Elderly Waiver and Alternative Care – Programs Supporting Older Adults at Home

Elderly Waiver and Alternative Care – Programs Supporting Older Adults at Home 2013 Age and Disabilities Odyssey Libby Rossett-Brown - Elderly Waiver/Alternative Care Program Administrator Gail Carlson – Alternative Care Operations June 18, 2013

Session Goals • Understand the basic concepts and policies of the Elderly Waiver (EW) and Alternative Care (AC) programs • Comparison of EW and AC Service sets • Become knowledgeable of each programs financial eligibility • AC fees and cost sharing

Acronyms • CMS Centers for Medicare and Medicaid Services • SRU Special Recovery Unit • MA Medical Assistance • EW Elderly Waiver • MCO Managed Care Organization • MSHO Minnesota Senior Health Option • MSC+ Minnesota Senior Care Plus • SIS-EW Special Income Standard-Elderly Waiver • LTCC Long Term Care Consultation • NF Nursing Facility • MNA Maintenance Needs Allowance

Acronyms • DHS Department of Human Services • LOC Level of Care • CL Customized Living • AC Alternative Care • CDCS Consumer Directed Community Supports • FFP Federal Financial Participation • HCBS Home and Community Based Services • PNA Personal Needs Allowance • PCA Personal Care Attendant

Purpose of Elderly Waiver (EW) and Alternative Care (AC) • Maintain people in their own homes – person chooses to live in the community • Connect people with services that they need • Support Caregivers • Support choice and informed decision making • Prevent or delay NF admissions • Move people out of institutions

Elderly Waiver • The Elderly Waiver program funds home and community based services for people age 65 and older who are eligible for Medical Assistance and require the level of care provided in a nursing home, but choose to reside in the community. • Authority found in MN Statute, Section 256B.0915 • Federal and State funding

Alternative Care • Contain MA expenditures by funding care in the home and community • Prevent impoverishment of older adults by assisting them to access services at an earlier point of need and prevent more costly levels of care • Authority found in MN Statute, Section 256B.0913 • State funded only

EW – Who is Eligible? • Age 65 or older • Eligible for Medical Assistance • A Minnesota Resident • Need nursing home level of care as determined by the Long term care consultation process (LTCC) • Requires a waiver service to remain in the community

EW-Who is Eligible? • The EW service cost for an individual cannot be greater than the estimated nursing home cost for that individual and is limited by the case mix classification • The person’s plan of care assures health and safety

AC-Who is Eligible? • Age 65 and older • Have chronic care needs • Chooses to reside in the community • Have financial resources to meet their own health related needs and independent living needs • At risk of NF placement as determined by the LTCC • May be eligible for Medicare Savings Programs

EW and AC Program Models • Voluntary Enrollment • Payer of Last Resort • Cost sharing by participants • Program and service is appropriate to need • Most cost effective way to meet the need • Enhance self sufficiency • Support and extend informal caregiving

EW client Characteristics FY13 Average Age: • 80 years old • 198 are 100+ years • Oldest is 107 • Total Eligible EW Clients FY13 27,798 Gender: • 73% female • 27% male Marital Status: • 48% are widowed 19%married Case Mix: • 17% A; 17% B; 22% L; 12% D, 13% E, 2%K Living Arrangements: • 2/3 live alone Ave Cost (State): • $10,675 per client/per yr or $890/month EW Total Cost: • Approx. $266 million (FY2013) Managed Care FFS 1,664 6% MSHO-EW 19,554 70% MSC+ -EW 6,580 24%

Minnesota Elderly Waiver Clients by County FY2013 • Total EW Clients 27,798

AC client Characteristics FY13 Average Age: • 82 years old • 27 are 100+ years • Oldest is 103 • Total Eligible AC Clients FY13 4,037 Gender: • 76% female • 24% male Marital Status: • Nearly 2/3 are widowed Case Mix: • 29% A; 24% B; 20% L;9% D, 8% E Living Arrangements: • 2/3 live alone Service Months: • 30 months average Ave Cost (State): • $6,096 per client/per yr or $797/month AC Total Cost: • Approx. $28.2 million (FY2013)

Minnesota Alternative Care Clients by County FY2013 • Total Eligible AC Recipients FY13 4,037

Enrollment Process for EW/AC • Community Assessment determines service needs – • County Social Service Department • Tribal Entity • Public Health Nurse/Social Worker • Managed Care Organization (EW) • Medical Assistance Eligibility (EW) – county financial worker • AC financial eligibility determined by the Case Manager

EW Financial Eligibility • Special Income Standard (SIS-EW) – income is equal to or below $2,130/month (300% SSI) • Clients can keep $971(as of 7/1/13) – Maintenance Needs Allowance (MNA) • If income exceeds $971 the client must pay for part all waiver service costs – Waiver Obligation.

