Richard C. Allen Centers for Medicare & Medicaid Services Presentation to

1. Money Follows the Person Rebalancing DemonstrationSection 6071 of the Deficit Reduction Act 2005 Richard C. Allen Centers for Medicare & Medicaid Services Presentation to 2007 Annual Conference of Assistive Technology ACT Programs

2. Medicaid Institutional and Community-Based Expenditures in 2005 Dollars: FFY 1980-2005 Source: Thomson/Medstat: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index.

3. Medicaid LTC Expenditures for Older Adults and People with Physical Disabilities, in 1995 and 2005 2005 1995 Source: Thomson/Medstat: CMS Form 64 Reports

4. Medicaid LTC Expenditures for Individuals with MR/DD, in 1995 and 2005 2005 1995 Source: Thomson/Medstat: CMS Form 64 Reports

5. Quest for a “Balanced” LTC System • The organization, financing, and delivery of Medicaid-funded LTC services is biased towards institutional care. • Almost two-thirds of Medicaid LTC expenditures are devoted to “institutional” care. • 13% of NH residents are under age 65. • 40.9% of NH residents have no ADLs. • 80% of NH residents have no, or only mild, or moderate cognitive impairments. • MDS Q1A: • For residents with a LOS of +30 days, 11% of the nearly2.8 million discharges from NFs were to the consumer’s home with no additional services and 28% went home with only home health services. • Reasons for the Bias: • Mandatory NF benefit. • Funding follows the setting, not the individual. • The use of separate line-item budgets to pay for institutional services and HCBS. • Overcoming the effects of historically high NF occupancy rates and waiting lists.

6. Quest for a “Balanced” LTC System • Passage of the Americans with Disabilities Act • Olmstead v. L.C. and E.W • President’s New Freedom Initiative and Executive Order 13217 • With HHS and CMS funded grants to states to foster: • choice of quality options for where to receive their care; and • greater control over the types of services and supports they need to live their lives. • Proportion of Medicaid LTC devoted to HCBS has grown significantly.

7. Objectives of the MFP program • A nursing facility transition program that identifies consumers in institutions who wish to transition and assists them in doing so. • A financial system the allows Medicaid funds budgeted for institutional services to be spent on HCBS when individuals move the community. • Quality management system that ensures the provision of, and improvement of services in both HCBS and institutional settings. • Broader rebalancing efforts to support and foster facilitate transition and diversion.

8. States Awarded MFP Grants • First Round: Arkansas, California, Connecticut, Indiana, Iowa, Maryland, Michigan, Missouri, Nebraska, New Hampshire, New York, Ohio, Oklahoma, South Carolina, Texas, Washington, & Wisconsin • Second Round: Delaware, District of Columbia, Georgia, Hawaii, Illinois, Kansas, Kentucky, Louisiana, New Jersey, North Carolina, North Dakota, Oregon, Pennsylvania, and Virginia

9. MFP Fundamentals • $1.75 billion over five years (January 1, 2007-September 30, 2011) • Participating states receive an enhanced FMAP for 12 months for qualified home and community based services for each person transitioned from an institution to the community. • Self-direction encouraged. • “Rebalancing” Benchmarks required. • States must participate in CMS’ national evaluation.

10. Qualified Individuals • Reside in an institution (6months – 2 year minimum period). • Institutions include: hospital, nursing facility, or ICF/MR. An IMD is also included to the extent that medical assistance is available under the State plan for service in the IMD. • Is receiving Medicaid benefits for inpatient services furnished by such inpatient facility. • Would need HCBS services in order to successfully reside in community based settings.

11. Qualified Residence • Where eligible individuals can move to. • A home owned or leased by the individual or the individual’s family member. • An apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual’s family has domain and control; or • A residence, in a community based residential setting, in which no more than 4 unrelated individuals reside.

12. Transition • How to Target Consumers for Transition? • Potential discrimination. • Can it be done at a reasonable cost? Conserve limited resources for those that are likely to benefit. • Developing NFT Infrastructure • Inform all residents about HCBS options. • Identification process. • Assessment and care planning. • Transition case management services. • One-time transition expenses (security deposits, household items, etc); • Monitoring of those transitioned.

13. MFP Quality Management System • Grantees must develop and submit for approval a quality management system (QMS) for demonstration participants during the demonstration year and a description of what system they will be transitioned to after the 12-month demonstration period. • QMS must meet or exceed the guidance for a QMS set forth under Appendix H of the 1915(c) HCBS waiver program.

14. Website See the following website for all information: www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp http://www.amda.com/advocacy/regulations.cfm For any questions, send to: MFPdemo@cms.hhs.gov