Monday, June 4, 2012

Expanding Community Based Long Term Care under the Health Reform Law

The Affordable Care Act (ACA) [also known as Health Reform and “Obamacare”] institutes various health insurance reforms over time and expands health coverage dramatically in 2014. Unless derailed by the pending Supreme Court decision (expected this month), or by the elections in November, a new system of coverage will begin in 2014 in which eligibility and enrollment is coordinated across Medicaid, the Children's Health Insurance Program, and newly created Affordable Insurance Exchanges. (People who cannot get insurance through their employer will be able to buy it directly in an Affordable Insurance Exchange).

The ACA also includes a number of provisions intended to improve the quality of long term care and foster its delivery in community settings. These include:

Community First Choice State Plan Option (CFC)CFC is a new Medicaid State Plan option that provides community-based attendant services and supports to those meeting nursing facility eligibility criteria. It’s set out in Section 1915(k) of the Social Security Act. States implementing this option will receive a six percent increase in their federal Medicaid matching (FMAP) funding.

At this time, Pennsylvania does not appear to be moving toward implementing this option. States appear to have been reluctant to move forward on CFC due to a lack of regulatory guidance and due to the overall uncertainty generated by the litigation over the ACA. However, a Final Rule was issued in April 2012 on CFC and the Supreme Court will soon issue its decision on the ACA.  
Medicaid Home-and Community-Based Services State Plan Option (1915(i)): Section 1915(i) of the Social Security Act (SSA) permits states to both extend home and community based services (HCBS) enrollment to individuals with incomes up to 300 percent of SSI and offer the full range of Medicaid benefits to all eligible individuals receiving services. While this State plan service package includes many similarities to options and services available through the current Pennsylvania Aging Waiver (a Section 1915(c) waiver), a significant difference is that 1915(i) does NOT require individuals to meet an institutional level of care requirement in order to qualify for HCBS services. See CMS State Medicaid Director Letter SMDL# 10-013

1915(i) was added pre-Health Reform by the Deficit Reduction Act of 2005. But 1915(i) financial eligibility was originally limited to those within 150% of the Federal Benefit Rate (FBR), and there were other restrictions that made 1915(i) less attractive than the 1915(c) waivers with which elder law attorneys are most familiar. But 1915(i) was modified/expanded by the ACA to make it more useful – for example, the financial eligibility level was raised to 300% of FBR similar to the Aging Waiver. Again, as far as I am aware, PA is not moving forward on this option at this time.

State Balancing Incentive Payments Program (BIPP): provides enhanced federal matching funds to states that adopt strategies to increase the proportion of their total Medicaid spending devoted to HCBS through reforms that increase consumer accessibility to needed services and supports, such as 1) the establishment of a “No Wrong Door— Single Entry Point System” that creates a statewide system of access points for long term services and supports (LTSS); 2) adoption of conflict-free case management; and 3) application of core standardized assessment instruments for determining eligibility for non-institutional services and supports used in a uniform manner throughout the state. Pennsylvania seems to be moving toward implementation of these delivery system reforms.
Money Follows the Person (MFP): MFP is an existing demonstration program in which Pennsylvania participates. Its goal is to facilitate the relocation of eligible individuals receiving ongoing care in institutions back to the community.  MFP provides increased federal matching funds for HCBS provided to individuals in the first year following relocation from an institution.  The ACA enhances MFP by reducing the institutional length of stay requirement from six months to 90 days and extending this demonstration through 2016. However, the program seems to be moving at a glacial pace both in Pennsylvania and nationally.  See,
Health Homes: Under the ACA states have the option to enroll Medicaid beneficiaries with chronic conditions into a health home to better coordinate care across providers. States who implement this option receive enhance federal funding for two years.
Medicare-Medicaid Coordination Office (MMCO) & Center for Medicare and Medicaid Innovation (CMMI): The over 9 million individuals who are eligible for both Medicaid and Medicare are referred to as “dual-eligibles.” Dual-eligibles account for a disproportionate share of the costs of both programs.  While duals represent only 15 percent of Medicaid enrollees, they account for 39 percent of Medicaid costs. The ACA permits greater integration of funding and services for dual-eligibles. 

MMCO is a new office within CMS whose goal is to better align Medicare and Medicaid for those who are eligible for both programs. The CMMI was created to research, develop, test, and support state efforts to implement innovative payment and delivery arrangements that may improve quality and reduce the cost of care within Medicare and Medicaid. We can expect to see Pennsylvania test new financial models to coordinate and reduce the cost of care for our dual-eligible population.  (Michael Hall, former Pennsylvania Secretary of Aging, is now the Director of the Integrated Health Systems in CMS’ Medicaid and CHIP office.)

Perhaps the resolution later this month of some of the uncertainty created by the legal challenge to the Affordable Care Act will clear the way for states like Pennsylvania to begin experimenting with more of these new innovative ways to deliver long term care in the community 

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