How Your State Can Simultaneously Save Medicaid Money and Comply with the ADA

Subject: How Your State Simultaneously Save Medicaid Money and Comply with the ADA

How Your State Simultaneously Save Medicaid Money and Comply with the ADA - Information Bulletin # 175 (9/06)

What an offer! Your State can simultaneously save precious Medicaid funds and comply with the ADA and Olmstead requirements. How? By developing a Money Follows the Person proposal that 'wows' CMS and wins a coveted MFP demonstration grant.

We have heard rumors that some State Medicaid officials have said that MFP will not save funds. NOT TRUE.

Thanks to the National Academy for State Health Policy in Portland, Oregon and Hendrickson Consulting, we now have a "Nursing Home Relocation Impact Calculator" which disability advocates can use to determine exactly how much Medicaid funds your State will save per person IF the your State receives an "enhanced" MFP federal match and IF your State then moves persons out of a nursing facility.

The "Nursing Home Relocation Impact Calculator"shows savings both for those states with "bed taxes" (See Information Bulletin # 172) and those states without bed taxes.

If you want to obtain the "Nursing Home Relocation Impact Calculator,"
because I cannot attach it to the list serve, you must email me and I will send you an individual attachment with the Calculator in an Excel spreadsheet format.

Once you have it, you must obtain and insert some simple information from your State. I do not have this information for your State, so YOU must obtain it. You must know what:

1. your State's Medicaid per day reimbursement for Nursing Facilities;

2. the federal-match % of your State's Medicaid;

3. whether or your State has a "bed tax." If it does have a bed tax, then you keep the 3% on the Calculator, but if you State does not have a bed tax, then delete the 3% and insert 0); and

4. the average annual waiver Medicaid cost per person for community services ("HCBS")(which you can find in the appendix to your State's Waiver application for persons who are either "aged" or "physical disability.")

By inserting those four items in the Calculator's spreadsheet, it will automatically calculate the Medicaid savings your State will achieve.

In the "Nursing Home Relocation Impact Calculator" which we have provided for example purposes only, we have assumed $125 dollars a day Medicaid reimbursement per person for a nursing home, a 57% federal match (i.e., the national average), a 3% "bed tax" (the maximum permitted after the Deficit Reduction Act of 2006), and $20,000 community-based Medicaid expenditures per person, i.e., Home and Community Based Services. Each State will be different. Just take the Calculator's Excel Spreadsheet and insert the correct figures for your State.

In the example, we have two columns, one "without a bed/provider tax"
andone "with a bed/provider tax." In the first box, we look at the "institutional costs" per bed. In our example sheet, with a provider tax, the state pays $18,839 of State funds for each person in a nursing facility.

In the second box, we look at HCBS (community costs). Here, however, we look at the cost in the community b with OR without the MFP "enhanced" match. That is, if the regular Federal match were 57%, then with MFP it increases to 79% and the cost to the State to provide services to that person in the community is reduced in half, i.e, from $8,600 to $4,300.

In the third box ("Differences/Savings with Regular FMAP"), we show the "difference" or SAVINGS to your State, again with and without the "bed tax." The differences are quite stark! The differences represent what the state will save if the person is moved to the community without a MFP.

If your State receives an MFP demonstration grant, then it will save
$15,319 per person by moving the person out of the nursing facility (without a MFP, it would save $11,019). If your State has a bed tax and is lucky enough to be awarded a MFP demonstration grant, it will still save $14,539.

Disability Advocates:
How could your State NOT apply for MFP?
Why would your State NOT want to save Medicaid funds AND stop
"unnecessary institutionalization"?
Didn't the Supreme Court in the Olmstead decision hold that if a State
could end "unnecessary institutionalization" and does not, that
is illegal discrimination under the ADA.

Thanks again to Bob Mollica and Leslie Henrickson.

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects.
To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.

MFP, Housing, and One State's Efforts - Information Bulletin # 174

MFP, Housing, and One State's Efforts - Information Bulletin # 174 (9/06).

Until November 1, 2006, when the Money Follows the Person applications must be submitted to CMS, we will pass along information which we hear from States regarding strategies being considered. Here is one from Ohio [slightly edited].

