Medi-Cal Community Based Options

A Summary Discussion For

Aging & Disability Resource Connections (ADRC) Professionals

California Health and Human Services AgencyOctober 2010

Why are ADRCs getting so much attention

HEALTH CARE

COMMUNITY SUPPORTS

Since 1999(US Supreme Court Olmstead Decision)

• Federal Medicaid policy has shifted from limited service menus to self direction and improving consumer access to community living options

• Demographics, life span, and baby boom explosion, assistive technology, and other factors have caused general assumptions about long-term care to be obsolete

• People can and do live actively and successfully with chronic conditions and “disability”

• One size (services & supports) does NOT fit all

From Single Service Silos

To ADRC Connections

ADRCs have what today’s consumers need!

LTC information & resources Mentorship and advocacyBroad knowledge of health care and social

supportsTrustworthy and no/low cost info & serviceExpertise with accessibility issues Experience with current trends and emerging

populations in need – people with economic, family or health care hardships andMORE!

Today’s Discussion by Popular (?) Request….

A brief venture into the world of Medi-Cal…

Don’t be afraid...

Medicaid & Long-Term Care

• Since the early 1900’s there have been long-term care institutions – public and privately funded

• July 30, 1965, Medicaid was established under Title XIX of the Social Security Act (SSA)

• Nursing facility services are among the mandatory state benefits (more on this later)

• Home and community-based services (HCBS) were few and limited to specific sub-groups of consumer population—developmentally disabled, etc.

Medicaid Since 1967

Service provider networks grew around specific sub-groups of consumers; e.g. developmentally disabled, mentally ill, and others

Medicaid waivers were developed with fixed menus of services intended to be available to a limited number of consumers

State and federal policy, funding and reporting requirements formed service delivery silos that were not linked

Improvements and growth were also in silos and depended on consumer advocacy

Olmstead & the Medicaid Bias1999

Mandatory Medicaid coverage for inpatient nursing facility services means all who are eligible can get inpatient nursing facility care (assuming availability).

AS COMPARED TO

Optional Medicaid benefits (like personal care) and limited HCBS waivers with specified services menus and capped for the numbers of people to be served

Olmstead Planning2000 to Present

CA began convening department directors Identify CA service networks and gaps Policy in place and policy needed What changes require legislation and/or funding Public forums to gather consumer inputs Study of financing options Grant initiatives and demonstrations

Time out…..It’s confusing!

Medicaid• Called Medi-Cal in CA• Health care coverage for those

with low income and few assets

• Automatic Medi-Cal with SSI/SSP eligibility

• Those who are eligible are entitled to a scope of benefits determined by states

• Covers LTC• Administered by States

Medicare• Health care coverage for those

over 65 years old, those under age 65 with certain disabilities, and people of all ages with end stage renal disease (ESRD)

• Part A -- hospital care • Part B -- primary medical care• Part D -- prescription drugs• Does NOT cover LTC (beyond

about 90 days rehab) • Administered by federal CMS

Medicaid/Medi-Cal Authority

Federal HHS • Federal Law - Title XIX of

the Social Security Act (SSA)

• Mandatory Benefits• Optional Benefits• HCBS waivers• Demonstrations• Grants & Other

initiatives

State Single Medicaid Agency (DHCS in CA)

(w/CMS approval)• State Law - W&I Code • Medi-Cal State Plan• State Plan Amendments (SPA)• