The Home and Community-Based Services (HCBS) Partners Panel’s Aging Workgroup met on October 13 to get the first review of the direction staff from the Department of Human Services (DHS) is considering for the waiver reform initiative. As background, during the special session this past summer, significant language was included in the omnibus health and human services bill that provides for reform of the state’s Medical Assistance program, organized as projects for a large federal change request. The HCBS Partners Panel is dividing into workgroups to provide feedback into the process — Association staff are participating in both the Aging and Disabilities workgroups, as well as the HCBS Partners Panel. Because of the significant nature of this work, we are requesting feedback from our committees and are posting several of the documents released at these meetings on our website.

The recommendations are due to the Legislature by January 2012, and they must be budget-neutral overall. One key area that will require more review and understanding is defining what is meant by budget-neutral (i.e., what are the parameters of budget neutrality — aging programs, disability programs, health care spending, etc.).

The Aging Workgroup topics on October 13 included: nursing facility level of care, reform benefit sets for publicly-funded aging services, consumer directed services, and point-of-entry development. In advance of the meeting, a SNAP survey was sent out to solicit ideas for a redesign of HCBS — we forwarded that survey to several committees and encouraged them to fill it out. A total of 125 responses were received statewide, with the majority of the feedback organized around services for persons with disabilities (summary of survey results can be found on our website here under the HCBS Partners Panel heading). We suggested at the meeting that the survey’s short turn-around time as well as the vagueness of the survey — five open-ended blanks to fill in ideas — may have contributed to the low response rate. We encouraged the development of another survey with more specific questions and a longer response period as they further develop some of their ideas. Here is a recap and background materials from the October 13 meeting:

   I. Nursing Facility Level of Care:
A separate workgroup is re-convening on this topic. In 2009–2010 a workgroup met to begin the discussions of how to transition, and how to plan for a “soft landing” for those who would no longer be eligible for nursing facility services or waiver benefits. We have staff and several members on this workgroup; however if you are interested in participating, contact Todd Bergstrom at 952-851-2486. If Minnesota does not get federal approval to implement this new level of care, an additional 1.67% rate cut will be applied to provider rates and grants (excluding nursing facilities) from July 1, 2012 to December 31, 2013. According to the DHS analysis, the percentage of individuals who will lose waiver eligibility with the new criteria is as follows: 3% CADI, 13.3% elderly waiver, and 8.6% alternative care. Similar data was not presented on how the level of care requirements will reduce nursing facility caseload. However, we are now assuming a significant reduction in nursing facility caseload from the number currently projected in the forecast (for 2015 monthly average recipient Medicaid caseload) of 16,708 to the caseload estimated under the new reformed benefit set of 14,224. We are assuming much of this reduction in caseload is due to the new level of care proposal — a nearly 15% decline.

   II. Reform Benefit Sets:
DHS envisions changing which services should be an entitlement, and which services will require approval. Rather than having one set of level of care criteria to approve eligibility for alternative care, CADI, elderly waiver and nursing facility programs, level of care would be used to approve clients for alternative care, CADI, and the elderly waiver program (non-residential and residential). Access to a specific benefit, including nursing facility care, would vary according to the specific needs of the client. In their graphics (posted on our website here under the HCBS Partners Panel heading), the entitlement services include essential community supports, elderly waiver non-residential, and elderly waiver residential. For essential community supports, individuals would have very low and low activities of daily living (ADL) needs, no behaviors, and no special nursing needs; the projected caseload for 2015 is 1,778. For the non-residential elderly waiver program, clients would have medium ADL needs, some behavior interventions required, some special nursing treatments and monitoring; they estimate a caseload of nearly 12,000. The elderly waiver residential program has a projected 11,000 caseload by 2015, and includes clients with medium and high ADLs, medium to high behavior, high need for assistance with eating, and special nursing needs. Nursing facilities are NOT included as an entitlement under this benefit set redesign. Clients in nursing facilities would be eligible for any of the waivers, but to be eligible for a nursing facility stay would need to reach the threshold of high ADL needs and special nursing and/or high behavior; hospital substitute; rehabilitation. 2015 caseload estimates for this level of care are 14,224 (down from today’s projection of nearly 17,000).

When questioned about assumptions, and whether there was a cost-benefit analysis on the various “silos,” DHS staff responded that they are securing a contract with an outside firm to look at the data set and to conduct this cost-benefit analysis. They acknowledged that there could be circumstances where the per-person costs are greater in a home setting compared to a nursing facility setting, and their contract would include this review.

   III. Consumer Directed Services:
The DHS 1915 (j) Consumer-Directed Advisory Task Force Final Report issued in October 2008 forms the basis of the recommendations for this reform. DHS is working on revising the budget methodology and redesigning the administrative functions between the fiscal support entity and lead agencies.

   IV. Point of Entry Development:
A separate initiative from the long-term care consultation (LTCC) expansion (aka mandatory transitional consultation) is the expansion of the Chisago County pilot where calls go into the counties and are referred seamlessly to Senior LinkAge Line counselors as needed. Other changes to expect under this category are increases in the use of virtual call centers, and a proposal to move the LTCC funding mechanisms away from the nursing facility payment rates to a separate mechanism.

At the next meeting of the Aging Workgroup, topics will include services for complex and high-cost individuals; employment supports and benefits planning; assisted living without walls; health care reform and care transitions; and health care homes.

Patti Cullen, CAE
952.851.2487
pcullen@careproviders.org

Our Sponsors