Providing Community-Based Long Term Care Services Under Medicaid Options for Tribal Communities

1. Providing Community-Based Long Term Care Services Under MedicaidOptions for Tribal Communities Dorothy Dupree, Director Tribal Affairs Group, CMS Dorothy.Dupree@cms.hhs.gov Anita Yuskauskas, Ph.D. Technical Director of HCBS Quality Center for Medicaid and State Operations, CMSAnita.Yuskauskas@cms.hhs.gov Priya Helweg, Policy Analyst Tribal Affairs Group, CMS Priya.Helweg@cms.hhs.gov

2. Beginning the Dialogue • Part 1 • AoA Listening Session • Part 2 • AI/AN Long Term Care Conference (Albuquerque, NM September 5-7, 2007) • National Indian Health Board Consumer Conference (Portland, OR September 24-28, 2007)

3. Changing LTC LandscapeInstitutional to Community Based

4. Source: Based on CMS/HCFA 64 data provided by The Medstat Group, Inc Institutional services are nursing facilities and ICF/MR. Community services are state plan home health and personal care and HCBS waivers (the latter two starting in 1985). Expenditures were adjusted for price increases based on the Skilled Nursing Facility Input Price Index developed by CMS, Office of the Actuary.

5. CMS Programs and LTC in Indian Country

6. CMS Shares Trust Responsibility Indian Health Care Improvement Act (IHCIA) • IHS bills for Medicare and Medicaid services • Only federal agency to bill another federal agency • IHS is payer of last resort • 100% FMAP

7. Title XIXMEDICAID Sec. 1905b “The Federal medical assistance percentage [FMAP] shall be 100 per centum with respect to amounts expended as medical assistance for services which are received through an Indian Health Service facility” 1996 Memorandum of Agreement between IHS and CMS to pay States 100% FMAP for Medicaid payments for services provided by facilities operated by tribes/tribal organizations under self-determination authorities.

8. 1996 Memorandum of Agreement • IHS maintains the list of IHS facilities and 638 programs eligible for 100% FMAP • Provided to CMS and State • State receive 100% FMAP for services rendered through a facility on this list.

9. Understanding Medicaid • Joint State and Federal • States authority • State ultimately accountable for program • State may delegate administrative authority to varying degrees to other entities.

10. Home & Community Based ServicesOpportunities

11. Key CMS LTC Community Based Programs • 1915(c) Waivers • Deficit Reduction Act State Plan Options • 1915(i) HCBS state plan option • 1915(j) Self-directed personal care option • Money Follows the Person (MFP) demo grants • Program for All Inclusive Care for the Elderly - PACE

12. HCBS Waivers: Section 1915(c) • In 1981, with Section 2176 of the Omnibus Budget Reconciliation Act of 1981, the home and community-based services (HCBS) waiver program was established. • Provides community based long-term care and support as an alternative to institutional placement. • Statutory authority can be found in Section 1915(c) of the Social Security Act.

13. HCBS Waivers National Overview • 284 Waiver Programs • More than 1 million participants • $21.2 Billion • 7.5% of total Medicaid spending • 24% of all Medicaid long-term services spending • 67% of all Medicaid community service spending

14. Number of Active Waivers Per State WA - 7 VT - 4 ME 3 MT - 3 ND - 3 MN 5 OR- 5 ID 4 NH - 4 WI 8 NY 8 SD - 4 MI 3 MA - 3 WY - 5 IA 6 RI - 7 PA - 11 NE - 7 NV 4 OH 7 CT - 7 IL 7 UT 5 IN 8 NJ - 8 CA 7 WV 3 CO - 10 VA 8 MO 7 DE - 6 KS - 6 KY - 4 MD - 7 NC - 7 TN - 6 NM 4 OK - 5 AR 6 DC - 3 SC - 6 AL 7 GA 5 MS 5 TX 11 LA 5 FL 12 AK 4 HI -5

15. Section 1915(c)Waiver Programs Waives: HCBS programs allow a State to waive certain provisions of the Social Security Act. • Statewideness • Comparability of services • Income and resource requirements

