HMA HealthManagement.com

Barbara Coulter Edwards

July 15, 2015

National Alliance to End Homelessness

Federal Medicaid: Supportive Housing Policy

Creating Medicaid Opportunities in States

HMA

• Federally designed; state administered (optional program) health coverage program

• Jointly funded state/federal (50-74% federal)

• 70 million people

– Lower income children (up to 300% FPL via Children’s Health Insurance Program)

– Adults up to 135% FPL (varies by state)

– Low income elders and people with disabilities

– Nursing facility residents whose income < costs

– People with disabilities who can work

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Medicaid

HMA

Expansion States

• Medicaid expansion under Affordable Care Act – all adults up to 135% FPL

• 29 states (including D.C.) have expanded

– Six of these states used “waivers” to tailor expansion parameters

• Newly eligible adults vary by state, but generally includes higher proportions of individuals with BH

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Projected Number of Medicaid Enrollees

4 Source: Actuarial Report On The Financial Outlook For Medicaid, CMS, 2013

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• $544 billion projected 2015 (plus > $10 billion for CHIP)

• Comprehensive primary, acute, behavioral health, pharmacy benefits (varies by state) – Essential Health Benefits for expansion adults

– MHPAEA applies for some Medicaid populations

• Institutional and home/community based long term care services and supports (varies by state)

• Wraps around Medicare for low income beneficiaries

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Medicaid

HMA

Medicaid and MH

• Medicaid is single largest source of BH care payments in U.S. (26% in 2011)

• Over half of all of the public financing for BH services

• Provided through available Medicaid services: “physician”, “hospital”, “pharmacy”, “rehabilitation”, “other licensed professionals”, etc.

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HMA

Medicaid Expenditures: LTSS

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National 2013

Acute Care*

LTSS

DSHospital

28.1%

68.2% *

*Includes MCO expenditures

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Medicaid: a Partner in Ending Homelessness

• Health-related complications for chronically homeless populations are common

• Housing often a critical factor in supporting successful treatment and recovery

• Success requires linking services with housing, timely

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HMA

Housing-Related Service Options

• Housing Transition Services – support an individual’s ability to prepare for and transition to housing – Tenant screening and housing assessment

(individual’s preferences and barriers to successful tenancy)

– Develop individualized housing support plan and housing support crisis plan

– Assisting with application and search process

– Identifying resources to cover expenses, assisting in move

– Ensuring environment is safe and ready for move-in

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HMA

Housing-Related Services Options

• Housing and Tenancy Sustaining Service – support individual to maintain tenancy

– Early identification and intervention for behaviors that may jeopardize housing

– Education on rights and responsibilities

– Coaching on relationship with landlords

– Advocacy and linkage with community resources to prevent eviction

– Assistance with housing recertification process

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State-Level Collaborative Activities

• Medicaid can support (administrative activities) strategic activities to assist in identifying and securing housing resources – Developing agreements with state and local housing

and community development activities to facilitate access to new and existing housing resources

– Participating in the planning processes of state and local housing and community development agencies

– Working with housing partners to create and identify opportunities for additional housing options (e.g., coordinating housing locator systems)

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HMA

Important Medicaid Policies

• Community integration is a right under the ADA – driving Medicaid LTSS reform

• Federal standards for settings in which HCBS are received

• Individuals are not eligible for Medicaid financing when a patient in an Institution for Mental Disease

• Most Medicaid enrollees are in Managed Care arrangements for some/all services

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HMA

July 26, 1990 Americans with Disabilities Act signed by President George H.W. Bush

Civil rights legislation that “prohibits discrimination and guarantees that people with disabilities have the same opportunity as everyone else to participate in the mainstream of American life.” (DOJ)

Olmstead decision: right to receive services in “most integrated community setting”

ADA Anniversary: 25 Years

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• Institutional (nursing home) care is mandatory service; home and community based alternatives to nursing facilities are optional

• Goal: elders and others with disabilities have choice to receive long term services and supports at home, in community

• LTSS should be person centered, consumer driven

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Medicaid Goal: Transform LTSS

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Home and Community-Based Services (HCBS) is 49.5% of LTSS

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82% 81% 76% 75% 74% 73%

70% 70% 67%

65% 63% 61%

59% 57% 55%

52% 52% 50.5%

18% 19% 24% 25% 26% 27%

30% 30% 33%

36% 37% 39%

41% 43% 45%

48% 48% 49.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Institutional

HCBS

Medicaid Institutional and HCBS Expenditures as a Percentage of Total Medicaid LTSS Expenditures, FFY 1995 - 2012

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Decreasing Isolation

Increasing Integrated

Life

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HCB Settings Challenge

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Integrated in and supports access to the greater community

Provides opportunities to engage in community life, seek employment and work in competitive integrated settings, control personal resources

Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services

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HCBS Settings Requirements

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Is selected by the individual from among setting options, including non-disability specific settings

Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint

Optimizes individual initiative, autonomy, and independence in making life choices

Facilitates individual choice regarding services and supports, and who provides them

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HCBS Settings Requirements

HMA

Legally enforceable lease or other written agreement (same responsibilities/protections from eviction as all tenants under local landlord tenant law)

Privacy in their sleeping or living unit

Choice of roommates, freedom to furnish and decorate their units

Freedom and support to control their schedules and activities; access to food and visitors at any time

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If Provider Owned or Controlled Residential Setting

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Settings in a facility providing inpatient treatment

Settings on grounds of, or adjacent to, a publicly owned or operated institution

Settings which have the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS

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Presumed NOT to be HCB

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Institution for Medicaid Disease

• Under the IMD payment exclusion, Federal Medicaid funds cannot be used for most patients in mental health and substance use disorder residential treatment facilities larger than 16 beds.

• Judged by “overall character” of an institution established and maintained for care and treatment of individuals with mental disease, regardless of licensure.

• Considers characteristics of staff, services, and residents

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Medicaid Managed LTSS Activity in 2014

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Resources

• http://www.medicaid.gov/federal-policy-guidance/downloads/CIB-06-26-2015.pdf - Informational Bulletin on Housing-Related Services

• http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html - links to HCBS regulations, guidance

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