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States Urged to Give Medicaid Beneficiaries Control
Over Long-Term Care
Concept of money following the person's own
preferences improves satisfaction and may reduce Medicaid costs.
Aug. 19, 2004 - More states than ever are
re-directing Medicaid funds to keep more people out of institutions and
living in their own communities and homes, and there are many approaches
that states can use to accomplish this, according to the Centers for
Medicare & Medicaid Services (CMS).
CMS has been gathering information on state
programs as part of their program called Money Follows the Individual,
and in a letter to state Medicaid directors this week the agency shared
some of what they have learned. The letter also is advising states about
what actions they can currently take while Congress reviews the
necessary changes in the law. (See more about Money Follows the
Individual at bottom of article.)
"There is growing evidence that states can enable
more people to live in the community by giving the elderly and people
with disabilities more control over how they get the Medicaid services
they need," said CMS Administrator Mark B. McClellan, M.D., Ph.D.
"Because the concept of money following the person's own preferences
improves satisfaction and may reduce Medicaid costs too, we intend to
keep taking steps to remove barriers, real or perceived."
The Medicaid program, by law, favors institutional
care for elderly and disabled individuals who needed help with
activities of daily living. However, only paying for institutional care
means that Medicaid beneficiaries would not have access to modern
options for living in the community.
President Bush has taken many steps to encourage
states to provide assistance in the home or in a community-based
setting, including the 2001 New Freedom Initiative and the 2002
Independence Plus Medicaid waiver program. As part of his ongoing
commitment under the New Freedom Initiative, President Bush proposed
legislation in his 2005 federal budget that would temporarily all states
more flexibility in their Medicaid payment systems without having to
seek waivers from CMS. Included in those changes was the proposal called
"Money Follows the Individual" that would further promote home and
community based care as an alternative to institutionalization.
President Bush has authorized $1.75 billion in funding for this
initiative between the years 2005-2009.
The letter to the Medicaid directors addresses
several areas of confusion that may be impeding state efforts to
rebalance their long-term care support systems, specifically:
Home and Community-based Services (HCBS) Waiver
Capacity and Cost Neutrality: The letter indicates that states may
request to amend their current home and community-based waiver programs
at any time to include additional participants. States that do so are
still required to demonstrate the continued cost neutrality of those
programs; however, most states have found that the waiver programs
continue to demonstrate aggregate cost neutrality even with the addition
of waiver participants.
Backfilling of Nursing Home Beds: The letter
clarifies that implementation of re-balancing strategies does not
require a commitment from states to refrain from backfilling nursing
facility beds.
Self-Directed Models: While CMS continues to
encourage states to consider Independence Plus and Cash and Counseling,
the letter clarifies that the agency also recognizes other strategies
for the provision of HCBS that expand the level of individual choice and
control without making major modifications to state infrastructures. The
selection as to which option is best may vary depending on the level of
other community supports available, or simply the inclination of the
individual. The letter describes a broad range of service delivery
models related to assistant services, all of which can help
beneficiaries achieve the goal of personal control and community living.
The letter also gives states specific examples of
successful programs that give beneficiaries more control and result in
more community participation, without raising Medicaid costs. For
example, the letter cites the efforts of states such as Nevada, which is
completely rebalancing its long-term care services programs so that
community services and supports are the primary source of support for
people living with disabilities. Maine and California programs are also
examples of state programs that help keep people in their home and
communities.
"Individuals and families have long wanted the
flexibility to control how they receive the long-term care services they
need," said Dr. McClellan. "Today's guidance makes clear that there are
many options available to states to achieve this important goal, and we
are ready to help any state that wishes to take action."
A copy of this letter can be obtained at
www.cms.hhs.gov/states/letters .
Overview of Promising Practices Reports
The Centers for Medicare and Medicaid Services
(CMS) is creating a repository of Promising Practices in Home and
Community Based Services to assist states, in partnership with their
disability and aging communities, to strengthen their community long
term support systems. These reform efforts are designed to enable
persons of any age who have a disability or long term illness to:
(a) Live in the most integrated community setting
appropriate to their individual support requirements and preferences;
(b) Exercise meaningful choices about their living environment, their
service providers, the types of supports they receive, and the manner in
which supportive services are provided; and
(c) Obtain quality services in a manner consistent with their living
preferences and priorities.
Effective models of long term support abound. New
innovations are being designed and implemented by state and local
programs continuously. Yet information about these efforts is not
widespread and the practical knowledge needed to make significant
improvements in long term support systems often goes unshared among
states. The purpose of the Promising Practices Reports is to disseminate
timely information on program and policy innovations so that all states
and stakeholders may benefit from the experiences of their peers across
the country. Most of the Promising Practices Reports are being developed
by The MEDSTAT Group under contract with the Disabled and Elderly Health
Programs Group within CMS.
Some states are undertaking comprehensive reform of
their entire system of home and community based services. Others are
identifying specific components as targets for incremental improvement.
Thus, some reports will focus on "whole systems". More frequently, the
Promising Practices Reports will focus on discrete components of home
and community-based service systems, such as person centered planning,
eligibility systems, personal assistance services, financing mechanisms,
quality improvement systems, and case management systems, that can be
incorporated into an overall program design.
Innovations are undertaken within the context of a
state's unique characteristics, history and environment. States and
communities seek accurate, timely information to consider whether the
adoption of a specific practice would be a good fit within their
existing policies and programs, and if so, what types of modifications
would be needed to achieve replication.
Finally, promising practices can be found in a wide
range of home and community based services programs targeted toward
diverse populations. A program's funding source does not necessarily
limit its broader applicability. In fact, any one specific program is
often supported by a combination of funding streams such as the Medicaid
Home and Community Based Services (HCBS) waiver program, regular
Medicaid state plan options, programs funded by other federal agencies,
and state and local resources.
The reports on this site are intended to stimulate
HCBS program changes, spark creative ideas, and serve as a launching pad
for the next generation of program innovations. Promising Practices
Reports do not, however, represent an endorsement of any practice by CMS
or by MEDSTAT. Rather, they are a starting point for fostering a dynamic
examination of ways to improve community support systems for persons of
all ages with disabilities.
By design, most reports succinctly describe
promising practices in two to three pages. In some areas, however, we
have produced longer reports and case studies to provide additional
detail.
CMS and MEDSTAT always welcome new ideas for
additional Promising Practices Reports. If you are implementing a
Promising Practice or know of one you think would be of interest to
other states or communities, please send your suggestion to CMS at
PromisingPractices@cms.hhs.gov.
More information can be obtained about the Money
Follows the Person initiative at www.cms.hhs.gov/promisingpractices.
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