Medicaid Managed Care National Perspective and Postcards from the Bleeding Edge Rocky Nichols Executive Driector, DRC Kansas

NCD Recommends P&A Medicaid Advocacy Program “CMS should fund a Medicaid Advocacy program within the federally mandated Protection and Advocacy agencies to ensure Medicaid managed care programs at the state level are adequately protecting the rights of consumers.”

Kansas - The Bleeding Edge of MMC People lost in the cracks – Not just death of case management “Death by a million burecratic paper cuts” – New verification forms to stay on waiting lists (not getting in mail) – People don’t get the form - Even those who have not moved – People send in the form – lost by central office – Not being informed of appeal rights NOA – – Many MMC Members were not Informed of Reductions in Services and Due Process Rights – Those Informed … were Misinformed and Systematically Discouraged from Filing Appeals – We thought this was fixed, but seeing it occur again

Case management as we know it is gone in Kansas under Managed Care! Loss of case management illustrates NCD’s Advocacy program Case management as we know it is gone – – All Waivers except I/DD “Care Coordination” by MCOs replaced case management Not same thing – case loads, services

Case management as we know it is gone Medicaid Managed Care (MMC) greatly weakened the Services and Supports System that helps Kansans before they qualify for Medicaid. Don’t fall through cracks. Huge Case Management Gap - no one helping the person navigate the system before they get a Medicaid card. Prior to MMC - case managers helped Medicaid applicants. Now, little navigating application process. Fall through cracks Undermines purpose of MMC, improved health outcomes. “Care Coordination” doesn’t help with navigation – case loads of 150+ Crisis case management under 60 yrs old limited under MMC; has always been (continues to be) limited for 60+

Kansas - The Bleeding Edge (cont.) Huge Reductions in PD Waiver Enrollment – Pre-and Post MMC --- Difference is after MMC, plummets further even AFTER $9 million added by Legislature to increase enrollment Dramatic Reductions in Waiver Capacity Pre & Post MMC (since 1/1/2013) – 23% reduction in PD Waiver slots – 7.5% reduction in I/DD Waiver slots – 6% reduction in TBI Waiver slots – Cumulative Reduction of 14% across all Waivers

PD Waiver Enrollment Plummets

PD Waiver Unprecedented – BOTH enrollment and wait list DROP

Since MMC … Waiver Capacity reduced 14% (2542 slots) MMC Started 1/1/2013 Capacity1/01/2013Proposed Difference PD Waiver7,8746,092(1782) DD point in time95528,836(716) TBI Waiver767723(44) Total18,19316,173 (2542)

PD Waiver Capacity Reduced 23% after MMC Total Change in PD Waiver Capacity = 23% decrease

I/DD Waiver Capacity Reduced 7.5% after MMC Total Change in DD Waiver Capacity = 7.5% decrease

TBI Waiver Capacity Reduced 6% after MMC Total Change in TBI Waiver Capacity = 6% decrease

Total Waiver Capacities Reduced 14% after MMC Total Waiver Capacity Reduction = 14% reduction

Medicaid Managed Care – National Concerns: Inaccessible facilities and materials Provider incentives (withholds, bonuses) create disincentives to serving people with disabilities Limited access to specialists, DME, prescriptions, and non-medical services (transportation, respite) Disputes over when Due Process is triggered and what constitutes compliance Failure to provide benefits pending appeal Poor understanding of EPSDT requirements Lack of transparency (e.g. formularies, rates)

1115 Global Waivers allow new “flexibilities” that disadvantage PWD’s States are receiving new “flexibilities” from HHS in trade for Medicaid expansion (IA, PA, IN, OH, KS…) (awaiting approval WY, UT, MT, FL, VA…) Concerns: Higher cost sharing (above “nominal” for non-emergent ER) Penalties for failure to pay cost-sharing Reliance on health savings accounts Waiver of non-emergent medical transportation requirement Incentives and rewards for healthy behaviors

Structure Already in Place for P&A Medicaid Advocacy Programs P&As exist in every state and territory and are experts in MLTSS Policy and Legal Analysis P&As have authority under federal law to “Pursue legal, administrative & other appropriate remedies” on behalf of individuals with disabilities Special authority to access persons, records, and facilities.

Principles of Protection & Advocacy Systems CLIENT-DIRECTED LEGALLY BASED INDEPENDENT ADVOCACY CONSUMER-MANAGED

P&A Continuum of Remedies Information and Referrals Outreach to Un-served and Underserved Populations Training, including Self – Advocacy Skills Legal Counsel and Advice Negotiation and Mediation Administrative Proceedings Individual Litigation Monitoring Public Policy and Legislative Advocacy Public Relations Systemic Litigation and Advocacy

P&A Experience Providing Ombudsman Services P&As already run ombudsman programs, for example: – Wisconsin has three, including: MLTSS for individuals under 60 yrs.; the state SSI managed care advocacy program; and the nonemergency medical transportation advocacy program. – Colorado, Illinois, and Rhode Island are providing legal advocacy as part of Duals Demo’s. – OH, WA, MM, LA. (Ombudsman programs not specific to dual demos)

Medicaid Law Includes Managed Care Non-Discrimination Requirement MC contracts must prohibit discrimination on the basis of health status or requirements for health services in enrollment, disenrollment, and re-enrollment. 42 U.S.C. § 1396b(m)(2)(A)(V)

ACA non-discrimination provision §1557 (42 U.S.C. § 18116) provides Individually Enforceable new authority to prohibit discrimination against individuals with disabilities in applying for health insurance and accessing healthcare services. Applies Civil Rights Act, Age Discrimination Act, and Rehab Act to any health program or activity which: 1)receives Federal financial assistance, including credits, subsidies, or contracts of insurance; 2) is administered by an Executive Agency; or 3) any entity established under Title I of the ACA (i.e. The Health care Marketplace/exchanges).

Anti-discrimination provisions §1302(b)(4)(B) the Secretary shall “not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in a way that discriminates against individuals because of age, disability, or length of life.” (b)(4)(C) the Secretary shall “take into account the health care needs of diverse segments of the population, including women, children, people with disabilities and other groups.”

Anti-discrimination provisions, continued (b)(4)(D) the Secretary shall ensure “that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individual’s age, expected length of life, or the individual’s present or predicted disability, degree of medical dependency or quality of life.”

P&As will Need Additional Funding to Meet Expanding Need NCD Recommends “Congress should establish a Medicaid Advocacy program and increase appropriations to the federally mandated Protection and Advocacy (P&A) agencies by an additional $5 million to hire Health Advocates to assist in monitoring and advocacy at the state level.”