Colleen Horton Hogg Foundation for Mental Health The University of Texas at Austin July, 2010 MEDICAID FUNDED LONG-TERM SERVICES AND SUPPORTS FOR PEOPLE.
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Colleen Horton
Hogg Foundation for Mental Health
The University of Texas at Austin
July, 2010
MEDICAID FUNDED LONG-TERM SERVICES AND
SUPPORTS FOR PEOPLE WITH DISABILITIES
Explain Medicaid funding for long term services and support.
Talk about all the waiver programs off ered through DADS and DSHS including: Eligibility requirements (eligibility) How to sign up Services available Funding amounts Where to get information
Include information about the consumer directed services options.
Provide information on other long term services and supports
Talk about the waiting lists.
Talk about how folks can impact change during the session.
WHAT I WAS ASKED TO DO…
History Entitlement program established in Texas in 1967 to provide health care
to certain low income individuals; Title XIX of Social Security Act (1965)
Purpose – to provide health coverage to: Low-income families, children & related caretakers Pregnant women Elderly People with disabilities
Eligibil ity Individuals receiving TANF and SSI Individuals receiving waiver services Individuals meeting income and disability criteria
Emergency Medicaid Services
MEDICAID(MUCH OF THE INFORMATION IN THIS PRESENTATION
TAKEN DIRECTLY FROM THE DADS WEBSITE)
Entitlement (no waiting list)
Mandatory ServicesOptional Services
Mandatory populationsOptional Populations
Texas Medicaid and CHIP in Perspective 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html
MEDICAID STATE PLANTHE STATE’S CONTRACT WITH THE FEDS
EPSDT-Texas Health Steps
Inpatient/Outpatient hospital care
Physician servicesNurse midwife
servicesNurse practitionerFQHCsLab & xraysPrenatal care
Family planning services
Skilled nursingChildren’s vaccinesNursing facility
careHome health careRural Health ClinicsNurse practitionersHome health careRural health clinics
MANDATORY SERVICES
Durable medical equip.PT, OT, SpeechPersonal care servicesDental servicesICFMRIMDs (under 21, over 65)Private duty nursing
(under 21)RX drugs (3 per mo.)Unlimited RX in nursing
facilities, ICFMR, managed care
Birthing center
Renal dialysisRehabilitation (chronic
mental illness, physical, development)
Targeted case management
Medical transportationOptometryPodiatryEmergency hospital
servicesLicensed professional
counselor (LPC)
OPTIONAL SERVICES
TANF recipients
Families based on age, income, and assets
Newborns up to 12 months whose mother is Medicaid certifi ed at the time of child’s birth
The majority of children in foster care
Some adopted children
Non-disabled, non-pregnant adults over age 65 w/ income below the TANF limit
Children under 19 and pregnant women over the income limit but have signifi cant medical bil ls (Medically needy/spend down)
SSI recipients (aged, blind and disabled)
POPULATIONS COVERED
Individuals receiving Primary Home Care services (up to 300% of SSI income limit)
Individuals receiving waiver services
Childless adults (not covered in Texas)
OPTIONAL POPULATIONS
Some things are diff erent for kids:
All medically necessary services
Texas Health Steps – Early and Periodic Screening, Diagnosis, and Treatment
Comprehensive Care Program
Personal Care Services
Voluntary participation in managed care (Star+Plus)
CHILDREN IN MEDICAID
How do I apply for Medicaid? By phone – call 211 (connects callers with information on health and human
services) On-line In person
Texas Medicaid and Healthcare Partnership (TMHP) contracts with state to provide Medicaid administration, reimbursement services, claims, prior authorization
Texas Medicaid and CHIP in Perspective 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html
Frew v. Hawkins (1996) – Texas HealthSteps
Alberto, N. – Private duty nursing and personal care services
NUTS AND BOLTS
Eligibility Under 19 years of age Children in families with low incomes and assets
Services 12 months of health care coverage
Cost Sharing Enrollment fees are $50 or less per family co-pays typically $3 -$5
CHIP CHILDREN’S HEALTH INSURANCE
PLAN
If you would like to request an application or check the status
of your application, call 1-877-543-7669.