"Representatives from the Ohio SILC, Governor's Council on PWD, Ohio Dept of Development, Ohio Centers for Independent living, and ODJFS came together in May to launch a statewide effort to increase housing options for PWDs in Ohio. In an effort to support ... rebalancing long term care system, we offer the following:

"1. Work with the Ohio Hosing Finance Agency and Ohio Dept of Develop to create additional rental assistance for PWDs. Following examples set by other states, additional incentives for developer ingenuity in subsidy creation can close the income gap so persons currently institutionalized can be eligible based on their SSI incomes to receive rental subsidies.
We strongly urge these two State agencies to follow the examples of other states.

"2. The Ohio Access Success Project makes money available to individuals transitioning back to the community for one time expanses such as utility and rent deposits, groceries, furniture, dishes, etc. In addition, transition funds should be made available for home modifications to individuals who have located housing to make that housing accessible.
This should include funds for renters and should not be restricted to people who own their homes.

"3. Ohio's Medicaid office should foster an Inter-Agency relationship with the Ohio Dept of Development and the Ohio Finance Agency to create a Bridge Subsidy Program specifically designed to assit people living in nursing homes transition to the community. Either HOME funds or Housing Trust Fund dollars could be used to support this subsidy. The Bridge Subsidy Program would be a temporary subsidy until individuals are accepted on a Tenant Based or Project Based Section 8 Voucher. Once they receive a Section 8 Voucher, the Ohio Bridge subsidy will be redirected to another individual. Availability of housing options is essential to the success of MFP."

What's your State doing to provide housing options for persons leaving nursing homes? Pass it along.

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects. To
contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.

--
Steve Gold, The Disability Odyssey continues

Information from the Family Care Councils of florida

Question: What does it mean, the money follows the person?

Julie Shaw, ADA Working Group:

Answer: There have been, for the last five years, vacant nursing home beds in every state in the country. For advocates fighting for community-based services and particularly for advocates that are urging their State to use a "Money Follow the Individual" program, the nursing home vacancy rates are important to understand. HHS Secretary Thompson suggested the "Money Follow the Individual" was an innovative model to increase community services. Texas is successfully using it. Simply stated, the "Money follows the individual" means that when an individual in a nursing home or other institution chooses to leave that facility, the funds necessary to support the individual's service needs in the community are transferred from the budget of the institution to the community. In the federal budget for FY 2004 that will be announced next week, there will be a "Money Follows the Individual" Rebalancing Demonstration -- $1.75 billion over five years, with $350 million proposed for FY 2004. This five-year demonstration would assist states in developing and implementing a strategy to "re-balance" their long term care systems so that there are more cost-effective choices between institutional and community options, including financing Medicaid services for individuals who transition from institutions to the community. Federal grant funds would pay the full cost of home and community-based waiver services for one year, after which the participating states would agree to continue care at the regular Medicaid matching rate. This significant demonstration would build upon existing state success stories and also provides incentives to states for increased use of home and community-based services and would help provide information on costs of different approaches.
The exact percentage is not even critical. Given vacancy rates of any size, as well as the national uproar about increasing Medicaid costs, tell your States to save money, do the right thing, give people a REAL CHOICE, and let the nursing home "money follow the person" into the community so they can live in their own homes.

How Many People are Still Institutionalized?

DD Institutions -
How Many People are Still Institutionalized?
Information Bulletin #105



How well are we moving towards the goal of ending, as the Supreme Court stated in Olmstead, unnecessary institutionalization in the DD community? Braddock's 2005 State of the States in Developmental Disabilities (for FY 2004) provides an opportunity to measure where we are and to compare states.

Of the nearly 500,000 persons in the US with DD who are in "out-of-home residential placements":

21% (103,000) were in institutions with 16+ persons;
11% (55,000) in institutions with 7 -15 persons; and
68% (335,000) in 1 -6 persons settings (Table 4).
Few people argue that the 103,000 and 55,000 (nearly 37%) in settings with 7+ persons are unnecessarily institutionalized.

Let's breakdown the 335,000 persons in settings of 1-6 people:

While smaller living arrangements are, obviously, less institutionalized, there are 22,000 people who are in either public or private ICF/MR settings. ICF/MRs, whether private or public, have many of the restrictions of larger institutions and are unnecessarily institutionalized.
About 155,000 persons in "supportive living/personal assistance." These persons "choose where and with whom they live..., and the individual has a personalized support plan that changes as her or his needs and abilities change."
The remaining 158,000 are in a catchall called "group homes" - these persons are in either a MA waiver program, "host homes," or "foster care."
Let's look at costs:

The average financial costs of these different settings are dramatically different and quite expensive.

