Why is Housing So Important? Virginia Association of Housing and Community Development Officials May 8, 2008

2 Four-year Medicaid Demonstration Project to assist seniors and people with disabilities who currently live in institutions to move to the community if they choose to –Person-centered: Over 1,000 individuals in Virginia to move to the community, each with an individual plan, supports they need, and someone to work with them before and after they move –Community-based: Partnerships among human services and housing agencies (local government and private) are key –State-planned and administered: Department of Medical Assistance Services (DMAS) (Virginia’s Medicaid agency) working with many other agencies, including state housing agencies –Federally-sponsored: Centers for Medicare and Medicaid Services (CMS) (federal Medicaid agency) –State- and federally-funded: 25% state/75% federal for 1 st year living in community; 50%/50% thereafter Overview: Money Follows the Person Demonstration Project

3 Money Follows the Person Project Timelines Operational Protocol (comprehensive program manual or Guidebook) submitted to CMS for review and approval April 18 CMS questions due in mid-May DMAS responses to CMS questions by late May If CMS approves Operational Protocol, transitions to begin starting July 1.

4 Community Supports for Individuals Who Transition Each individual will enroll in a Medicaid home and community-based “waiver” or a Medicaid program called “PACE” All Medicaid waivers and PACE pay for a variety of services available to people enrolled, based on their individual needs for each service Non-Medicaid services will also be available

5 Housing for Individuals Who Transition Each individual must move to a “qualified residence” in the community –Home owned or leased by the individual/family member –Apartment leased by the individual/family member –Setting in which no more than four unrelated individuals reside Group homes (4 or fewer beds) Sponsored residential settings 4-bed Assisted Living Facilities Adult Foster Care

6 Medicaid and Housing* HUD-subsidized housing programs are largely Federally-driven by Congress and HUD. Medicaid is a Federal/State partnership. Some aspects are determined by the Federal government, others by the State. HUD Housing Choices Vouchers (Section 8), 202, 811 and Hope VI programs are standardized programs that operate consistently across States. Medicaid programs can (and do) vary from state to state. Medicaid and HUD housing programs use very different methods to determine financial eligibility. A person can be eligible for a HUD housing program, but may not be eligible for the Medicaid program. Medicaid funds cannot be used to pay for room or board. * The information on this and several subsequent slides is excerpted largely from A Medicaid Primer for Housing Officials, Rutgers Center for State Policy/National Academy for State Health Policy, September A copy has been included in your materials.

7 To Understand How Money Follows the Person Relates to Housing, It Helps to Understand the Basics of the Medicaid Program

8 The Medicaid Basics Provides primary, acute, and long-term support services to individuals who meet income, resource and other categorical requirements (e.g., residency, citizenship) States have considerable flexibility to determine who is eligible and what services will be covered Medicaid costs are shared between the Federal government and States Medicaid pays for a significant amount of the long-term support services provided to low- income individuals

9 Medicaid Eligibility Medicaid eligibility is very complicated Eligible beneficiaries are “entitled” to all “mandatory” and “optional” services the State covers under the regular Medicaid program (called the “State plan”) if they meet the “medical necessity” criteria to receive the service Some people are “dually eligible” for both Medicaid and Medicare

10 Medicaid’s “Institutional Bias” Institutional placement is an entitlement. Home and community-based “waiver” services are not an entitlement. States may create waiting lists when they reach the maximum amount that has been approved for the waiver program. The Money Follows the Person Demonstration Project is designed to reverse the institutional bias.

11 Who is Eligible for Medicaid? Primary eligibility categories: Mandatory eligibility groups, e.g., people who receive benefits under the Supplemental Security Income (SSI) program Optional categorically needy group, e.g., people who receive payments under a State Supplement to SSI – In Virginia, the state supplement is called an “auxiliary grant.” Auxiliary grants are available in assisted living facilities and adult foster care programs in Virginia. Medically needy group. States may extend Medicaid eligibility to additional qualified persons who may have too much income to qualify under mandatory or optional categorically needy groups –Virginia has a Medically Needy program that covers seniors and people with disabilities.

12 How Do You Apply for Medicaid? In Virginia, applications are currently handled in person by the local social services departments. This Fall, an on-line Medicaid application will be made available on a statewide web portal called “Virginia Easy Access” –Once completed, the application will be electronically transmitted to the appropriate local social services department Applications are supposed to be processed within 90 days for applicants who apply for Medicaid on the basis of disability and within 45 days for all other applicants. It can take longer if the application is not complete or required documentation is missing.

13 How Do People Get Long-Term Medicaid Services in the Community? Services that support people to live independently in their home or apartment are primarily covered by States under home and community-based waiver service programs. – The major exception is services for persons with mental illness, who rely heavily on mandatory and optional State Plan services. The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program that features a comprehensive service delivery system to address the long-term needs of individuals who are eligible for nursing home care. The service package permits individuals over 55 to continue living at home while receiving services rather than be institutionalized.

14 What is a Home and Community-Based Waiver? Home and community-based waiver services help individuals who are eligible for Medicaid who otherwise qualify to be admitted to an institution to live independently in the community To be approved by the Centers for Medicare and Medicaid Services, the cost of waiver services cannot exceed what the State would have spent in the absence of the waiver Services can be targeted to certain groups or regions of the state – Virginia’s waivers are targeted to certain groups, but all are available statewide.