You may also go online to www.chipmedicaid.com and print an application.
Fax or mail completed applications to the Texas ACCESS Alliance at:P.O. Box 14200 Midland, TX 79711 FAX: 1-877-542-5951
HOW TO ENROLL IN CHIP
MAXIMUM MONTHLY INCOME LIMITSFOR HEALTH CARE COVERAGE PROGRAMS FOR
CHILDREN
Family Size
Medicaid for Children Under
Age 1
Medicaid for Children Ages 1
to 5
Medicaid for Children Ages 6
through 18CHIP
Medicaid for Youth
Transitioning out of Foster Care
1 $1,670 $1,201 $903 $1,805 $3,610
2 $2,247 $1,615 $1,215 $2,429 $4,857
3 $2,823 $2,030 $1,526 $3,052 $6,104
4 $3,400 $2,444 $1,838 $3,675 $7,350
5 $3,976 $2,859 $2,150 $4,299 $8,597
6 $4,553 $3,273 $2,461 $4,922 $9,844
7 $5,130 $3,688 $2,773 $5,545 $11,090
8 $5,706 $4,102 $3,085 $6,169 $12,337
For each additional
person, add:$577 $415 $312 $624 $1,247
Source: HHSC Financial Services, 2007 Medicaid Expenditures,
STARManaged care – acute care
STAR+PlusManaged care – acute care and long term services and supports
PCCM (Primary Care Case Mgt.)Primarily in rural areas
NorthstarBehavioral health managed careDallas/Ft. Worth
IDD Pilot – current study
MANAGEDCARE
MRA Service coordination Respite Employment services Flexible services
LMHA Children’s mental health services Adult mental health services Crisis services State hospitals
COMMUNITY SAFETY NET SERVICES39 MHMR COMMUNITY CENTERS
Will allow parents of children with disabilities in families with income up to 300% of federal poverty limit, to buy into the state Medicaid Program
SB 187 - Authorizing legislation/SB 1 – appropriation (Senator Deuell and Rep. Lucio)
Development - underway
Implementation ???
A program at risk.
MEDICAID BUY-IN FOR CHILDREN
State/Federally fundedCommunity-based long term services and supportsState must submit a waiver application to CMS
Texas has too many waivers! Nine diff erent (1915(c) waivers with diff erent administrative units and rules, service arrays, rates, monitoring requirements, billing guidelines, etc.
Developed to provide alternatives to institutionalization Waive certain Medicaid rules (e.g. state-wideness) 1915(c) waivers “waive off” of some institutional setting
(e.g. nursing facility, state school, ICFMR)
MEDICAID 1915(C) WAIVERS
Community Living Assistance and Support Services (CLASS)
Home and Community-based Services (HCS)Medically Dependent Children’s Program (MDCP) Deaf-Blind with Multiple Disabilities (DBMD) Community Based Alternatives (CBA)Consolidated waiver (CWP)Youth Empowerment Services (YES) Texas Home Living (TxHmL)STAR+PLUS
Federal requirement – waiver programs must be cost neutral in the aggregate.
TEXAS 1915(C) WAIVER PROGRAMS
August, 2009
CLASS HCS MDCP DBMD CBA Managed Care
Total
# on interest
list
27,674 42,360 14,347 79 34,050 5,633 124,143
March, 2010
# on interest
list
30,363 43,385 17,052 262 35,278 5,743 132,083*
(Unduplicated 102,647)
WAIVER INTEREST LISTS
Interest List CBA ICM STAR+ CLASS DBMD*
* MDCP HCS
0-1 years 18,979 1,358 4,274 6,909 222 5,464 9,296
1-2 Years 14,847 12 48 6,268 34 4,662 7,934
2-3 years 1,452 2 30 5,458 6 3,917 6,444
3-4 years N/A 2 17 4,241 N/A 3,009 5,097
4-5 years N/A N/A N/A 2,607 N/A N/A 3,899
5-6 years N/A N/A N/A 2,561 N/A N/A 3,268
6-7 years N/A N/A N/A 2,320 N/A N/A 3,222
7-8 years N/A N/A N/A N/A N/A N/A 2,935
8-9 years N/A N/A N/A N/A N/A N/A 1,290
9+ years N/A N/A N/A N/A N/A N/A N/A
TIME ON THE INTEREST LIST/MARCH 2010
HTTP:/ /WWW.DADS.STATE.TX.US/SERVICES/INTERESTLIST/
CLASS provides home- and community-based services to people with related conditions as a cost-effective alternative to placement in an intermediate care facility for persons with intellectual disabilities or a related condition (ICF-MR/RC).
