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)

30 % or the Medicaid Population

58% of Medicaid Costs

PEOPLE WITH DISABILITIES

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

If you need more information feel free to contact me at:

colleen.horton@austin.utexas.edu

THE END