1. Building a Roadmap for Financing Long- Term Services & Supports Refined MassHealth Expansions and Layering of our Proposals Long-Term Care Financing Advisory Committee January 13, 2010 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

2. 2 Overview of presentation 1. Public input sessions 2. Review and preview of analytic work 3. Refined Medicaid expansion proposals 4. Layering of the Roadmap 5. Committee business

3. Section 1 Public Input Sessions 3

4. Goals and format Goals: Inform the public about both the challenges the Commonwealth faces in financing LTS and the work of the Advisory Committee Collect feedback on the financing options currently being considered by the Advisory Committee Basic Format: Legislative briefing (60 minutes) - one week prior to public events Public input sessions -  45-minute presentation of current state of LTS financing and Advisory Committee’s work over the last year, including options for reform  75-minute small-group discussions of questions related to financing options  Possible use of “first responders” and/or large group discussion of personal involvement with LTS financing 4

5. Accessibility and input opportunities All materials and language used shall be accessible to the general public, and will not include jargon or references to specific knowledge base Additional input opportunities:  Post presentation on website with PowerPoint and transcript  Website at which people can view topics/questions and submit responses/comments  Use press release and social networking site(s) to direct traffic to site  Create registration site to facilitate tracking anticipated number of participants  Distribute topics/questions in advance (at time of invitation)  Ask organizations to do outreach to constituencies and perhaps collect info on pre-distributed questions prior to session(s) – challenge of context? 5

6. Participants Participants: Advisory Committee: 2-3 members (including at least one convener)  1-2 members to be “first responders” to presentation? Public: three populations  Current consumers of LTS: younger people with disabilities, elders, and caregivers  Future consumer of LTS: people planning (or not) for their future LTS needs  Professionals: providers, trade organizations, etc. Challenges: Targeting specific groups could require different strategies Different levels of knowledge of LTS system Discussions in small groups highly dependent on participant mix 6

7. Content Presentation (45 minutes) Introductions of Advisory Committee members Status update on work and scope of Committee Description of current LTS financing system and its challenges Options for reforming LTS financing  LTC Insurance Partnership model  Public contribution program  MassHealth expansion/improvements 7

8. Content (2) Small group discussions (75 minutes) Problem statement providing context for each option Discussion questions  Focus on fostering conversation, not eliciting technical information  Requesting assistance in considering the financing options, not presenting them as a plan ~25 minutes for each topic  LTC Insurance Partnership model  Public contribution program  MassHealth expansion/improvements Report back to large group – key themes and comments that raise new issues 8

9. Draft discussion questions “The Commonwealth needs multiple solutions to the LTS financing challenges it faces. These solutions need to be focused on all levels of the financing system, both public and private. We would like your assistance in thinking about the best way to craft these solutions.” Each financing option will be prefaced with a brief description of how the financing option might impact an individual/family in terms of cost, coverage and access - i.e., cost of premiums, change of eligibility, and/or benefit level.  An example: “As currently structured, the federal contribution program would require individuals to pay an average of $125/month in premiums for at least five years in order to qualify, and then would provide a LTS benefit of $50-100/day depending on the level of need.” 9

10. Draft discussion questions (2) Possible discussion questions:  LTC Insurance Partnership model: Would the LTC insurance products available under a Partnership model, with the protections and benefits described, provide a sufficient incentive for you to purchase LTC insurance? What would make LTC Insurance more attractive to you?  Public contribution program: Would a contribution program like the federal program previously described be attractive to you (what would make you want to participate)? What information would you want to have in order to feel comfortable participating? If you had to pay, would this feel worth it? How do you think this program would address the issues that the current system faces?  MassHealth expansion/improvements: As we strive to ensure there are options for financing LTS for all people in MA, would you support improvements/small expansions to the Medicaid program, such as those described previously, to provide LTS to low- income seniors and people with disabilities? 10

11. Schedule Legislative briefing – January 26 th from 12-1 PM Three events in early February:  Downtown Boston – Transportation Building Tentatively scheduled for February 2 nd – afternoon  Worcester area Tentatively scheduled for February 8 th – late afternoon/evening  Western Massachusetts – Northampton Council on Aging TBD 11