15 Waiver Eligibility Individuals must meet the State’s medical (functional level) criteria for admission to an institution: –Intermediate Care Facility for Persons with Mental Retardation (now known as “Intellectual Disabilities”) –Nursing Home –Hospital Individuals must meet the financial requirements for Medicaid

16 Virginia’s Home and Community Based Waivers Elderly and Disabled with Consumer Direction (largest, with over 12,000; no waiting list) Mental Retardation (waiting list for “slots”) Developmental Disabilities (waiting list for “slots”) Day Support (no waiting list) Alzheimers and Dementia Assisted Living (no waiting list) Technology-Assisted (no waiting list) HIV/AIDS (no waiting list)

17 Who Provides Waiver Services? Qualified public and private human services agencies who enter a ”provider agreement” with DMAS provide the bulk of waiver services. These are called “agency- directed” services. Some services can be “consumer-directed,” meaning that the individual using the waiver is the “employer” and therefore hires, supervises and fires his or her service provider. Depending on the waiver, the following services can be consumer-directed: –Personal Assistance –Respite –Companion –Individual Supported Employment Individuals who consumer direct are assisted by “Services Facilitators”

18 Can Waivers be “Project-Based”? No. Waiver services are available to eligible individuals and cannot be assigned to providers. Medicaid waiver services stay with the individual when the individual moves. CMS requires that people who use waiver services have a choice of all qualified providers of the services covered under a waiver. The Department of Medical Assistance Services determines what providers are qualified.

19 New Medicaid Services Under Money Follows the Person Transition Services – Up-front household expenses when setting up a household – Being added to five waivers – $5,000 lifetime maximum per person Transition Coordination – 3 months before and 12 months after the individual moves – Being added to Elderly or Disabled with Consumer Direction Waiver Consumer-Directed Individual Supported Employment – Being added to three waivers 24-Hour Emergency Back-up Through VIRGINIA for the first 12 months following transition to the community

20 Existing and New Services To Be Added to Waivers Elderly and Disabled with Consumer Direction (EDCD) - Environmental Modifications - Assistive Technology - Transition Coordination - Transition Services Technology Assisted (TECH) - Personal Emergency Response System (PERS) - Transition Services HIV/AIDS (AIDS) -Environmental Modifications -Personal Emergency Response System (PERS) -Assistive Technology -Transition Services

21 Existing and New Services To Be Added to Waivers, cont’d Individual and Family Developmental Disabilities Services (DD) -Consumer Directed Individual Supported Employment -Transition Services Mental Retardation (MR) -Consumer Directed Individual Supported Employment -Transition Services Day Support (DS) -Consumer Directed Individual Supported Employment

22 Non-Medicaid Services Under Money Follows the Person Supplemental home modification funding if amount needed exceeds Medicaid $5,000 maximum “Bridge rent” for up to 90 days after signing a lease if needed for home modifications to be completed before the individual moves Funding for each provided by the Virginia Department of Housing and Community Development

23 Waiver Services That Help People Find Community Housing Depending on the waiver, one of the following individuals is available to assist individuals moving to the community from institutions: –Case Managers (MR, DD and AIDs Waivers) –Transition Coordinators (EDCD Waiver) –Health Care Coordinators (TECH Waiver) These are the people who will be contacting PHAs when rental assistance is needed

24 The Housing Challenges Housing and Medicaid/human services operate in different worlds Medicaid cannot pay for room or board in the community Therefore, there are no funds available under the Demonstration to pay ongoing rental expenses for these individuals Yet, for some individuals, renting an apartment may be the best (or only) option Most of these individuals are expected to have very low income

25 What are We Doing to Address the Housing Challenges? Operational Protocol contains extensive section an Appendices on housing: –Transition services, environmental and supplemental home modifications, and bridge rent –Qualified residences Owning your own home Renting a home or apartment (including HUD subsidies) Living in adult foster care, assisted living facilities, sponsored residential programs, and group homes –Transportation information also included

26 What Else Are We Doing to Address the Housing Challenges? Housing Task Force created by Secretaries of Health and Human Resources and Commerce and Trade – Includes federal, state, local and private housing and human services partners; VAHCDO and HUD-Richmond represented Task Force will develop Annual Housing and Transportation Action Plan designed to: –Increase affordability and availability of community housing –Increase availability of accessible transportation –Recognize importance of housing and transportation link –Education, awareness, and partnership building among housing and human service agencies and the individuals they serve

27 PHAs and the Annual Housing Action Plan Centers for Independent Living will contact you to ask you to partner with local agencies to support individuals transitioning under the Demonstration. They will: –offer assistance to you in understanding community living needs and preferences of people with disabilities and seniors –assess local housing capacity needs and work with you to develop strategies to address the needs identified in future plans and planning processes –document local changes in public housing policy, and work with you to foster and sustain increased housing options A human services directory and the Medicaid primer will be available to all housing agencies

28 How Will This Project Benefit PHAs? Existing communication and policy gaps between some service providers and some housing agencies can be bridged Practical information on housing needs and preferences of seniors and people with disabilities will be provided Medicaid services will be offered not only to individuals in institutions, but also to individuals currently using Medicaid “waiver” services in the community Individuals currently using Medicaid Waivers and public housing can get more services they need

29 For Further Information Visit the Money Follows the Person Website