Medicaid Long-Term
Services and Supports
Eric Saber, Health Policy Analyst
Long Term Care and Community Support Services
Maryland Department of Health and Mental Hygiene
December 19, 2011
1
Agenda
National Context for Rebalancing Efforts
 Affordable Care Act





Money Follows the Person Extension
Balancing Incentive Payments Program (BIPP)
Community First Choice (CFC)
Status Updates
2
Nationally, rebalancing efforts have reduced the
proportion of LTSS spending on nursing facilities from
73.4% to 66.6% between 2004 and 2009.
United States Medicaid Spending on Long-Term
Services and Supports: Older Adults and Persons
with Physical Disabilities 2004-2009
73.4%
72.0%
70.8%
68.2%
66.8%
66.6%
26.6%
28.0%
29.2%
31.8%
33.2%
33.4%
2004
2005
2006
2007
2008
2009
HCBS
Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons
with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.
3
Maryland is behind these national trends and in 2009,
ranked among the poorest in home and communitybased services (HCBS) financing. . .
Percentage of Medicaid Long-Term Services and Supports Spending for HCBS:
Older Adults and Persons with Physical Disabilities 2009
80%
70%
60%
Maryland = 14.9%
50%
National Average
= 33.4%
40%
30%
20%
10%
0%
States
Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons
with Physical Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.
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. . . indeed, Maryland was nearly alone among the
states in going backwards between 2004 and 2009.
Change in the Percentage of Medicaid Long-Term Services and Supports Spending for
HCBS: Older Adults and Persons with Physical Disabilities 2004-2009
35%
30%
25%
Maryland = -5.0%
20%
15%
10%
National Average = 6.8%
5%
0%
-5%
-10%
States
-15%
Source: National and State Long-Term Services and Supports Spending for Adults Ages 65 and over and Persons with Physical
Disabilities. 2011. Analysis of Thompson Reuters data by The Hilltop Institute.
5
While Maryland Medicaid’s payment rates to
nursing facilities are higher than average. . .
Average Daily Medicaid Reimbursement Rate for
Free-Standing Nursing Facilities: FY 2007 (or most
recent available data prior to 2007)
$450.00
$400.00
$350.00
Maryland = $193.21
$300.00
$250.00
$200.00
National Average: $154.13
$150.00
$100.00
$50.00
$-
States
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Source: Harrington, et al. (2008). State Data Book on Long Term Care, 2007. US Dept of Housing and Urban Development.
. . . payments to nursing facilities haven’t kept up with
medical inflation (and things are much worse for homeand community-based service providers).
Compounded Medicaid Nursing Facility and HCBS
Reimbursement Rate Changes and National Health Care
Expenditures Per Capita Changes since 2002
50%
45%
40%
Average Annual Increase:
+5.9%
35%
Nursing Facilities
30%
HCBS
Reimbursement
25%
20%
Average Annual Increase: +4.6%
National Health
Care Expenditures
Per Capita
15%
10%
Average Annual Increase: +1.4%
5%
0%
2002
2003
2004
2005
2006
2007
2008
2009
2010
Sources: Maryland Medicaid Long Term Care Rate Changes. (2011). Department of Health and Mental Hygiene
and U.S. Bureau of Labor Statistics, Occupational Archives. 1999-2010 and www.cms.gov.
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Affordable Care Act





Supports most integrated setting, person-centered planning,
and individual control.
Includes increased focus on quality and accountability.
Offers new or improved home and community-based services
(HCBS) State Plan options.
Offers enhanced Federal funding to help states modify
delivery systems.
Key Provisions



Money Follows the Person Extension
Balancing Incentive Payment Program
Community First Choice: 1915(k)
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MFP Overview

Federal demonstration created by the Deficit Reduction Act of
2005, offered through the Centers for Medicare and Medicaid
Services (CMS) and designed to:



Assist states in rebalancing long-term care systems
Increase the use of Home- and Community-Based
Services (HCBS)
Remove barriers to receiving services in the community

Maryland is one of 30 jurisdictions currently participating in
the demonstration

Affordable Care Act extended the demonstration and offered
grants to additional states


Transitions through December 31, 2016
Spending through 2019
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MFP Overview

To access MFP funds, states must transition individuals
receiving Medicaid services from “qualified institutions” to
“qualified residences”

MFP Eligibility


90 days in institution
1 day of Medicaid eligibility in the institution

The State receives enhanced federal matching funds for
services provided to demonstration participants for 365 days

Enhanced matching funds result in “savings” to the State

States are required to spend savings on approved
rebalancing initiatives

Savings can not:


Pay for services
Off-set ongoing state costs
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Federal Requirements