12. Advisory Committee input Outstanding questions:  Outreach: What organizations can help? Do different populations need to have different marketing materials?  Attendance: How much would time and location affect participation? Do we need to have daytime and evening sessions? Can at least 2-3 Advisory Committee members attend each session?  Do all the sessions have the same format, with the same target audience? Do the draft discussion questions elicit information that will be helpful in the consideration of the financing options? 12

13. 13 Section 2 Review and Preview of Analytic Work

14. Recap of last month Assessed potential Medicaid cost avoidance from CLASS, mandatory state contribution program (our model) and LTC Partnership program (our model) Key points:  Take-up rates from voluntary programs (CLASS, Partnership): Make small impact on Medicaid cost avoidance Leave many without financing options (except to spend-down) Could be increased with targeting, group LTCI coverage with conversion requirement, financial incentives (didn’t seem to be appetite for subsidies)  Mandatory state contribution program makes bigger splash, but need to: Carefully design the program (eligibility, benefits, premiums, etc.) Thoughtfully propose and explore impact of a new mandate Exempt or subsidize those for whom it is unaffordable 14

15. Recap of last month (2) Medicaid expansions can help address unmet need among lower-income and minimize likelihood of spend-down Various options for expanding Medicaid with a broad range of costs  Cost estimates depend on population selected, benefits selected, utilization Our Medicaid expansions focus on 2 key gaps in coverage:  Disparities in financial eligibility for Medicaid for seniors Ineligible for Medicaid coverage because income/assets higher than current limits  Disparities in access to HCBS once in Medicaid for younger people with disabilities Ineligible for HCBS waivers because not at institutional level of care or do not meet disability eligibility criteria (not “right” type of disability) 15

16. 16 Today’s presentation Refined Medicaid expansion proposals from last month:  Focused policy parameters on most critical gaps in coverage  Targeted only to those with self-care needs  Included asset information  Financial eligibility expansions to seniors with self-care needs (new enrollees eligible for existing LTS) Up to 200% FPL with increase in asset limit Up to 300% FPL with increase in asset limit  Service expansions to younger people with disabilities with self-care needs (new LTS to existing enrollees) Limited v. comprehensive benefit package Targeted v. broad population Layering and sequencing of public and private LTS financing mechanisms  Begin discussion on how programs fit together over time

17. Take away points from today’s presentation There are various options for achieving equity in Medicaid coverage for seniors and people with disabilities  We focused on 2 key coverage gaps Targeted Medicaid expansions cost money, but do not “break the bank” First cut on MassHealth expansion entails policy options and cost estimates for possible expansions  Ultimately, must also address administrative infrastructure, financing (new or redistributed?), care delivery mechanisms, incremental implementation, etc. Need to finalize public and private financing options to be able to layer and sequence proposals 17

18. 18 Section 3 Refined MassHealth Expansion Proposals

19. Goal: Equity in Medicaid Ensure that similarly situated seniors and people with disabilities have access to the same services Coverage gap #1: Medicaid financial eligibility rules create access inequities  People with disabilities at any income or asset level can access MassHealth state plan services (Standard or CommonHealth) Sliding scale premiums apply at higher income levels One-time spend-down for non-working disabled adults in CommonHealth  Only Seniors below 100% FPL and with assets below $2,000 can access MassHealth state plan services (Standard) Seniors with income above 100% FPL can access MassHealth by spending down their income to $522/month or 58% FPL 19 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

20. Visual of current financial eligibility disparities IncomeAssets 20

21. Projected cost to expand Medicaid financial eligibility to seniors (age 65+) with self-care needs Expand Eligibility for Seniors (age 65+), Community-based with Self-care Needs (ADLs) # of new Members who would receive existing services Covered months of Care PMPY – Base (for full year) Cost Estimates in Millions of Dollars Low CaseBase CaseHigh Case 1. Increase income eligibility for seniors from 100% to 200% FPL, asset limit increased to $10,000 10,000 115,000$14,000$100$130$160 2. Increase income eligibility for seniors from 100% to 300% FPL, asset limit increased to $10,000 12,000 124,000$14,000$120$150$180 21 Eligibility is based on when a senior would spend down their assets during the year Seniors with more assets would take longer to spend down their assets and be eligible for fewer months of care Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

