Federal Initiatives Impacting the Aging Network

1. Federal Initiatives Impacting the Aging Network Sandy Markwood, n4a WRAAA Annual Luncheon May 10, 2012

2. Today’s Agenda Long-Term Services and Supports Systems Transformation Implementation of the Affordable Care Act Older Americans Act Reauthorization Update The Federal Budget Process FY13 Appropriations Outlook Advocacy Strategies- Letting Your Voice be Heard!

3. LTSS Systems Transformation Medicaid Managed Care, Dual Eligibles, HCBS

4. State Agency Restructuring State Agencies that have restructured since 2009 FL Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

5. Population Growth Shifting Demographics Also Contribute to Increased Demand Source: This table was compiled by the U.S. Administration on Aging using 2000 Census data

6. Population Growth While the number of persons with disabilities is also increasing Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

7. What is Medicaid Managed Long-Term Care? MMLTC is Delivery Model States Use in Lieu of Fee-for-Service Capitated MMLTC • State Medicaid Agency and contractors enter into agreement under which contractor accepts risk of providing defined Medicaid LTC services • Alternative types of MMLTC capitation packages: • Medicaid-covered LTC services only • All Medicaid-covered acute and LTC services • All Medicare and Medicaid-covered services(additional plan contract with CMS required for Medicare portion) StateMedicaidAgency ManagedCareContractor Providers Capitated Payment NegotiatedPayments(FFS, Per Diem, etc.) Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.

8. Three Basic MMLTC Models Dual eligibles may also be enrolled in Medicare managed care and receive Medicaid LTC services in either FFS Medicaid, or in MMLTC Models 1 or 2 Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.

9. Medicaid Managed Care Source: On the Verge: The Transformation of Long-Term Services and Supports; NASUAD, AARP Public Policy Institute, HMA; February 2012.

10. Dual Eligibles

11. Dual Eligibles State Demonstrations to Integrate Care Green States: Through the State Demonstrations to Integrate Care for Dual Eligible Individuals program , CMS provided design contracts of up to $1 million to 15 states to develop new approaches to better coordinate care for dual eligible individuals. Maroon States: Thirty-eight states (including the 15 that received grants) submitted letters expressing interest in pursuing the demonstration program. Source: National Senior Citizens Law Center Duals Advocacy Website

12. HCBS Waivers Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

13. HCBS Waiver Expenditures

14. HCBS Waivers Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

15. HCBS Waiver Caseload Source: On the Verge: The Transformation of Long-Term Services and Supports; NASUAD, AARP Public Policy Institute, HMA; February 2012.

16. Affordable Care Act 1915(i), Community First Choice, BIPP, MFP, Health Homes

17. §1915(i) State Plan Option • Section 1915(i) State Plan Option was established in 2005 and amended by the Affordable Care Act. • Similar to §1915(c) HCBS waivers in flexible service and benefit design, but— • No requirement that people meet institutional level of care to qualify. • While states may target HCBS to one or more specific populations, they may not cap enrollment for the targeted population(s). • Few states have exercised this authority so far. However, in recent NASUAD survey: • 22 states reported consideration of §1915(i). • 3 states said they will implement—CA, IN, TX.

18. Community First Choice • Community First Choice Option gives states option to add new participant-directed state plan HCBS attendant services and supports benefit. • Participating states will receive enhanced FMAP of 6% for enrollees. • There are two levels of eligibility: • People eligible for Medicaid under State Plan with incomes up to 150% of poverty who don’t need institutional level of care. • People with incomes above 150% of poverty and up to 300% of SSI who meet institutional level of care requirements. • NASUAD’s recent survey found: • 18 states are considering participation. • 5 states definitely plan to participate—AK, AZ, CA, NY, RI.

