On April 27, 2011, the commissioner of the Department of Human Services (DHS), Lucinda Jesson, issued a letter to the chief conferees for the Health and Human Services (HHS) conference committee spelling out the 41 major concerns the department has with the HHS bill. The concerns are many, and reflect the gulf between the proposals currently on the table. The HHS bill also carries the bulk of the $1+ billion hole in the overall legislative budget proposal—$772 million in the House version and $600 million in the Senate version, mainly tied to either overstated savings or provisions that cannot be implemented. We won’t share with you all 41 of the concerns, but the following concerns were identified under the continuing care section, which starts with concern #15. Read the full letter and disputed numbers sheet on our website.

15. Waiver caps for people with disabilities. The House proposal freezes enrollment in three disability waivers, then reduces the number of people served to the level of enrollment in March 2010. The proposal results in close to 5,800 people being unable to access waiver services and 1,250 people forced into nursing homes to receive care. This is an unprecedented level of reduction that affects Minnesota’s most vulnerable citizens. Freezing growth will impact individuals moving from institutions to the community, including those seeking to leave institutions such as Anoka or Cambridge State Operated Services, or specialty hospitals, such as Bethesda. It also eliminates a safety net that otherwise diverts people from institutions and other costly deep end services, that will affect aging parents who reach a point where they need assistance for their adult child with a disability, or families coping with a spouse or family member with an acquired disability (e.g.: MS, a spinal cord injury, or a brain injury). The Senate proposal freezes waiver growth at the June 30, 2011 level, but does allow reuse of existing funds. This limit would also significantly impact people’s ability to return to or remain in the community. Although both proposals keep the state at the minimum maintenance of effort (MOE) required to meet federal requirements, either proposal may still be challenged in court as a violation of the Americans with Disabilities Act, as further clarified in the precedent-setting U.S. Supreme Court’s Olmstead decision.

16. Suspend growth in the elderly waiver. Elderly waiver pays for home and community-based services for people who need long-term care services and are at risk of going into a nursing home. The program serves people at a much lower cost than a nursing home. Although the proposal to cap the elderly waiver saves several million dollars per year, it results in approximately 256 people entering nursing homes over two years. In particular, people who are currently spending down their own assets in an assisted living setting will not be able to access elderly waiver funding once their assets are depleted. Currently 30% of all people who enter elderly waiver already live in an assisted living setting. So, on average, 122 people per month will find themselves in this situation. If they are unable to access elderly waiver funding, most would have little choice other than to move to a nursing home, because they no longer have homes of their own.

17. Nursing facility rate equalization phase-out. The House proposes to allow nursing facilities to charge rates to private pay residents higher than the rates determined by MA by up to 8%, subject to actual costs, phased in over four years. The Senate eliminates the limitation altogether, after a four year phase-out. This will result in more rapid spend-down to MA eligibility and therefore, to higher nursing facility case loads. It will also create an incentive to discriminate in admissions against individuals who are MA eligible. This discrimination results in reluctance by some elderly to use their resources for home and community-based services because they will want to preserve resources to be able to access a preferred nursing facility. DHS opposes the repeal of rate equalization.

18. Lack of funding for federal compliance eligibility changes. The American Recovery and Reinvestment Act (ARRA) and the Affordable Care Act (ACA) prevent states from implementing more restrictive eligibility standards, methodologies or procedures for Medicaid (as well as for CHIP, the federal Children’s Health Insurance Program) than those that were effective on July 1, 2008, and March 23, 2010, respectively. Eligibility changes passed by the 2009 legislature were delayed in 2010 to avoid violating the ARRA requirement. However, the ACA extends the MOE requirement until January 1, 2014 for adult eligibility groups and until September 30, 2019 for eligibility groups containing children. The Governor’s budget proposed to delay the eligibility changes to comply with federal law and avoid federal penalties. The Senate bill does not delay these eligibility changes, putting the state in violation of federal law requirements. The House bill includes the policy language to enact the needed delays but does not track the costs in its spreadsheet, putting the MA forecast at risk.

19. Reduction to Senior LinkAge Line. Aging Prescription Drug Assistance grants provide 50% of the funding for the Senior LinkAge line. Eliminating these grants will cut in half Senior LinkAge Line’s capacity to take calls statewide and to administer a targeted program that helps elderly people return to their own homes following a nursing facility stay. These services provide assistance to elderly people and their families that help people find home and community-based services to meet their needs and to avoid or delay more expensive institutional care. By fiscal year 2013, eliminating this grant will result in a net cost annually to the general fund.

20. Proposal to eliminate personal care assistance (PCA) alternative grant. The House proposal eliminates the appropriation for grants to provide alternatives for those recipients losing access to PCA services due to July 1, 2011 changes in program access criteria. Legislation in 2009 required the development of a less expensive alternative, preferably with federal match, to serve people no longer eligible for PCA. Without the grant funding, the proposed plan (included in the Senate bill) to serve children and adults with behavior and mental health needs, and adults who need assistance to live independently, will not be implemented and there will be additional offsets as people use more expensive services.

21. Eliminate caregiver support grants. The Senate proposes eliminating all state-funded caregiver grants ($456,000 per year). These funds serve as match for the federal Older Americans Act funding. Without this match, the state stands to lose $2.1 million in Older Americans Act federal funding annually. Caregiver grants serve 8,436 people and families annually with service such as in-home respite, caregiver counseling, disease progress education, and supplemental services. All are designed to support the caregiver as they have defined the support needed in order to prolong their caregiving career.

22. Eight-bed provision under the disability waivers: The House proposal requires DHS to seek waiver amendments to all of the disability waivers to allow up to eight people to live together in existing residential buildings. Minnesota has moved away from using larger congregate settings in favor of smaller settings with four or fewer people. This was a deliberate policy decision that reflects a move toward more cost-effective service delivery options, and policy that supports the Americans with Disabilities Act. Because of the increased occupancy in eight-bed buildings, they would no longer meet standards for foster care licensure, and these settings must be licensed as a supervised living facility (SLF) by the Department of Health. As such, these settings would not be subject to the corporate foster care moratorium, and would therefore lead to increased program costs.

23. Six-month reassessments. The House proposal requires case managers to visit and reassess individuals’ progress toward achieving outcomes at least every six months. Concerns with this proposal include adding administrative requirements for more frequent assessments, which require more frequent billing for services. This is a duplication and expansion of current requirements, where face-to-face visits occur at least twice per year, and anytime an individual’s condition has changed a reassessment is required. We suggest that additional training around current statutory requirements may achieve the same outcome, without the requirement of a six-month reassessment.

Patti Cullen, CAE
952.851.2487
pcullen@careproviders.org

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