22. Notes and assumptions on expanding financial eligibility Assumes current benefit package  The $14,000 PMPY is based on the assumption that 2/3 of new enrollees age 65+ with self-care needs utilize services at the same rate as community LTS users, exclusive of waiver enrollees, and 1/3 utilize services at the same rate as frail elder waiver enrollees. Base case = 100% of projected cost; Low Case = 80% of Base Case costs. High Case = 120% of Base Case costs. There are approximately 10,000 seniors with self-care needs under 200% FPL (ACS data) who are not currently enrolled in MassHealth. National asset data indicates that this population has few assets other than home equity (US Census). We assume that all 10,000 will spend- down to Medicaid eventually. The number of months required to spend- down to Medicaid eligibility is determined by the asset limitation. 22 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

23. Notes and assumptions on expanding financial eligibility (2) Currently, seniors with income higher than the current Medicaid income limits can spend-down to Medicaid by spending a portion of their income on health care costs that would otherwise be paid by Medicaid. If the income eligibility level is increased, Medicaid would pick up more of these costs. The cost estimates for financial eligibility expansions include an estimated $20-$40 million in costs that Medicaid would assume for current members. We assume that the federal government would pay 50% of any expansion costs, but that 50% is not deducted from these cost figures. 23 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

24. Notes and assumptions on expanding financial eligibility (3) Assumes the following average assets per person (50%/50% blended rate of one- and two-person family assets) [Source: US Census]  100% – 199% FPL - $4,700  200% – 299% FPL - $26,000 Average time to spend down assets to required level (based on the above assets and monthly cost of care)  $2,000 of assets 100% – 199% FPL – 2.4 months  $10,000 of assets 100% – 199% FPL – 0.0 months 200% - 299% FPL – 14.1 months  Therefore, a member with $4,700 in assets would need to spend down their assets on care for approximately 2 months ($2,000 asset test); whereas, that person would be immediately covered at an asset test of $10,000  Assumes the assets per person follows a normal distribution where almost all people’s income levels would be included in 3 standard deviations This assumption was made to calculate how many months of care people would receive  For example, if the average 200%-299% FPL member would spend down in approximately 14 months then 50% of members would spend down their assets in14 months or less  Within this subset, each person would spend down their assets at various times throughout the year  For example, one person may have the assets to pay for 3 months of care prior to qualifying whereas a different individual may need to pay for their own care for 11 months prior to qualifying 24 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

25. Goal: Equity in Medicaid Ensure that similarly situated seniors and people with disabilities have access to the same services Coverage gap #2: Once eligible for MassHealth, coverage rules create access inequities to key HCBS  Seniors can access medically necessary Medicaid state plan services… And a broader range of non-medical HCBS through SCO, Frail Elder waiver and state-funded home care program  People with disabilities can access medically necessary Medicaid state plan services… But must have a specific disability - developmental disability, traumatic brain injury, acquired brain injury (soon) or autism (for kids only) - and be at an institutional level of care to access a broad range of non-medical HCBS through a waiver 25 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

26. Projected cost to expand access to HCBS for current Medicaid members with disabilities (age 19-64) with self-care needs Expand Access to HCBS to Current Members with Disabilities (age 19-64) with Self-care Needs (ADLs) # Current Members who would receive additional services Cost Estimates in Millions of Dollars PMPY - BaseLow CaseBase CaseHigh Case 1.Provide Limited HCBS package to targeted group of 10,000 members with disabilities 10,000$15,000$120$150$180 2.Provide Limited HCBS package to 30,000 MassHealth members with disabilities* 30,000$15,000$360$450$540 3.Provide Comprehensive HCBS package to targeted group of 10,000 members with disabilities 10,000$27,000$220$270$320 4.Provide Comprehensive HCBS package to 30,000 MassHealth members with disabilities* 30,000$27,000$650$810$970 26 * ACS data identifies 40,000 people in MA between the ages 19 - 64 with disabilities under 200% FPL who self-identify as having self-care needs. Currently, 10,000 MassHealth members with disabilities receive HCBS through a waiver. Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

