Home Living

TxHmL waiver eligibility 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 services Adaptive aids Minor home mods Specialized therapies Behavioral support Dental treatment Nursing Respite Day Habilitation Employment assistance Supported employment Community support

Texas home living waiver 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

Other non-waiver services / programs 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

STAR+Plus 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

Star+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)

Service Delivery Options 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

Three types of service delivery 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

Types of services that can be consumer directed 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.

Money 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

state supported living centers 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 state supported living centers Formerly called State Schools

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 82nd Legislature

If there ever was a time or need for advocacy…it is now! $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

Begin your advocacy 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” www.capitol.state.tx.us Government was never meant to be a spectator sport. Barbara Jordon

Resources Information about the Medicaid waivers http://www.dads.state.tx.us/providers/waiver_comparisons Texas Medicaid and CHIP in Perspective 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html Imagine Enterprises http://www.imagineenterprises.com/ Texas Legislature on Line http://www.capitol.state.tx.us

If you need more information feel free to contact me at: colleen If you need more information feel free to contact me at: colleen.horton@austin.utexas.edu The End 