NASDDDS National Policy Agenda

1. NASDDDSNational Policy Agenda Dan Berland NACBHD 2005 Legislative and Policy Conference March 4, 2005

2. Serving Persons with Co-Occurring Disabilities

3. Dispute with CMS Over Active Treatment Criteria Background • In late 2000, CMS began applying new criteria to determine when ICF/MR residents are in need of active treatment services. • The application of the new criteria occurred as part of an intensive series of federal contractual look behind review. • CMS indicated that residents with intact ADLs do not require active treatment and, therefore, states may not claim FFP on their behalf. • The disputed criteria impacts mainly residents with mild cognitive impairments & severe behavioral disorders.

4. Dispute with CMS Over Active Treatment Criteria Background cont... • During 2001-03, CMS notified 7 states that payments on behalf of such residents were being deferred. • Two states (MD & IA) that refused to withdraw payment claims subsequently received disallowance notices. • NY was cited for failing to meet CoPs in a specialized facility for dually diagnosed. • MD & IA appealed CMS’ disallowances.

5. Dispute with CMS Over Active Treatment Criteria NASDDDS Involvement • NASDDDS sponsored several membership conference calls in 2001-02 to foster interstate communication & joint problem solving. • NASDDDS representatives met with CMS officials to discuss possible approaches to resolving the dispute in November 2003. • In December 2003, a special work group was commissioned to recommended revisions in federal ICF/MR guidelines.

6. Dispute with CMS Over Active Treatment Criteria NASDDDS Involvement cont... • The recommended changes were vetted through the NASDDDS leadership & presented to CMS in May 2004. • CMS unveiled a draft protocol for determining AT needs at a May 2004 stakeholders’ meeting. • The draft protocol applied successive screens to determine whether individuals with intact ADLs qualify for AT when their co-occurring health and behavioral disabilities are considered. • The protocol ruled out AT, however, for persons with a history of “criminal behavior.”

7. Dispute with CMS Over Active Treatment Criteria Recent Developments • In mid-December, CMS notified states that the deferral and disallowance notices were being lifted pending further analysis of the issue. • The announcement came on the eve of the HHS Appeal Board’s hearing on the MD & IA disallowances. • CMS reserved the right to re-institute the deferrals/disallowance if later it was determined that AT was not needed.

8. Dispute with CMS Over Active Treatment Criteria Recent Developments cont... • CMS now plans to complete an internal review of its revised protocol, followed by an on-site application of the protocol in a selected facility. • NASDDDS has supplied CMS with a list of qualified state observers. • CMS will select from this list persons to participate in the internal protocol review and to observe the on-site re-reviews.

9. Dispute with CMS Over Active Treatment Criteria Recent Developments cont... • NASDDDS’ ICF/MR task force also will be asked to review and comment on the draft protocol. • These activities are supposed to take place in February & March, but a specific schedule has yet be announced.

10. NASDDDS’ Study of Services for Persons with Co-Existing Conditions • Launched early in 2004, the aim of the study is to gain a better understanding of how states organize, finance and deliver community services to dually diagnosed adults. • Chas Moseley, NASDDDS’ Director of Special Projects, is directing this study.

11. NASDDDS’ Study of Services for Persons with Co-Existing Conditions cont... Among the products of the study to date are: • A report summarizing interviews with several national experts on serving dually diagnosed individuals. (http://www.nasddds.org/pdf/PickingUpThePiecies.pdf) • A report summarizing the findings from a survey of NASDDDS member state agencies. (http://www.nasddds.org/pdf/NTR-CoexistingConditions.pdf) • The summary proceedings from a small, invitational symposium on serving individuals with co-existing conditions which the Association sponsored last fall. (http://www.nasddds.org/pdf/GettingALifeMonograph.pdf)

12. NASDDDS’ Study of Services for Persons with Co-Existing Conditions cont... • The final phase of the study involves an in-depth examination of policies and practices in 13 selected states. • The aim is to identify commonalities and differences in the approaches used in the selected states and pinpoint the common characteristics of successful service systems. • The findings and conclusions from this phase of the work will be summarized in a final study report that will be available in the spring of 2005.

