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  1. Medicaid funded long-term services and supports for people with disabilities Colleen Horton Hogg Foundation for Mental Health The University of Texas at Austin July, 2010

  2. What I was asked to do… • Explain Medicaid funding for long term services and support. • Talk about all the waiver programs offered 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.

  3. Medicaid(Much of the Information in this presentation taken directly from the DADS website) • 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 • Eligibility • Individuals receiving TANF and SSI • Individuals receiving waiver services • Individuals meeting income and disability criteria • Emergency Medicaid Services

  4. People with disabilities 30 % or the Medicaid Population 58% of Medicaid Costs

  5. Medicaid State PlanThe State’s contract with the feds • Entitlement (no waiting list) • Mandatory Services • Optional Services • Mandatory populations • Optional Populations • Texas Medicaid and CHIP in Perspective 2009 - http://www.hhsc.state.tx.us/medicaid/reports/PB7/PinkBookTOC.html

  6. Mandatory services • Family planning services • Skilled nursing • Children’s vaccines • Nursing facility care • Home health care • Rural Health Clinics • Nurse practitioners • Home health care • Rural health clinics • EPSDT-Texas Health Steps • Inpatient/Outpatient hospital care • Physician services • Nurse midwife services • Nurse practitioner • FQHCs • Lab & xrays • Prenatal care

  7. Optional Services • Renal dialysis • Rehabilitation (chronic mental illness, physical, development) • Targeted case management • Medical transportation • Optometry • Podiatry • Emergency hospital services • Licensed professional counselor (LPC) • Durable medical equip. • PT, OT, Speech • Personal care services • Dental services • ICFMR • IMDs (under 21, over 65) • Private duty nursing (under 21) • RX drugs (3 per mo.) • Unlimited RX in nursing facilities, ICFMR, managed care • Birthing center

  8. Populations Covered • TANF recipients • Families based on age, income, and assets • Newborns up to 12 months whose mother is Medicaid certified 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 significant medical bills (Medically needy/spend down) • SSI recipients (aged, blind and disabled)

  9. Optional populations • Individuals receiving Primary Home Care services (up to 300% of SSI income limit) • Individuals receiving waiver services • Childless adults (not covered in Texas)

  10. Children in medicaid Some things are different 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)

  11. Nuts and Bolts • 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

  12. CHIP Children’s Health Insurance Plan • 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

  13. how to enroll in CHIP • 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

  14. MAXIMUM MONTHLY INCOME LIMITSFOR HEALTH CARE COVERAGE PROGRAMS FOR CHILDREN Source: HHSC Financial Services, 2007 Medicaid Expenditures,

  15. STAR • Managed care – acute care • STAR+Plus • Managed care – acute care and long term services and supports • PCCM (Primary Care Case Mgt.) • Primarily in rural areas • Northstar • Behavioral health managed care • Dallas/Ft. Worth • IDD Pilot – current study ManagedCare

  16. Community Safety Net Services39 MHMR Community Centers • MRA • Service coordination • Respite • Employment services • Flexible services • LMHA • Children’s mental health services • Adult mental health services • Crisis services • State hospitals

  17. 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

  18. Medicaid 1915(c) Waivers • State/Federally funded • Community-based long term services and supports • State must submit a waiver application to CMS • Texas has too many waivers! Nine different (1915(c) waivers with different 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)

  19. Texas 1915(c) Waiver Programs • 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.

  20. Waiver interest lists

  21. Time on the interest list/March 2010http://www.dads.state.tx.us/services/interestlist/

  22. 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). Class Community Living Assistance supports and Services

  23. CLASS Eligibility requirements • 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

  24. Services available in CLAss • Psychological Services • Behavioral supports • Respite care • Specialized therapies • Medical supplies • Support family services • Adaptive aids • Case management • Habilitation • Minor home modifications • Nursing services • OT, PT, Speech

  25. How to apply for class waiver services • 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 offered (slot is available).

  26. Utilization review/increased costs • 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

  27. 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. HCS Home and Community-based Services

  28. HCS Eligibility • 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

  29. Services available in HCS • Nursing • Dental treatment • Respite • Supported employment • Day habilitation • Residential Services • Supported home living • Foster/companion care • Supervised home living • Service Coordination • Adaptive aids • Minor home modifications • Counseling and therapies • Speech, OT, PT • Audiology • Dietary • psychological

  30. How to apply for HCS waiver services • 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!

  31. Utilization review/increased costs/waiting list • 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.

  32. 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. MDCP Medically Dependent Children’s Program

  33. MDCP Eligibility • 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

  34. Services Available in MDCP • Respite • Adjunct support services • Adaptive aids • Minor home modifications • Transition services

  35. How to apply for MDCP services • 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!

  36. Utilization review/waiting list • 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)

  37. 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. DBMD Deaf/Blind Multiple Disabilities

  38. Eligibility for DBMD Disability/Functional • Meet ICFMR or related conditions care criteria. Have deaf-blindness with a third disability resulting in a need for one or more services. Financial • Must meet Medicaid eligibility. • Have an individual plan of care that does not exceed specific limits.

  39. Services available in DBMD • Intervener • Nursing services • OT, PT, Speech • Orientation & mobility • RX • Respite care • Supported employment • Transition assitance • Adaptive aids • Medical supplies • Assisted living * • Behavior support • Case managements • Chore Provider • Employment assistance • Minor home mods • Habilitation

  40. How to apply for dbmd waiver services • Call 1-877-438-5658 and ask for the DB-MD waiver representative.

  41. Utilization review/waiting list • 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)

  42. This 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. CBA Community Based Alternatives

  43. Eligibility for cba Disability/functional • be at risk of entering a nursing facility, • be 21 or older • Must 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

  44. Services available in cba • OT, PT, Speech • Personal assistance services • Respite care services • Dental services • Unlimited RX • Transition assistance services • Adaptive aids • Medical supplies • Adult foster care • Assisted living • Emergency response services • Home delivered meals • Minor home mods • Nursing services

  45. How to apply for cba services • Call your local Department of Aging and Disability Services Office. • DADS local offices can be found at: http://dads.state.tx.us/contact/combined/cfm • Call 211

  46. Utilization review/waiting list • 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)

  47. 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). CWP Consolidated waiver program

  48. CWP eligibility • No age limit • Must currently be on an interest list 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 specific institutional level of care criteria for an ICF-MR/RC, or • Must meet medical necessity determination for nursing facility services.

  49. Services Available in CWP • 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. • 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

  50. How to apply for cwp services • Contact local Department of Aging and Disability Services office. • DADS local offices 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