Community Living Assistance supports and Services
CLASS
Disability/functional Related conditions (not primary diagnosis of intellectual
disabilities) Must meet level of care needed for ICFMR eligibility Must have a need for habilitation Assessment conducted by direct service agency nursing
staff Must be diagnosed before the age of 21 years
Financial 300% for the federal poverty level; $2,000 countable assets Based on child’s income, not family income Determined by HHSC Medicaid enrollment division, not
DADS Service plan may not exceed 200% of cost of care in ICFMR
CLASS ELIGIBILITY REQUIREMENTS
Adaptive aidsCase
management HabilitationMinor home
modificationsNursing services OT, PT, Speech
Psychological Services
Behavioral supportsRespite careSpecialized
therapiesMedical suppliesSupport family
services
SERVICES AVAILABLE IN CLASS
Call toll-free - 1-877-438-5658 to have a person placed on the interest list.
Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.
Need to confirm annually that you want to remain on the waiting list.
Assessment to determine eligibility is not done until services are off ered (slot is available).
HOW TO APPLY FOR CLASS WAIVER SERVICES
Amount of services/budget based on plan of care.
CLASS waiver costs have increased 25% since 2006.
Cost cap for CLASS is approximately $57,000
DADS utilization review unit looking closely at those plans of care that exceed a certain threshold ; Children - ($43,000) (3/2010) Adults - $57,368
UTILIZATION REVIEW/INCREASED COSTS
HCS provides individualized services and supports to persons with intellectual disabilities who are living with their family, in their own home or in other community settings, such as small group homes.
Home and Community-based Services
HCS
Disability Must have an intellectual disability with IQ of 70 or below,
or Have a related condition with an IQ of 75 or less Must meet the level of care criteria for an ICFMR Assessment and service coordination done by local MHMR
Center staff
Financial 300% of the SSI income limits; no more than $2000 in
countable assets Based on child’s income, not family income Determined by HHSC Medicaid enrollment division, not
DADS Service plan may not exceed 200% of cost of care in an
ICFMR
HCS ELIGIBILITY
Service Coordination
Adaptive aidsMinor home
modificationsCounseling and
therapiesSpeech, OT, PTAudiologyDietarypsychological
NursingDental treatmentRespiteSupported
employmentDay habilitationResidential ServicesSupported home livingFoster/companion careSupervised home
living
SERVICES AVAILABLE IN HCS
Apply for services by Contacting you local mental retardation authority (MRA)
MRA website: http://www.dads.state.tx.us/contract/mra.cfm or call 211.
Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.
Need to confirm annually that you want to remain on the waiting list. If your local MRA doesn’t contact you, call them!
HOW TO APPLY FOR HCS WAIVER SERVICES
Amount of services based on assessed Level of Need (LON)
Number of individuals waiting for HCS services = 43,385 (3/2010)
Current waiting time = about 9 years (3/2010)
Service coordination now conducted by local MRA (MHMR community center)
Cost caps vary by level of need.
UTILIZATION REVIEW/INCREASED COSTS/WAITING LIST
MDCP provides services to support families caring for children and young adults who are medically dependent and to encourage de-institutionalization of children in nursing facilities.
Medically Dependent Children’s Program
MDCP
Disability Must meet medical criteria for nursing facility admission Must be under the age of 21 years Must meet disability criteria for social security or Medicaid
benefits
Financial Eligibility 300% SSI income limits; no more than $2,000 in countable
assets Based on child’s income, not family’s
MDCP ELIGIBILITY
Respite
Adjunct support services
Adaptive aids
Minor home modifications
Transition services
SERVICES AVAILABLE IN MDCP
Call 1-877-438-5658 to have the child's or young adult's name placed on the MDCP interest list.