EW Financial Eligibility • Clients do not have to meet the waiver obligation in full each month to remain eligible. • Waiver obligations cannot be collected until services are delivered

SIS-EW Example • Mr Is it summer – not married and income is $1000/month • Special income standard is 2130 – He is below the standard Maintenance needs allowance (MNA) is $971 Calculation: Income minus the MNA = difference of $29 He will have a $29 waiver obligation This amount is paid towards waiver services used in a month

Financial Eligibility non SIS-EW • Income is greater than $2130/month • Keep $719/month income (medically needy income standard 7/1/13) • Will have a medical spenddown – must pay a portion of medical costs and waiver costs.

Non SIS-EW example • Mrs Flowers has income of $3000/month • Special income standard is $2130 She will need to spend down to 75%FPG ($719) because she is already over 100%FPG ($958) There are other disregards and deductions • Client will need to meet a medical spendown of $2281 and will pay a portion of medical costs and waiver costs

EW Asset Limit • MA method B: $3000 for a household of 1 • Married couples: The community spouse is entitled to an asset allowance and an asset assessment needs to be completed • An asset assessment protects a specified amount of assets for the community spouse. • Asset assessments are completed by the financial worker

AC Financial Eligibility • Financial resources are within 4.5 months of Medical Assistance Eligibility ($25,881 7/1/13) and • Capable of meeting own remaining health needs and • Capable of meeting a monthly fee requirement • Spousal Impoverishment rules apply

AC Financial Eligibility • Monthly income is >$1149 (7/1/13) or • Assets are >$3000 (MA Asset limit) and • Total combined adjusted monthly income and assets are less than the projected nursing facility care cost for 135 days (+MA asset limit of $3000) • 7/1/13 this is $25,881

AC Financial Eligibility • Income is ≤$1149 and assets are ≤$3000 applicant is ineligible for AC • Can be temporary served under AC up to 60 days during their application to Medical Assistance/Elderly Waiver • If income and assets available are greater than the projected nursing facility care cost for 135 days(+MA asset limit of 3000) client is ineligible for AC and cannot be temporarily served

AC Financial Worksheets • Alternative Care Program Eligibility Worksheets: DHS 2630A Married person with a community spouse DHS 2630 Unmarried individuals, or Married couples when both may choose AC or a married person whose spouse is an EW recipient or is living in a nursing facility Case Manager determines financial eligibility

Estate Claim Recovery • Effective 7/1/2003, DHS and the county pursue estate claims for people that use the AC program • An estate claim is a method of recovering AC payments from the estate of a deceased person • It is only payable from the assets in the estate of the recipient of AC services. • The estate will pay a portion of the claim before it will give heirs any inheritance • The estate may include a life estate or any joint tenancy interests in real estate that is owned at the time of death. • Lead agency role to inform clients concerning estate recovery - Use form 5186

Estate Claims • Estate claims are imposed for recipients over the age of 55 who receive Medical Assistance. The law has changed recently concerning QMB, SLMB , QI1. • Dates of service before 1/1/2010 » subject to recovery • Dates of service after 1/1/2010 » Exempt from recovery • Liens are only imposed if stay in a nursing facility or hospital is greater than 30 days (paid for by MA)

AC Monthly Fees – Cost Sharing • Fees are used to help fund the program • Fees are based on income and assets; sliding fee scale-0%, 5%,15% or 30% of the cost of AC services • Dollar amounts and effective date of fees are entered into the service agreement MMIS screen when a client enters the AC Program, even if the amount due is $0; • All Alternative Care services shall be included in the estimated costs for the purpose of determining the fee. • See Bulletin 12-25-05 for detailed information on AC Fees

Payment Options Include • DHS Form 4639 describes payment options • Personal checks, money orders, or cashiers checks made out to DHS-AC Fees and mailed to: • DHS-AC Premiums • PO Box 64835 • St. Paul, MN 55164-0835 • Credit card payments and bank withdrawals (including recurring payments) made at: • http://payments.dhs.state.mn.us • Payment plan (including partial payments) • Representative Payee or greater family involvement • Automatic withdrawal of AC fees from a checking or savings account is no longer a payment option • Do not send cash

AC Monthly Fees - Contacts • MAXIS email at DHS.MADE@state.mn.us • For current or past month fee changes • Refunds • Special Recovery Unit at (651-431-3205) or 1-800-657-3762 • For client billing questions

AC Monthly Fees – Cost Sharing Case Managers can change fees on the service agreement for the following month: • If there is a change in condition which results in a change in the cost of services; • If there is a change in the adjusted income or assets; • A client enters a nursing facility as an admission for more than 30 days

AC Monthly Fees *Income minus recurring and predictable medical expenses 20

Over Due Fees • Case managers are responsible for notifying AC clients if they are behind in paying their fees. This information can be found on Infopac report RN190. This report is organized by county of service. Clients are identified as open (O), closed (C) or deceased (D). • Clients continue to receive overdue fee notices until they are current in payment of their fees, or for one year after they have been closed or deceased.