19. Balancing Incentive Payments Program • State Balancing Incentive Payments Program (BIPP) is temporary, noncompetitive grant program to encourage states to balance Medicaid spending toward HCBS. • To be eligible, states must have spent <50% of total Medicaid LTSS dollars on non-institutional services in FY 2009. Through 10/1/2015: • States that spent <25% on HCBS will receive 5% FMAP increase for HCBS. • States that spent <50% but >25% on HCBS will receive 2% FMAP increase for HCBS. • NASUAD’s recent survey found: • 21 states considering participation. • 3 states definitely plan to participate—GA, NJ, NH. *

20. Health Homes • Health Homes are providers or a health team that coordinates care across settings for people: • with 2 or more chronic conditions, or • with one chronic condition and at risk for another, or • with one serious and persistent MH condition • States may offer these services by amending their state plans, and participating statesreceive 90% enhanced FMAP for health home services for up to 8 quarters per enrollee. • NASUAD’s recent survey found: • 14 states plan to implement (As of January 2012, 7 states had submitted Health Home State Plan amendments to CMS —IA, MO, NC, NY, OR, RI, WA. Some approved; others pending) • 10 are considering implementation • .

21. Money Follows the Person The Money Follows the Person Demonstration Program provides transition funds and enhanced FMAP for states to help Medicaid beneficiaries leave nursing homes for HCBS in community settings. Began in 2007; extended to 2016 by Affordable Care Act. 43 states + DC are currently implementing MFP. In February 2012, CMS issued invitation to the remaining states to apply for MFP planning grants.

22. State Intention to Pursue ACA Options

23. Federal Budget and FY13 Appropriations Outlook

24. What’s In The Federal Budget?(Source: Center on Budget and Policy Priorities) Funding for these two parts of the budget must be renewed each year.

25. Federal Budget Process Winter: President’s Budget, blueprint for Congress to follow…or ignore Early Spring: Congressional budget resolution sets broad parameters Late Spring/Early Summer: Appropriations committees begin work October 1: New fiscal year begins

26. Appropriations Process FED SPENDING = Entitlement spending (Medicare, Soc Sec), interest on the national debt, and then discretionary (foreign aid, domestic) funding DISCRETIONARY SPENDING • Congress has to act each year to continue funding for domestic discretionary spending • Sets up special appropriations committees by federal agency (Labor/HHS/Education) • These are the Members of Congress with great power over how much $$$ we get for OAA!

27. OAA Appropriations Have Not Kept Pace With Demand Source: NASUAD Analysis of U.S. Census data (Current Population Survey) and AGid

28. Service Demand Increased Demand for Services, SFY11 Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

29. n4a Appropriations Advocacy • OAA needs at least a 12 percent increase to keep pace with projected population growth and inflation in 2013 and begin to make up for years of stagnant funding; • Give special attention to three OAA programs, Title III B Supportive Services, III E NFSCP and Title VI Grants for Native Americans, which are particularly overdue for increases; and • See n4a 2013 Policy Priorities for other appropriations recommendations….

30. Appropriations Advocacy • Advocacy Groups send letters to Appropriations Committees • As do Members of Congress, both individually and in groups • Sanders OAA 12% Letter, 18 Signers • Requests from the field are important too!

31. Aging Program Funding (FY 2013) • President’s Budget: hold the line + addition of SHIPs, Title V, APS • OAA program funding for the most part maintained • Exception is Program Innovations

32. Status of FY 2013 Appropriations Senate Labor/HHS bill marked up as early as late May, early June But House starting from different spending level Discretionary Levels • Senate -- $1.047 trillion* • House -- $1.028 trillion • Current Year = $1.043 * Set by Budget Control Act, Summer 2011

33. OAA Appropriations Forecast: End-of-Year Storms No floor votes for approps bills, no public conference committee Continuing resolutions (CRs) until after the election at least Lame Duck Session: approps, Medicare “doc fix,” Bush tax cuts and Jan. 2013 sequester!