Be prepared to provide Social Security and Medicaid numbers, type of disability, age of the onset of the disability, date of birth, address and telephone number of the person to be placed on the interest list.
Need to confirm annually that you want to remain on the waiting list. If your local MRA doesn’t contact you, call them!
HOW TO APPLY FOR MDCP SERVICES
Service coordination/case management is performed by DADS regional MDCP staff (nurse and/or social worker)
Cost cap is 50% of cost of nursing facility care (wrap-around Comprehensive Care Program services)
Number of children waiting = 17,052 (3/2010)
Current waiting time = 3-4 years (3/2010)
UTILIZATION REVIEW/WAITING LIST
DB/MD waiver provides home and community-based services to people who are deaf-blind with multiple disabilities as a cost-effective alternative to institutional placement. The program focuses on increasing opportunities for consumers to communicate and interact with their environment.
Deaf/Blind Multiple Disabilities
DBMD
Disability/FunctionalMeet ICFMR or related conditions care criteria. Have
deaf-blindness with a third disability resulting in a need for one or more services.
FinancialMust meet Medicaid eligibility.Have an individual plan of care that does not exceed
specific limits.
ELIGIBILITY FOR DBMD
Adaptive aidsMedical suppliesAssisted living *Behavior supportCase managementsChore ProviderEmployment
assistanceMinor home modsHabilitation
IntervenerNursing servicesOT, PT, SpeechOrientation &
mobilityRXRespite careSupported
employmentTransition
assitance
SERVICES AVAILABLE IN DBMD
Call 1-877-438-5658 and ask for the DB-MD waiver representative.
HOW TO APPLY FOR DBMD WAIVER SERVICES
Fewer “slots” and number served than other waivers
Provides services similar to other waivers and some services specific to those experiencing multiple disabilities.
Number on waiting list = 262 (3/2010)
Current wait = 2-3 years (3/2010)
UTILIZATION REVIEW/WAITING LIST
Community Based Alternatives
CBAThis program provides home-and community-based services to people who are elderly and to adults with disabilities as a cost-effective alternative to living in a nursing home.
Disability/functionalbe at risk of entering a nursing facility, be 21 or olderMust meet medical necessity for Medicaid nursing
home care
Financial Meet Medicaid income eligibility requirements (300%
SSI) and have no more than $2,000 in countable assets
Cost of plan of care may not exceed 200% of the cost of care in a nursing facility
ELIGIBILITY FOR CBA
Adaptive aidsMedical suppliesAdult foster careAssisted livingEmergency
response servicesHome delivered
mealsMinor home modsNursing services
OT, PT, SpeechPersonal
assistance servicesRespite care
servicesDental services Unlimited RXTransition
assistance services
SERVICES AVAILABLE IN CBA
Call your local Department of Aging and Disability Services Offi ce.
DADS local offi ces can be found at: http://dads.state.tx.us/contact/combined/cfm
Call 211
HOW TO APPLY FOR CBA SERVICES
Case management performed by DADS regional staff.
Eligible individuals living in STAR+Plus areas must receive their services through STAR+Plus and are not able to obtain services on fee-for-service basis.
Number on waiting list = 35,278 (3/2010)
Current anticipated wait = 2-3 years (3/2010)
UTILIZATION REVIEW/WAITING LIST
The Consolidated Waiver Program provides home and community-based services to people who are eligible for care in a nursing facility or intermediate care facility for persons with intellectual disabilities or a related condition (ICF/MR-RC).
Consolidated waiver program
CWP
No age l imit
Must currently be on an interest l ist in Bexar County for one of the following programs: Community Based Alternatives Community Living Assistance and Support Services Deaf-Blind with Multiple Disabilities Medically Dependent Children Home and Community-based Services
Must have a service plan developed by a DADS and the participant using the person-directed planning process.
Must meet specifi c institutional level of care criteria for an ICF-MR/RC, or
Must meet medical necessity determination for nursing facil ity services.