13. Survey Outcomes Information on: • Distribution of funding and support responsibilities • Barriers to service delivery • Organization of crisis response services • Achieving positive outcomes

14. Relationships with Mental Health 55% Effective, very effective or extremely effective 45%Not or not very effective Relationships with Corrections 73%Not or not very effective 22%Effective 5%Very effective Working Together In 65% of states, policy is developed in collaboration with other state agencies

15. Long-term support Program planning, case management service coordination Clinical consult and Rx Crisis intervention and support Short-term in-patient psychiatric services Quality oversight, assurance and improvement Responsibility for Funding and Service Provision

16. Who Pays?

17. Who Provides?

18. Top 5 Most Challenging Barriers • Insufficient Number of Providers • Provider Unwillingness • Lack of Coordination • System Structure Gets in the Way • Lack of Targeted Funding

19. Provider Availability Barriers • Trained Staff 69% • Crisis Intervention and Support 56% • Clinical Services 49% • Residential Supports 47%

20. What Works?

21. Effective DD/MH collaboration Ineffective DD/Cor collaboration Funding distributed by service Long-term by DD Short-term psychiatric by MH Regional crisis service Crisis services funded by DD & MH Quality assessed by DD alone or with MH Barriers Staff with expertise Qualified providers Provider unwillingness Crisis support Typical State

22. Purpose Review current status and practice trends Identify ideal program elements Integrate best practice into existing systems Agenda for change Participants State DD directors and staff – 7 Experts – 9 Mental Health - 3 Providers – 2 Others - 3 Symposium

23. Focus on the Individual Focus on Staff Develop Core Capacities Make it work – focus on operations But in the end – Its All About Relationships Key Themes

24. Caging the Tiger: Possible Medicaid Reform Strategies

25. Alternative Medicaid Reform Strategies: Pick Your Poison • A Capped Entitlement (State Block Grant). • Federalize Services to Dual Eligibles. • Strengthen State Cost Containment Powers. • Emphasize Cost-Efficient Service Delivery. • Continued Gridlock over Medicaid Policy.

26. DD Implications of a Medicaid Block Grant • Would shift the financial burden to the states. • Few, if any, states would be able to sustain current eligibility & benefits, much less close existing service gaps. • Impact on DD services would vary depending largely on the effectiveness of local advocacy. • Added pressure to close/downsize ICFs/MR.

27. DD Implications of a Medicaid Block Grant cont... • State-to-state discrepancies in access to services would widen. • The program’s social safety net role would weaken. • No guarantee that Congress wouldn’t cut state funding levels in future years.

28. DD Implications of Federalizing Services to Dual Eligibles • In theory, states would achieve substantial savings; but most of the savings probably would be returned to the U.S. treasury. • The shift in responsibility wouldn’t reduce -- and could exacerbate -- the federal deficit. • Federalization would create a two-tiered system of DD benefits and complicate the task of organizing & financing state/local services.

29. DD Implications of Strengthening State Cost Containment Powers • Differences among state Medicaid programs would be further accentuated by the choices states make in exercising their new powers. • The specific effects on DD services would depend on the relative effectiveness of interstate advocacy efforts. • The net program savings would be hard to predict due to fierce intrastate opposition. • The safety net role of the Medicaid program is likely to be weakened. • The preferred approach of the Bush Administration?

30. DD Implications of Emphasizing Cost-Effective Service Delivery Methods • This approach would involve a more tightly managed set of benefits & a stronger emphasis on outcomes. • Properly structured, this approach could make it easier to promote individualization and consumer direction. States would achieve substantial savings. • It would, however, challenge many traditional operating assumptions and, thus, be opposed by a variety of existing stakeholders. • A variety of tough system design choices would be required.

31. DD Implications of Continued Legislative Gridlock • DD service systems are likely to be buffeted by intrastate initiatives to contain the growth in Medicaid outlays. • One potential threat is the centralization of Medicaid administration &, consequently, less DD system management autonomy. • Another is the possibility of reallocating Medicaid dollars among programs, purportedly to achieve greater equity. • Managing DD service systems would be harder.

32. Medicare Part D and State DD Agencies Association Activities • Submitted comments to proposed rules Issues: • ICFS/MR as Long-term care facilities • Waiver population treated the same as those in institutions • Long-Term Care Pharmacy services • Timing of auto-enrollment • Funding to state and local agencies for outreach and enrollment support • Formulary requirements

33. Medicare Part D and State DD Agencies Association Activities cont... • Invited CMS staff to present at Annual Meeting • Along with NACBHD and five other organizations, met with Medicare’s Director of Outreach to discuss education efforts for individuals with DD • Joined CMS’ Medicare Partners Group • Medicare Part D Teleconference • Organized Medicare Part D Work Group

34. Medicare Part D Issues • Outreach and education • Will CMS coordinate with local support? • Will CMS reach all dual eligibles? • Formulary concerns • Will formularies cover the drugs duals with DD need? • Will duals with DD be able to navigate the appeals process? • Will duals with DD have access to non-formulary, medically necessary drugs? • Cost-sharing • How will duals with DD afford co-pays?