Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group

1. Trends in Health Care Impacting Services for Individuals with Intellectual & Developmental Disabilities Barbara Coulter Edwards Director Disabled and Elderly Health Programs Group Center for Medicaid, CHIP and Survey & Certification Centers for Medicare & Medicaid Services November 29, 2011

2. State Fiscal Conditions

3. Medicaid Spending & Enrollment

4. 5% Drive 55% of Medicaid Expenditures

5. Long-Term Care Expenditures Dominate Top 5%

6. State Response to Fiscal Pressures • Benefit redesign and modification; rate reductions • Payment reform to drive systems change and outcomes • Increased movement toward integrated systems of care (holistic approaches) • Transformation of long-term services and supports

7. Integrated Care • Primary Care/Acute Care/Long-term Care • Physical Health/Behavioral Health • Medicare/Medicaid

8. Integration Models • Managed Care Organizations • Accountable Care Organizations • Health Homes • Patient Centered Medical Homes

9. Supports for Integration • Primary care provider increase (2013) • Payment reforms • No payment for HACs • Center for Medicare and Medicaid Innovation • Medicare-Medicaid Coordination Office (“Duals”)

10. The Current Landscape: Medicaid Long-Term Care • 35% of total Medicaid spending; $115 billion in 2010 • Institutional LTC still the entitlement • HCBS spending in 2010 - $57 billion • 63% in section 1915 waivers • Not all populations have equal access to HCBS • Systems often fragmented and complex to navigate

11. I/DD Leads Physical Disability and MH in HCBS Waiver Spending (Billions)

12. Federal HCBS Spending Doubles ICF/ID Spending in 2009

13. LTSS System Transformation • A key element of effective cost management • Key to State compliance with obligations under Olmstead/ADA • CMCS offering TA to leverage ACA and other available tools of transformation • Expectations around managed care for individuals living with chronic and disabling conditions

14. Tools for Transformation under the Affordable Care Act • Efforts underway to implement new opportunities created under the Affordable Care Act • Health Homes for Individuals with Chronic Conditions • Community First Choice State Plan Option • Balancing Incentive Program • Expansion and increased flexibility of current Medicaid programs • Money Follows the Person • 1915(i) State Plan Option

15. Additional Supports for Transformation • Real Choice Systems Change Grants – housing collaboration • PHI State Data Center on Direct Workforce • Taxonomy • Balancing Indicators • ADRC & MFP Supplemental Grant opportunity

16. The Foundation for a Redesigned Service System for Individuals with Chronic Conditions

17. Significant Challenge in Systems Change – Defining HCBS • What is a home and community-based setting? • 1915(c) - HCBS Waiver program • 1915(k) – Community First Choice State Plan • 1915(i) – HCBS State Plan

18. Various Populations = Varying Views

19. Various Stakeholders = Varying Views

20. Americans with Disabilities Act • Requires that when a state provides services to individuals with disabilities, it must do so “in the most integrated setting appropriate to their needs.”

21. DOJ Technical Guidance- 6/23/11 • Integrated settings are those that: • Provide individuals with disabilities opportunities to live, work, and receive services in the greater community, like individuals without disabilities; • Are located in mainstream society; • Offer access to community activities and opportunities at times, frequencies and with persons of an individual’s choosing; • Afford individuals choice in their daily life activities; and • Provide individuals with disabilities the opportunity to interact with non-disabled persons to the fullest extent possible.

22. Segregated Settings • According to the DOJ guidance, segregated settings often have qualities of an institutional nature. These settings include, but are not limited to: • Congregate settings populated exclusively or primarily with individuals with disabilities; • Congregate settings characterized by regimentation in daily activities, lack of privacy or autonomy, policies limiting visitors, or limits on individuals’ ability to engage freely in community activities and to manage their own activities of daily living; or • Settings that provide for daytime activities primarily with other individuals with disabilities.

23. Opportunities in Challenging Times • This is a time of unprecedented opportunity to transform the system of care for individuals with disabilities • Efficiencies in Program Design and Development • Increased focus on coordination to achieve improved care, improved experiences of care, and cost savings • Incentives and additional programs to provide for home and community-based services