Ongoing recession state Medicaid deficits continue ARRA extension needed Many states built extension in their budgets for next year Six month

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2 Ongoing recession state Medicaid deficits continue ARRA extension needed Many states built extension in their budgets for next year Six month extension in President s FY 2011 Budget $24 Billion 2

3 State budget deficits due to economic recession Medicaid program hit hard American Recovery and Reinvestment Act (ARRA) February 2009: $87 billion for 2 years - formula depending on state unemployment rates Expires on December 31,

4 Tax extenders vehicle House dropped extension Senate extension on floor Votes? Conference Compromise 4

5 Other must pass vehicles Pay fors/deficit increase Obama/States/Advocates 5

6 Long term services & supports Acute care consumer provisions Employer provisions Other disability issues 6

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8 Opposition and controversy None perfect Implementation challenges Most fears unrealized 8

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10 Disability and aging communities worked together Goal Ensure two-pronged inclusion of LTSS in health reform: National LTSS insurance program avoid impoverishment Improve Medicaid reduce institutional bias 10

11 Accomplished: CLASS Act Improvements to Medicaid Community First Choice Option; Improve existing Section 1915(i) option; New state balancing incentives; Spousal impoverishment protections; Extend Money Follows the Person demonstration; Expand Aging and Disability Resource Centers 11

12 Title VIII, P.L New national LTSS insurance program Based on voluntary payment of premiums Pay premiums through employer, when the employer is willing Automatic enrollment with opt-out Pay premiums directly, when employer chooses not to participate Nominal premium ($5.00) for full-time students and people with income below poverty level Vesting after 5 years of premium payments 12

13 Eligibility to participate/enroll Must be working to enroll Cannot enroll family members No exclusions based on pre-existing conditions Benefits eligibility is based on functional need Need for assistance with activities of daily living or equivalent 13

14 Cash benefits for maximum consumer and family control At least two tiers of payment levels minimum $50/day ($18,000/year) No impact on federal benefits eligibility No means-testing No need for lifetime impoverishment Individual can continue to work Advocacy and advice/assistance available 14

15 The need for change: Institutional Bias within Medicaid People with disabilities and their families do not have an equal choice Long waiting lists for community-based services and supports 15

16 Disability Community Long Term Goal: Enact the Community Choice Act, S. 683 / H.R Senators Harkin (D-IA), Specter (R-PA) & Rep. Davis (D-IL) Would mandate Medicaid community-based attendant services and supports Too costly and politically impossible to enact a mandate to states Worked with White House and Congressional Sponsors on a first step in that direction Community First Choice Option 16

17 Section 2401, P.L New state Medicaid plan option included in health reform law Comprehensive home and community based services for people eligible for an institutional level of care (nursing home, intermediate care facility (ICF), or IMD) States receive 6 percent additional federal match for CFC services 17

18 Community First Choice (CFC) Option (continued) Included services and supports: Assistance with activities of daily living (ADLs) Assistance with instrumental activities of daily living (IADLs) Assistance with health-related tasks Acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish the above Back-up systems or mechanisms (such as beepers, electronic devises) Voluntary training on how to select, manage, and dismiss attendants 18

19 Manner of service provision: Hands-on assistance Supervision Cueing Other permissible services transitions costs (rent and utility deposits, bedding, kitchen supplies, etc.) needs identified in person-centered plan that would increase independence or substitute for human assistance (if the human assistance would have been paid for) 19

20 States must provide consumer-controlled services, statewide, in the most integrated setting appropriate create a Development and Implementation Council majority of members must be people with disabilities, elderly individuals, and their representatives establish a comprehensive quality assurance system incorporating feedback from consumers, families, providers 20

21 Maintenance of effort- 1 year Advocates could begin working with states now Available beginning October 1, 2011 Effective date enacted in reconciliation bill 21

22 Existing Medicaid 1915(i) Option States can provide services without a waiver States must establish eligibility that is less strict than for institutional and HCBS waiver services states serve people who are not eligible for the state s HCBS waiver Very few states have taken up this option to expand community-based services 22

23 Department of Health and Human Services CLASS Act Design/implementation of program/public education Proposed and final regulations Centers for Medicare and Medicaid Services (CMS) Community First Choice Option; Section 1915(i); State Rebalancing; Spousal impoverishment protections Guidance to states Funding decisions Proposed and final regulations Will need your input and responses to alerts on regulations, etc. 23

24 Implementation (continued) Implementation of Medicaid LTSS changes States have many choices Community First Choice Option Section 1915(i) HCBS option State Balancing Incentives Work with Governor, State Legislature 24

25 60 s - Medicaid & SSI 70 s - Free appropriate public education 80 s - Early Intervention, Preschool, Supported Employment & Medicaid Waivers 90 s - ADA 10 s - Health Care Reform 25

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27 Expand Coverage and Access to Care 32 million uninsured will be covered New Insurance Exchange with Premium Sharing Subsidies, and Cost Sharing Caps Large Expansion of Medicaid Eligibility Significant Insurance Market Reforms Emphasis on Prevention Bending the Cost Curt over Time 27

28 Bars pre-existing condition exclusions for children under 19 (9/2010) and everyone (1/2014) Individuals with pre-existing conditions can t be charged higher premiums Rescissions Insurers can t drop individual when s/he gets sick or apparent pre-existing condition is discovered (late September 2010) 28

29 For individual and group markets: Prohibits lifetime limits on $ value of coverage (late September ) Prohibits annual limits (2014) Prior to 2014: Restricted annual limits, to be defined by HHS Secretary, are permitted 29

30 Individual and Group Plans (2014): Bars eligibility rules based on health status-related factors: Health status, medical condition (mental or physical illness), disability Guaranteed Issue and Renewability (2014) Small group and Individual plans must accept every employer and individual who applies 30

31 Expands Medicaid eligibility to 133 % of Federal Poverty Line (2014) approximately $14,600/ individual; $29,400/family of 4 (2009 FPL Guidelines) Federal Share (FMAP): 100% for (3 years) Phases down to 90% for 2020 and subsequent years 31

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33 Members Worried Voter Anger Utah, W. Va., Ky, Nev. Over 10% Already Bolting Bipartisanship Rare Politics Rule 10 Legislative Weeks 33

34 Unemployment Jobs Bills Tax Extenders FY 2011 Funding Energy Banking Reform Supreme Court Nomination Lame Duck? 34

35 WIA/VR ESEA Deficit Commission Medicaid FMAP ARRA Cliff Rosa s Law 35