35. Sequester! Budget Control Act: If Congress fails to act by the end of the calendar year, $1.2 trillion in automatic, across-the-board cuts would take effect through a sequestration process Cuts expected to be 8-9% for programs like OAA Exempted programs: Social Security, Medicaid and several low-income entitlement programs. (Medicare benefits could not be cut either, but provider payments could be reduced by up to 2 percent.) Takes effect on January 2, 2013

36. Potential Impact of Sequester (In millions of dollars) Source: NASUAD analysis of projected cuts. www.nasuad.org

37. Older Americans Act in the 112th Congress

38. OAA Reauthorization

39. Reauthorization of OAA TIMELINE • AoA Listening Sessions, Winter 2010 • Groups survey members, write recommendations, release by spring 2011 • Senate HELP Subcomm holds listening sessions, summer 2011 • Act “expires” Sept. 30, 2011 • Fall 2011: AoA shares tech asst for Hill

40. AoA Suggestions Add parent caregiver of adult children with disabilities to NFCSP Consolidate nutrition programs Expand the # of programs allowed to cost-share (would still need waiver from AoA to test cost-sharing for nutrition and case management) Incentive payments to enhance Aging Network capacity LTCOP updates Establish minimum Title III funds for State Legal AsstDevel Program; states pick which if any AAAs to fund Transform Title IV

41. AoA Suggestions Increase min amt of state admin from $500k to $750k, affects low-population states Transfers Title V Senior Community Service Employment Program to AoA from Dept. of Labor Establish Senior Medicare Patrol within Title VII; from competitive grants to formulas to states III D: Allow states to fund disease prevention and health promotion services directly by grant/contract (aka not all AAAs will be funded); all programs must be evidence-based

42. n4a’s OAA Reauthorization Priorities Preserve the Act’s flexibility and person-centered approach Strengthen the Aging Network’s role and capacity in the coordination and provision of home and community-based services Expand evidence-based health promotion and disease prevention Improve community preparedness for an aging population Set adequate authorization levels

43. What are the issues under discussion? Cost-sharing Coordination (e.g., ADRCs, community health centers) Smaller programs shifting to be state-run (e.g., legal services, III D) Elder justice: APS, LTCOP

44. What are the issues under discussion? Investment in workforce, specifically home care, direct care workers Caregiver assessments Financial exploitation Home care ombudsmen programs and home care consumer bill of rights

45. S. 2037 • Consolidates $ for C1 and C2 but sets floors: 40/35/25 • Recommends increases of 50% in funding for nutrtion, supportive services, SCSEP and HPDP • Encourages collaboration with Federally Qualified Health Centers • Add “economic security” to objectives, redefine “greatest economic need” to 200% FPL • Redefines “greatest social need” to include LGBT individuals and older adults with HIV/AIDs or Alzheimer’s • Senior Center Modernization encouraged • Legal services: establishes new definition “integrated legal assistance delivery system”; boosts state’s role over current local role for AAAs And more…

46. Reauthorization of OAA TIMELINE • Sanders Bill (S. 2037) Released, January 2012 • Other Dem Senators followed with their bills (Kohl/Mikulski, Franken, Casey, Blumenthal); more to come • Senate Mark-up in June? • Merely in the queue in House

47. OAA Bills • S. 2037 Chairman Sanders (I-VT) • S. 1750 Franken (D-MN) • S. 1819 Kohl (D-WI) and Mikulski (D-MD) • S. 1982 Casey (D-PA) • S. 2077 Blumenthal (D-CT) Up next? Manchin, Bennet, others

48. Advocacy Strategies

49. Grassroots Activities Reach out to freshman MoCs to educate them about your agencies and the work you do Stay in regular contact with Members and staff Invite your local congressional offices to do site visits, attend events Participate in the federal regulatory process to make your voice heard

50. Questions? Sandy Markwood smarkwood@n4a.orgwww.n4a.org www.facebook.com/n4aACTION www.twitter.com/n4aACTION or www.twitter.com/AmyGotwals