Over Due Fees • Case managers need to work with clients and their families to make arrangements to pay overdue fees (including a partial payment plan); however clients be ineligible for the AC Program after 60 days of nonpayment of fees. • Eligibility may be extended while making arrangements to pay outstanding fees 256B.0913 Subdivision 4

Overdue Fees • When clients move to a new county, the new lead agency is responsible for collecting the fees, including past due fees incurred prior to the move. The current county of service must update the county fields on the screening document before the client will show up on the RI90 report under the new county. • Clients who are dis-enrolled for non payment of fees are not eligible to re-open to AC for 30 days • The client must be mailed the Notice of Action Home and Community-Based Waiver Programs and AC (DHS-2828) form and be closed to the AC Program with 10 day notice per instructions in bulletin #12-25-05

AC Infopac Reports RN-190 and RN-193 are available • AC RN-190 is a bi-monthly report that provides information on AC clients with over due fees by county of service and case manager. It provides the clients name, due date, balance due by due date, PMI and Swift ID and status (O-open, C-closed or D-Deceased). • RN-193 provides client name, address, pmi, swift Id and case manager name by county of service.

Fees may be waived if: • A person is residing in a NF and receiving case management only • A married couple is requesting an asset assessment under the spousal impoverishment provision • A person is eligible for AC but has not received any services • A person has chosen CDCS for which the cost of services is not greater than the cost of services minus the monthly fee that would otherwise be assessed • Income and assets determine that the fee can be waived • The client is on temporary AC The AC waiver reason is identified on the screening document

EW/AC Benefit Set • AC services are generally the same as those offered under the EW program • AC is a state funded program so it has some unique differences from EW which is a federally funded program • AC does not have residential services such as: Foster Care or Customized Living • Both programs are payers of last resort

EW/AC Benefit Set • Services on both programs: Adult Day Service/ADS bath Caregiver Training/Education Case Management Chore Services Companion Services Home Delivered Meals Home Health Aide

EW/AC Benefit Set • Homemaker services • Environmental Accessibility Adaptations • Personal Care Assistant • Respite Care • Nursing • Specialized Supplies and Equipment • Transportation • Consumer Directed Community Supports

EW Only Services • Foster Care • Residential Care • Customized Living/24 hour Customized Living • Transitional Supports

AC Only Services • Conversion Case management • Nutritional Service • Discretionary Services

Specialized Supplies and Equipment • Includes durable and non durable medical supplies and equipment which are provided as necessary to the direct treatment of the recipients condition and which medical assistance does not fund. • Medical Assistance equipment and supplies are defined in Minnesota Rules, parts 9505.0310. Also a section of the MHCP Provider Manual

Specialized Supplies and Equipment Devices, controls or medical appliances or supplies specified in the community support plan that enable a person to increase their ability to: • Perform activities of daily living • Perceive, control or interact with their environment or communicate with others • The most cost effective way

Specialized Supplies and Equipment • Items necessary for life support or to address physical conditions along with ancillary supplies and equipment necessary to the proper functioning of such items • Once an item is purchased it becomes the property of the person it was purchased for

Specialized Supplies and Equipment • Items, equipment and supplies that exceed the scope or limits in the state plan may be covered. • May cover evaluation of the need for equipment and/or device and, if appropriate, subsequent selection and acquisition. • The service includes equipment rental during a trial period, customization, training and technical assistance to enrollees • Maintenance and repair of devices • EW/AC Section of MHCP

Oral and Enteral Nutritional Products • MA may pay for nutritional products whether or not they are oral or tube fed • EW/AC may pay for nutritional products with the following requirements: - There is a physicians orders, medical documentation and a physical reason why the person cannot obtain their caloric intake without the supplements - The Doctor has established that the person needs the product to maintain body weight and strength in the community

Personal Emergency Response Services (PERS) • Includes more traditional systems which require the individual to press an alert or panic button worn on a pendant or bracelet in the event of a fall or an emergency. • Payment can include installation and testing, the monthly service fee and the system/equipment purchase.

Elderly Waiver and Alternative Care – Programs Supporting Older Adults at Home