CWP ELIGIBILITY
Adaptive aids Medical supplies Assisted living
/residential care Audiology Behavior communications
specialist Dental Dietary Nursing services Orientation and mobility Personal assistance svcs. RX Psychological services Respite care
Emergency response system
Family surrogate svcs. Habilitation Home delivered meals Independent advocate Minor home
modifications Social work OT, PT, speech/language Transportation Transition assistance
svcs.
SERVICES AVAILABLE IN CWP
Contact local Department of Aging and Disability Services offi ce.
DADS local offi ces can be found at: http://dads.state.tx.us/contact/combined/cfm
When names “comes up” on one of the other waiting lists in Bexar County, and there is an open slot in CWP, individuals have the option to choose between the standard waiver or the consolidated waiver program
HOW TO APPLY FOR CWP SERVICES
Waiver services should not be considered an “all you can eat menu.”
Every child should have access to the services they truly need, but those children and families fortunate enough to be receiving waiver services also have a responsibility. It’s not a contest of whoever gets the most, wins.
With tens of thousands waiting for services, every extra dollar used aff ects how long all the children on the waiting list will have to wait.
FOOD FOR THOUGHT…
Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families.
Youth Empowerment Services
YES
Pilot Project approved by CMS
Achieves cost neutrality by waiving off of state hospitals
Access through MHMR centers in Bexar and Travis counties
Intended to expand to other parts of Texas if successful
Provides intensive mental/behavioral health services in the community
Intended to prevent hospitalization/residential treatment
Pilot in Travis and Bexar counties only
Administered by DSHS
YES WAIVER PILOT
Disability/Functional Be between the ages of 3-18 years; Reside in Travis or Bexar County; Reside in a non-institutional setting with the child or
adolescent’s Legally Authorized Representative (LAR); or in the child or adolescent’s own home or apartment, if legally emancipated;
Choose, or have the LAR choose, the waiver program services as an alternative to care in an inpatient psychiatric facility;
Meet Department State Health Services (DSHS) clinical criteria (including, but not limited to risk of self-harm, risk of severe disruptive or aggressive behavior, family resources, and risk of challenging school behavior); and
There must be a reasonable expectation that, without Waiver services, the child or adolescent would qualify for inpatient care under the Texas Medicaid inpatient psychiatric admission guidelines
YES WAIVER ELIGIBILITY
Financial
Must be eligible for Medicaid, under a Medicaid Eligibility Group included in the approved waiver; parental income is not counted in financial eligibility;
YES WAIVER ELIGIBILITY CONT’D.
RespiteCommunity living
supportsFamily supportsTransitional
servicesAdaptive aidsMinor home mods
Professional services
Supportive family-based alternatives
Non-medical transportation
Paraprofessional services
SERVICES AVAILABLE IN YES WAIVER
Travis County -- ATCIC’s YES Waiver Interest List Message Line at 512-804-3191 ,or
e-mail YES@atcic.org. ATCIC maintains an interest list for individuals interested in receiving YES waiver services
Bexar County – Center for Health Care Services, (210) 731-1300
HOW TO APPLY FOR SERVICES
Allows more flexibility in the funding of intensive community-based services and supports for children with serious emotional disturbances (SED) and their families.
The waiver is designed to reduce Medicaid psychiatric hospital expenses for children with SED by providing community-based services.
YES
Waiver “lite”
This program provides selected essential services and supports to people with mental retardation who live in their family homes or their own homes.
Texas Home Living
TXHML
Disability/FunctionalNo age limit.Have a determination of mental retardation made in
accordance with state law or have been diagnosed by a physician as having a related condition.
Not be assigned a pervasive plus level of need (LON 9).
Live in their own home or with their family.