27. Notes and assumptions on expanding access to HCBS  Case Management  Family Support/Community Habilitation  Individual Support/Community Habilitation  Grocery Shopping/Delivery  Home-delivered meals  Homemaker services  Laundry services  Respite care  Supportive employment  Peer counseling  Limited benefit package could include services such as:  Comprehensive benefit package includes limited benefit package plus services such as:  Companion services  Assistive Technology  Non-medical transportation  Specialized medical equipment  Expanded counseling  Medical management  Chore services  Behavioral health services (for those who currently do not have access to BH services)  Skilled Nursing  Environmental adaption  Agency personal care  Home Health Aide  Home-based wandering service  Supportive Home Care Aide  Day services 27 * These benefit packages do not include residential habilitation.

28. Notes and assumptions on expanding access to HCBS (2)  Base case = estimated PMPY x number of enrollees. Low Case = 80% of Base Case costs. High Case = 120% of Base Case costs.  We assume that the federal government would pay 50% of any expansion costs, but that 50% is not deducted from these cost figures. 28 Medicaid expansion cost estimates were developed specifically for this presentation, and should not be used for other purposes.

29. Expansion options not included in this analysis Although we chose 2 key coverage gaps to address, there are a number of eligibility/service expansion options that we could consider to address inequities in Medicaid For example, others include:  Expand access to PCA for MassHealth members with mental or cognitive disabilities who not require hands-on assistance (who need assistance with cueing and monitoring)  Expand access to CommonHealth (and Medicaid state plan service) for non-working people with disabilities by easing the one-time deductible rules  Expand access to behavioral health services for seniors on MassHealth Efforts in many of these areas are included in MA’s larger Olmstead plan activities 29

30. Section 4 Layering of the Roadmap 30

31. Layering and sequencing of LTS financing options To develop recommendations we need to: 1. Finalize our mix of public and private financing options so we can start to layer and sequence Difficult to try to intersect several different future scenarios 2. Layer the private and public options: Analyze how public and private options are likely to interact, e.g., net coverage levels, cost exposures, and cost offsets Relationship between voluntary federal effort and state initiatives 3. Sequence the recommendations in time: Recommend when in the multi-year roadmap we should take actions (e.g., implement a state contribution program) When we should make expenditures (e.g., for a Medicaid expansion or to establish a state contribution program) When cost offsets are likely to occur (e.g., estimate the time from taking an action or making an expenditure until benefit from cost offset) 31

32. Low High FINANCIAL RESOURCES High LTS NEED Low Medicaid ( Expanded) Medicaid Spend-down LTS financing system with our proposed changes Contribution Program Personal Resources Consumer Protections Informal Caregiver Support LTC Insurance LTC Partnership 32

33. With these changes, have we actualized a LTS system that achieves our key objectives? 1. Ensure a strong public safety net for the poor and most vulnerable. 2. Limit financial pressure on the state financing system so that state funds are preserved for those most in need. 3. Encourage personal responsibility for financing LTS to the maximum extent possible. 4. Enable middle-income people of all ages to access the LTS they need without becoming impoverished. 5. Ensure appropriate participation of and support for informal caregivers. 33

34. Questions to consider/discuss (assumes CLASS passes): Do our proposals expand financing options and maximize coverage levels to the greatest extent possible? Is the Medicaid cost avoidance significant enough to justify promoting private interventions? Do we want/need to adjust Medicaid more to complement private interventions? To what extent should we talk about a mandatory (v. voluntary) state contribution program to supplement CLASS?  With or without subsidies for those for whom it is unaffordable? 34

35. Section 5 Committee Business 35

36. Committee business Legislative briefing and Public input sessions  Legislative briefing: January 26 th  Public input sessions: Boston: tentatively February 2 nd Worcester area: tentatively February 8 th Western MA: TBD Next meeting  Date: Thursday, February 25 th, 2010 from 9:00 -11:30am  Location: One Ashburton Place, 21 st Floor Future meetings? 36