An Overview of Federal and State Funding and Programs for Long-Term Services and Supports September 2015

OVERVIEW Page 2 I. Who Pays for Long-Term Services and Supports (LTSS)? II. Receiving Care in the Community III. Support Under the Affordable Care Act IV. Getting Medicare Coverage V. Questions

WHO PAYS FOR LONG-TERM SERVICES AND SUPPORTS? » Medicare coverage for LTSS is limited and only covers medically necessary care. Medicare focuses on medical acute care, such as doctor visits, drugs, and hospital stays. Medicare coverage also focuses on short-term services for conditions that are expected to improve, such as physical therapy to help you regain your function after a fall or stroke. » Private coverage is expensive and not widely purchased. » Medicaid and states are the primary payers for LTSS including nursing home facility stays and services provided outside of facilities called home and community-based services. » There is also an unmeasured cost to individuals, family members, and other caregivers such as time spent providing care. Page 3

MEDICAID LTSS EXPENDITURES TARGETED TO PEOPLE WITH DEVELOPMENTAL DISABILITIES, BY SERVICE CATEGORY, FY 1995– 2013 (IN BILLIONS) (TRUVEN AND CMS, JUNE 2015) Page 4

WHO PAYS FOR LONG-TERM SERVICES AND SUPPORTS? Page 5

RECEIVING CARE IN THE COMMUNITY » Receiving care outside of an institution and in the home or community has many benefits: ›Receiving care outside of a facility is often the preference of the individual ›Receiving care outside of a facility is less costly particularly as individuals living longer and are in better health » Many individuals can stay at home or in their communities provided they have supports. In addition to family caregivers, there are home health aides, nurses, remote monitoring and other resources that can help individuals stay in their homes and communities. Page 6

INSTITUTIONAL VERSUS HCBS » For the first time in FY 2013, more than half of LTSS was spent on HCBS (51.3 percent). This milestone reflects continuing federal and state efforts to increase spending on HCBS relative to spending on institutional services such as the Money Follows the Person Demonstration and the Balancing Incentive Program (created under the Affordable Care Act). This trend has been steady over the past decade, with the HCBS percentage of LTSS growing by one to three percentage points each year. » Most HCBS funding in Medicaid is through 1915(c) waivers. There are often restrictions with these waivers and waiting lists. » The move from institutional care to HCBS is also referred to as “rebalancing.” Page 7

MEDICAID HCBS EXPENDITURES AS A PERCENTAGE OF TOTAL LTSS EXPENDITURES, FY 1995 – 2013 (CMS 64 REPORTS) Page 8

SUPPORT UNDER THE AFFORDABLE CARE ACT » Under the Affordable Care Act a number of new programs were created to promote and facilitate HCBS ›Money Follows the Person Demonstration – provides funding to move individuals out of facilities into HCBS ›Balancing Incentive Program – increases federal match to allow states to make structural reforms to increase nursing home diversions and access to non-institutional LTSS ›Section 1915(i) HCBS state plan option – creates options to allow states to tailor their HCBS waiver programs ›Section 1915(k) Community First Choice state plan option – provides increased federal match to provide home and community-based attendant services and supports to eligible Medicaid enrollees Page 9

OVERVIEW OF THE FEDERAL REGULATIONS » A final rule (CMS 2249F) was issued in January 2014 that affects HCBS provided through Medicaid waivers. The new regulations: ›Provide a new definition of a home and community-based setting ›Define person-centered planning requirements and conflict of interest standards for case management ›Require states to develop transition plans for bringing all HCBS settings into compliance » The objective is to ensure that HCBS waiver participants can enjoy the benefits of living, working, and participating in their communities alongside all other residents. Page 10

HCBS SETTINGS REQUIREMENTS » All Medicaid HCBS settings must: ›Be integrated in the community and provide full access to the greater community ›Be selected by the individual from among multiple setting options ›Support the individual’s choice of services and supports ›Ensure privacy, dignity, respect, and freedom from coercion and restraint » The rules applies to both residential and day settings ›Guidance for residential settings available on CMS’s website ›CMS plans to issue additional guidance about day settings in the future Page 11

HCBS SETTINGS REQUIREMENTS » Individuals in residential settings should be able to have: ›Freedom to control their own schedules ›Privacy in their living unit ›Freedom to furnish or decorate their unit as they wish ›Choice of roommates ›Access to food at any time ›Visitors at any time » Any aberration for health or safety reasons must be explained and documented in the individual’s person- centered service plan Page 12

HCBS SETTINGS REQUIREMENTS » CMS does not consider settings to be “community-based” if they: ›Are located in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or an institution for mental disease ›Are located in/on the grounds of/adjacent to a public institution ›Have the effect of isolating individuals from the broader community, such as: o Farmsteads in rural areas o Gated communities for people with disabilities o Residential schools Page 13

PERSON-CENTERED PLANNING » The person-centered planning process must: ›Allow the individual to lead the process, when possible ›Include family members, friends, and others selected by the individual ›Provide individuals with necessary information to make informed decisions about their choice of available services and providers ›Reflect the individual’s strengths, preferences, goals and desired outcomes Page 14

GETTING MEDICARE COVERAGE – ARE YOU ELIGIBLE? » Medicare Parts A, B and D ›Part A – inpatient coverage (usually no premium, there is a deductible and copays) ›Part B – doctor visits, outpatient coverage (premium, deductible, and copays) ›Part D – prescription drugs (premium, deductible and copays) ›Medicare Advantage » You qualify at age 65 or older if: ›You are a U.S. citizen or a permanent legal resident; and ›You or your spouse has worked long enough to be eligible for Social Security or railroad retirement benefits — usually having earned 40 credits from about 10 years of work — even if you are not yet receiving these benefits; or ›You or your spouse is a government employee or retiree who has not paid into Social Security but has paid Medicare payroll taxes while working. Page 15

GETTING MEDICARE COVERAGE – ARE YOU ELIGIBLE? » You qualify under age 65 if: ›You have been entitled to Social Security disability benefits for at least 24 months (which need not be consecutive); or ›You receive a disability pension from the Railroad Retirement Board (RBR) and meet certain conditions; or ›You have Lou Gehrig's disease (amyotrophic lateral sclerosis), which qualifies you immediately; or ›You have permanent kidney failure requiring regular dialysis or a kidney transplant — and you or your spouse has paid Social Security taxes for a certain length of time, depending on your age. ›You live in Puerto Rico and get benefits from Social Security or the RRB Page 16

GETTING MEDICARE COVERAGE » started-with-medicare.html started-with-medicare.html » Apply for Medicare » Choose coverage – Medicare advantage plan, drug coverage » Fill out an "Initial Enrollment Questionnaire" (IEQ) » Page 17

QUESTIONS Page 18 Questions? Johanna Barraza-Cannon