For the larger State operated institutions, the average cost is $146,000 per person per year and private ICF/MR cost $68,000 per person per year (Table 6).
For the smaller (15 or less), the private ICF/MR institutions cost $75,000 and the public (same size) ICF/MR institutions cost $86,000 per year.
In comparison with those settings of 6 or less persons, the supportive living/personal assistance cost only $21,000 and Medicaid Home and Community Based Waivers average $38,000 per year per person.

These different costs for institutional and noninstitutional settings raise questions:

Why are we continuing with costly unnecessary institutionalization in ICF/MRs and other large institutions when States could save money and integrate persons more cheaply?
How much of the high per capita costs are due to the significant needs of the population versus the professional/provider industry benefitting from alleged "needs" and not the real needs of the individual?
How many persons in each setting has a cognitive disability acquired prior to age 22, or a physical disability acquired prior to age 22, and how many have both labels?
Would not a system based on the needs rather than age of onset better serve the disability community philosophy of cross-disability cooperation premised in the ADA?
It is important, for both independence, civil rights and costs, to know by state how many persons with DD in your State who are NOT in supportive living/personal assistance or NOT in one of the "group homes," but are still in institutions (whether in a State institution, private or public ICF/MR regardless of the size, larger "other residential," or nursing home).

In many of the following states, the goal of ending unnecessary institutionalization is within reach, but it requires taking on the public and private ICF/MR institutions. In other states, why are there so many persons still institutionalized.

Here's a State by State breakdown of people who are institutionalized because they are in settings of 7+ or in ICF/MRs of 1- 6 years.

Alabama - 1,992 out of 4,295 are still in institutions, 46%;
Alaska - 7 out of 977 are still in institutions, less than 1%;
Arizona - 291 out of 7,454 are still in institutions, 4%;
Arkansas - 3,512 out of 6,176 are still in institutions, 57%;
Calif. - 16,241 out of 55,052 are still in institutions, 30%;
Colorado - 991 out of 7,748 are still in institutions, 13%;
Conn. - 2,057 out of 7,222 are still in institutions, 28%;
Delaware - 243 out of 970 are still in institutions, 25%;
D.C. - 1,114 out of 1,521 are still in institutions 73%;
Florida - 6,034 out of 16,198 are still in institutions 37%;
Georgia - 3,320 out of 7,954 are still in institutions 42%;
Hawaii - 182 out of 1,234 are still in institutions 18%;
Idaho - 835 out of 3,647 are still in institutions 23%;
Illinois - 11,339 out of 19,652 are still in institutions 58%;
Indiana - 5,845 out of 15,043 are still in institutions, 39%;
Iowa - 4,769 out of 10,663 are still in institutions 45%;
Kansas - 658 out of 5,139 are still in institutions, 13%;
Kentucky - 1,634 out of 4,063 are still in institutions, 40%;
Louisiana - 6,342 out of 8170 are still in institutions, 78%;
Maine - 830 out of 4,009 are still in institutions, 21%;
Maryland - 520 out of 6,865 are still in institutions, 8%;
Mass. - 3,127 out of 11,909 are still in institutions, 26%;
Michigan - 4,633 out of 16,424 are still in institutions, 28%;
Minn. - 2,572 out of 14,893 are still in institutions, 17%;
Miss. - 3,142 out of 4,970 are still in institutions, 63%;
Missouri - 3,886 out of 8,688 are still in institutions, 45%;
Montana - 681 out of 2,040 are still in institutions, 33%;
Nebraska - 715 out of 3,443 are still in institutions, 21%;
Nevada - 254 out of 1,570 are still in institutions, 16%;
New Hampshire - 122 out of 2,273 are still in institutions, 5%;
N.J. - 5,188 out of 12,509 are still in institutions, 42%;
New Mexico - 487 out of 2,894 are still in institutions, 17%;
New York - 24,633 out of 54,338 are still in institutions, 45%;
N.C. - 5,792 out of 18,178 are still in institutions, 32%;
North Dakota - 960 out of 1,921 are still in institutions, 50%;
Ohio - 4,272 out of 18,785 are still in institutions, 23%;
Oklahoma - 2,986 out of 5,451 are still in institutions, 55%;
Oregon - 650 out of 5,003 are still in institutions, 13%;
Penn. - 6,685 out of 24,415 are still in institutions, 27%;
Rhode Island - 331 out of 2,219 are still in institutions, 15%;
S.C. - 2,297 out of 4,785 are still in institutions, 48%;
South Dakota - 991 out of 2,550 are still in institutions, 39%;
Tennessee - 2,793 out of 6,862 are still in institutions, 41%;
Texas - 15,879 out of 23,310 are still in institutions, 68%;
Utah - 1,108 out of 3,409 are still in institutions, 33%;
Vermont - 33 out of 1,275 are still in institutions, 3%;
Virginia - 3,757 out of 7,373 are still in institutions, 51%;
Wash. - 1,983 out of 13,067 are still in institutions, 15%;
W.V. - 1,076 out of 4,572 are still in institutions, 24%;
Wis. - 3,515 out of 18,436 are still in institutions, 19%;
Wyoming - 250 out of 771 are still in institutions, 32%;