16. Characteristics of HCBS Waivers Beneficial to AI/AN Communities • Waiver of statewideness • 100% FMAP possible – case by case basis • Full range of LTC like services • Consultation Between State and tribes • Case Management

17. The HCBS State Plan Option: DRA Section 1915(i) • Effective January 1, 2007 • States can amend their state plans to offer HCBS as a state plan optional benefit. • Breaks the “eligibility link” between HCBS and institutional care • Individualized care plans • Other program attributes

18. HCBS Covered Services - both 1915(c) and 1915(i) • Case Management • Homemaker/chore • Home health aide services • Personal care • Adult day health • Habilitation • Respite care

19. HCBS Covered Services - both 1915(c) and 1915(i) • For persons with chronic mental illness • Psychosocial rehabilitation services • Clinic services • Day treatment or other partial hospitalization services • “Other services” - only 1915(c)

20. State Plan Option for Self-Directed Personal Care DRA Section 1915 (j) • New, simplified application • States may opt to offer self-directed personal care services, including those offered by family members • Provide items that increase independence or substitute for human assistance • Individualized budgets • Incorporate participant direction into existing or new HCBS waivers.

21. State Plan Option for Self-Directed Personal Care DRA Section 1915 (j) • Can waive both Statewideness & Comparability: • target populations, limit numbers and limit by geographic areas. • Requirements for • Evaluating consumer’s need for personal care • Safeguards for health, welfare and financial accountability • Annual reports and periodic evaluations

22. Planning Budgeting Spending Service Delivery …Are individualized and directed by the person and those closest to him or her HCBS Self-Direction

23. HCBS + Self-Direction Means: • Services can be sensitive to culture, traditions & community • Families stay intact; people can hire family members • Supports separate from housing • Individuals & their families determine what is best, not the funder

24. 2007 Money Follows the Person (MFP) • MFP Rebalancing Demonstration • Real Choice Systems Change grants • Comprehensive, coordinated strategy • Assist States, in collaboration with stakeholders • Widespread changes to their long-term care support systems • http://www.cms.hhs.gov/RealChoice/

25. PACEProgram of All-Inclusive Care for the Elderly Key Components • Focus on Frail, Nursing Home Eligible Population • Comprehensive Medical and LTC Services • Integrated Team Management Care • Integrated Medicare and Medicaid Financing • Provider Assumption of Financial Risk • http://www.cms.hhs.gov/pace/

26. Waivers and Indian Country • Medicaid money must flow through the state; • Tribe(s) may explore an agreement with State agency • Can waiver state-wideness and designate geographic area, ex., a Reservation • Tribe(s) may tailor services and provider qualifications (can be specific to a tribe) • 100% FMAP for HCBS services under compacting - 638 Authority

27. Exploring Tribal / State Administrative Partnership Options Examples - options for assuming authorities delegated by State Medicaid Agency

28. Accessing HCBS Long Term Care Services • Eligible Tribal Memberscan apply to be consumers for benefits in their area. • Qualified Tribal Providerscan contract with the State or administering agency as a waiver provider or to perform certain administrative functions. • Tribal Governmentscan perform a wide range of administrative functions re HCBS program operations on behalf of the State Medicaid Agency.

29. Tribal Management of HCBS in Minnesota - Elderly Waiver…A Promising Practice The State of Minnesota contracts with the White Earth Nation to provide eligibility determination for and case management of Medicaid and state-funded home and community-based services to persons aged 65 and older who live on their reservation. • http://www.cms.hhs.gov/PromisingPractices/Downloads/mnltctribal.pdf

30. Next Steps • Tribal Programs Assessment • Tribal Communities Needs Assessment • Tribal Resources Inventory • Define Tribal Role • Understand State Programs & Opperations • Begin dialogue with State • Proposal to the State • CMS provides technical support • Native American Contact in each Region

31. CMS HCBS Web Sites • http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/05_HCBSWaivers-Section1915(c).asp