FinancialMust meet Medicaid eligibilityOnly waiver that considers the family income instead
of only the child’s income; many children eligible for HCS are not eligible for TxHmL
Have a plan of care that does not exceed the specific program annual cost limit of $12,000
TXHML WAIVER ELIGIBILITY
Adaptive aidsMinor home modsSpecialized
therapiesBehavioral
supportDental treatmentNursing
Respite Day HabilitationEmployment
assistanceSupported
employmentCommunity
support
TXHML WAIVER SERVICES
Does not have a separate waiting list
HCS waiting list used when slots are available
If TxHmL is accepted, individual’s name remains on HCS waiting list
Only waiver that allows all services to be consumer directed
TEXAS HOME LIVING WAIVER
Early Childhood Intervention
School services
DARS employment services
In-Home and Family Support (DADS)
Children with Special Health Care Needs (DSHS)
Community MHMR services
Social Security
OTHER NON-WAIVER SERVICES / PROGRAMS
Requires waiver from CMS
Provides all waiver services available in CBA with the option to offer more
Provider rates are negotiated with the health plan, not mandated by state
STAR+PLUS
Those who are SSI eligible in the STAR+Plus regions have an entitlement to long term services and supports (CBA services).
Those who have income between SSI and 300% of SSI do not have an entitlement and must be placed on the waiting list.
Number waiting for services = 5,743 (3/2010)
STAR+PLUS ENTITLEMENT
Consumer directed services is not a service; it’s a way of delivering services
Three options for service delivery
CDS is one mechanism available to enhance opportunities for self-determination/direction
All waivers have some services that can be provided through the CDS options
Not all waiver services can be provided through CDS
SERVICE DELIVERY OPTIONS
Agency Model Agency is responsible for arranging for provision of services Agency is responsible for recruitment, hiring, training,
monitoring Individual has little say with respect to who provides their
care Direct care workers are employees (or contractors ) of the
agency
Service Responsibility Options Model (SRO) Agency is the employer of record, but client participates in
the hiring of attendants and respite providers
Consumer Directed Services Model (CDS) Individual receiving the services is the employer of record Client is responsible for recruitment, hiring, training,
supervising attendants, respite providers, therapists, nurses
THREE TYPES OF SERVICE DELIVERY
HabilitationRespite IntervenerSupported home livingAdjunct support servicesPersonal assistance servicesProfessional therapiesNursing
Note: not all services listed above can be consumer directed in all the waivers. Check with your case manager/service coordinator.
TYPES OF SERVICES THAT CAN BE CONSUMER DIRECTED
Allows an individual residing in a nursing facility to transition to community services.
An attempt to end the institutional bias in the H&HS system.
Only available to individuals residing in nursing facilities.
Not available for individuals in ICFsMR or state schools (state supported living centers).
Voluntary closure is not the same as money-follows-the-person.
MONEY FOLLOWS THE PERSON
13 facilities, 4,200 residents at $150,000 per year, per resident
Olmstead – least restrictive setting
Promoting Independence Advisory Committee
Community Living Options Information Process (CLOIP)
No MFP only target population slots
Children in State Schools Workgroup
DOJ Investigation
Formerly called State Schools
STATE SUPPORTED
LIVINGCENTERS
Projected $18 billion defi cit
5% cuts being implemented
Additional 10% must be identifi ed
Only two ways to cover the defi cit – raise more revenue or cut spending
“Everything is on the table except raising taxes”
May provide opportunities for major changes
Items previously “off the table” are now on
Mental health services may be hit harder than others (limited federal match)
THE 82ND LEGISLATURE
$18 Billion deficitLots of competition for the limited resourcesPossibility of major systems changes
Get connected with other parents and advocatesBecome informed on the issuesBegin crafting your message(s)
Visit you legislators during the interimMake a plan
IF THERE EVER WAS A TIME OR NEED FOR ADVOCACY…IT IS NOW!
Write down three things you’ll do this summer to begin your advocacy eff orts. (e.g., make an appointment to meet your legislators, contact advocacy organization, etc.)
Become familiar with this website” www.capitol.state.tx.us
Government was never meant to be a spectator sport.Barbara Jordon
BEGIN YOUR ADVOCACY
Information about the Medicaid waivershttp://www.dads.state.tx.us/providers/waiver_comparisons
Texas Medicaid and CHIP in Perspective 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html
Imagine Enterpriseshttp://www.imagineenterprises.com/
Texas Legislature on Linehttp://www.capitol.state.tx.us
RESOURCES
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