US - 179,194 out of 492,385 are still in institutions, 36%

[These were computed by subtracting the number of persons in the state's settings in "other residential" from the state's "Total persons served by setting."]


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Steve Gold, The Disability Odyssey continues

Nursing Home Vacancies and "Money Follows the Person"

Source: Steve Gold, Esq/

Nursing Home Vacancies and "Money Follows the Person"
Information Bulletin No. 45 from Steve Gold

MONEY FOLLOWS THE INDIVIDUAL
There have been, for the last five years, vacant nursing home beds in every state in the country. For advocates fighting for community-based services and particularly for advocates that are urging their State to use a "Money Follow the Individual" program, the nursing home vacancy rates are important to understand. HHS Secretary Thompson suggested the "Money Follow the Individual" was an innovative model to increase community services. Texas is successfully using it.

Simply stated, the "Money follows the individual" means that when an individual in a nursing home or other institution chooses to leave that facility, the funds necessary to support the individual's service needs in the community are transferred from the budget of the institution to the community.

In the federal budget for FY 2004 that will be announced next week, there will be a "Money Follows the Individual" Rebalancing Demonstration -- $1.75 billion over five years, with $350 million proposed for FY 2004. This five-year demonstration would assist states in developing and implementing a strategy to "re-balance" their long term care systems so that there are more cost-effective choices between institutional and community options, including financing Medicaid services for individuals who transition from institutions to the community.

Federal grant funds would pay the full cost of home and community-based waiver services for one year, after which the participating states would agree to continue care at the regular Medicaid matching rate. This significant demonstration would build upon existing state success stories and also provides incentives to states for increased use of home and community-based services and would help provide information on costs of different approaches.

ADVOCACY STRATEGIES
Even though this new demonstration money may be available in October 2003 you should pressure your Medicaid Director and your state legislatures to begin now to do a Texas like "money follow the individual" program so you will have a head start when the new $$$$ becomes available.

You can NOW begin to plan to implement this:

Identify persons in the nursing homes and other institutions who want to get out;
Tell your legislators that "money follows the individual" saves money;
Build a coalition of IL, DD, Aging, MH advocates that say with one voice "Let the money follow the individual"
WHY DOES IS IT SAVE $$$$$
Under Medicaid, nursing home services are an "entitlement." Therefore, any person who meets the "level of care" (disability) for your State's nursing homes has a right to receive services in the institution. Because there are vacancies in nursing homes, when a State adopts a Medicaid "money follows the person" program, there is NO ADDITIONAL COST to the State. In fact there will be a saving of money since community-based services are in the aggregate cheaper than nursing homes.

An example: Person A resides in a nursing home funded by your State's Medicaid. In your State, there is a nursing home vacancy rate. If Person A wants to live in the community and the "money follows the individual," it is irrelevant that Person B may want to move into a nursing home because (1) whether or not Person A is in the nursing home or in the community, Person B has an right to reside in the nursing home, and (2) given the vacancy rates, there are unused beds for Person B regardless where Person A lives so the State will pay for Person B wherever Person A lives.