Qualified Institutions




Nursing Facilities (NFs)
State Residential Centers (SRCs)
Institutions for Mental Disease (IMDs)
Chronic Hospitals


Exploring expansion to include Psychiatric Residential Treatment
Facilities (PRTFs)
Qualified Residences



A home owned or leased by the individual or the individual's
family member;
An apartment with an individual lease, with lockable access
and egress, and which includes living, sleeping, bathing, and
cooking areas over which the individual or the individual's
family has domain and control;
A residence, in a community-based residential setting, in
which no more than 4 unrelated individuals reside.
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Existing Waivers
Maryland will serve MFP participants using five
home- and community-based waiver programs

The Traumatic Brain Injury (TBI) waiver


The Community Pathways (CP) waiver


Self-directed waiver for adults with developmental disabilities
The Living at Home (LAH) waiver


Serves adults with developmental disabilities
The New Directions (ND) waiver


Serves adults in chronic hospitals and State-owned nursing
facilities
serves people with physical disabilities between 18 and 65
The Older Adults Waiver (OAW)

serves adults with disabilities over the age of 50
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Rebalancing Initiatives

Increase outreach to institutional residents

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Improve the transition process

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Enhance Transitional Case Management
Housing Assistance
Enhance existing community-based services



Peer Outreach Contracts
Program Education
Application Assistance
Peer Mentoring
New Waiver Services
Improve Systems

Statewide ADRC sites
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Balancing Incentive Payments
Program (BIPP)

Offers an enhanced federal medical assistance percentage
(FMAP) for all HCBS covered during the “balancing incentive
period” through September 30, 2015.



Within six months, states must initiate “structural changes” to
their LTSS systems that include:




Maryland qualifies for a 2% enhanced payment rate.
All enhanced federal payments must be used to fund new and
expanded Medicaid community-based LTSS.
Creation of a Single Point of Entry system for LTSS
Development of a Standardized Assessment Instrument
Implementation of Conflict Free Case Management
By the end of the BIPP period states must:


Increase HCBS to 50% of total Medicaid LTSS spending
Implement required structural changes
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BIPP Updates – Financial

Received CMS assurance that Maryland is eligible to
apply for a 2% enhanced match based on the
Federal Fiscal Year (FFY) 2009 LTSS spending
percentages included in BIPP Application


Maryland’s calculated percentage in the BIPP
Application was 36.8%
Services included in this percentage are
waiver programs (including DD waivers),
home health and personal care expenditures.
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Community First Choice (CFC)



Optional State Plan benefit to offer Attendant Care and related
supports to individuals, providing opportunities for self-direction.
Includes 6% enhanced FMAP.
CMS is still discussing policy decisions.


Specifically, CMS is discussing whether all CFC participants must meet
the State’s institutional level of care, or whether CFC also is available
for people who require attendant care but are not at institutional level of
care.
Final Federal regulations may not be available until 2012.
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Community First Choice (CFC)

We propose to offer all required and optional services allowed
under CFC regulations. Specifically, CFC would offer:



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Personal / Attendant Care;
Personal Emergency Response Systems (PERS);
Voluntary training for participants;
Transition Services; and
Services that increase independence or substitute for human assistance.
Services offered under CFC would no longer be covered as a
waiver service, but rather covered as a State Plan service.
Waiver participants are eligible to receive all State Plan
services.
The State will:


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Refine this concept as federal guidance emerges, especially regarding the
potential institutional level of care qualifying criteria
Seek technical assistance from CMS on policy decisions;
Establish an Implementation Council; and
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Analyze further policy decisions and implementation plan for CFC.
Community First Choice (CFC)

CFC is not creating a new eligibility standard.


CFC is a consolidation of current State Plan eligible
participants who receive personal care into one robust
program offering additional services and self-direction.
The program is expected to grow based on
increased utilization due to:



Increased services to certain current participants,
Participation of currently eligible participants not
receiving services, and
Improved reimbursement to most providers.
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Improvements possible under CFC

In addition to services offered under CFC, with
the enhanced match the State would be able to
also provide the following:
 Enhanced quality assurance.
 A provider registry.
 Trainings to providers.
 Coordinated rates across programs.
 An option to develop a back-up system.
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Status Updates


Long Term Care Reform Workgroup is submitting
a report to the legislature in December 2011.
Long Term Care Reform Workgroup will transition
to the Money Follows the Person Workgroup and
the Community First Choice Implementation
Council in January.



MFP-BIPP stakeholder meeting on January 10, 2012
Community First Choice Implementation Council will
meet in January after council selection is complete.
Core Standardized Assessment stakeholder
meetings were held on December 12 and 15 for
stakeholder input.
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