VACANCY RATES
That nursing homes have increasing Medicaid vacancy rates is quite clear: nationally in 1996, there was a 15.2% vacancy rate; 1997, there was 16.1% ; 1998, there was 16.6%; 1999, there was17.3%; and 2000, there 17.6%. That trend has continued in 2001 when the national vacancy rate was about19%.

Nursing Home Beds Vacancy Rates by State as of January 2, 2003.
Alabama 10%; Alaska 16%; Arizona 19%; Arkansas 27%; California 16%; Colorado 10%; Connecticut 7%; Delaware 14%; D.C. 9%; Florida 14%; Georgia 8%; Hawaii 11%; Idaho 33%; Illinois 20%; Indiana 22%; Iowa 15%; Kansas 15%; Kentucky 10%; Louisiana 22%; Maine 10%; Maryland 13%; Mass.10% ; Michigan 12%; Minnesota 7%; Mississippi 12%; Missouri 24%; Montana 12%; Nebraska 14 %; Nevada 29%; New Hampshire 9% New Jersey 12%; New Mexico 18 %;New York 7 %; North Carolina 12%; North Dakota 7%; Ohio 15%; Oklahoma 30%; Oregon 28%; Pennsylvania 12%; Rhode Island 10%; South Carolina 9%; South Dakota 8%; Tennessee 11%; Texas 25%; Utah 24%; Vermont 8%; Virginia 10%;Washington 18%; West Virginia 11%; Wisconsin 15%; Wyoming 18 %. Source: OSCAR (01/02/2003).

The exact percentage is not even critical. Given vacancy rates of any size, as well as the national uproar about increasing Medicaid costs, tell your States to save money, do the right thing, give people a REAL CHOICE, and let the nursing home "money follow the person" into the community so they can live in their own homes.

Texas Money Follows the Person

Source: Steve Gold, Esq.

stevegoldada@cs.com


Texas' Money Follows the Person has operated since September, 2003.
Here is the data for the past nearly two and a half years.

Since it began in Texas, 10,711 people have opted to leave the nursing
facilities, have the institutional MA funds follow them, and move into the
community. Who are these 10,771people and where did they move?

1. Who are they?

Nearly 7.5% are over 90 years of age, and 10 were over 100 years old.
About 38% were under 65 years old, and 11% were under 44 years.
Another 19% were between 65 and 74.

65% were female and 64% were white (not of Hispanic origin).

2. What were their living arrangements when they left the nursing
facilities?

Nearly all received Medicaid Waiver services.

22% live alone, 47% live with family, and 2% live with other persons
who are in a waiver program.

Most of the remaining 29% live primarily in Residential Care or Adult
Foster.

It seems quite reasonable to conclude for at least the 69% who live
either alone or with their families that Texas and the federal
government's Medicaid Programs save significant amounts of money. One
estimate is that Texas saves between 20 and 35% of what it previously
spent for these people in nursing facilities.

Texas's Money Follows the Person has never had an enhanced federal
which will now be available with the new federal Money Follows the Person
MA legislation.

Disability Advocates:

1. Your States can begin a Money Follows the Person program NOW - like
Texas did, or

2. It is estimated that in late August the federal RFP will be available
for the enhanced federal match.

3. Either way, there is NO EXCUSE for States NOT to start a Money
Follows the Person program.

If your State's MA officials wish to learn more about the Texas success,
they can email Mark Gold (not a relative), Manager, Promoting Independence
Initiative, TX Dept of Aging and Disability Services,
www.dads.state.tx.us/business/pi/index.html or 512-438-2260.

Source: The Center for an Accessible Society
2980 Beech St
San Diego, CA 92102
(619) 232-2727

DISABILITY ISSUES INFORMATION FOR JOURNALISTS

Millions of Americans depend on Medicaid to finance their long-term services. But 80 percent of all Medicaid long-term care funds go to nursing homes and other institutional service providers. Only 20 percent supports people living in the community. To be blunt, the government is now spending $45 billion a year to warehouse 2 million Americans, many of whom could receive services in their own homes. This issue will become more acute as the U.S. population ages. Today, roughly 13 percent of the population is over age 65, with 2 percent over age 85. By the year 2040, however, the percentage of Americans over 65 will jump to 21 percent, including 4 percent over 85, thanks to the demographic phenomenon of the "baby boom."

Welcome to the Money Follows The Person Legislation Blog

Thank you for visiting our Blog. The objective of the Blog is to provide information about the new federal legislation.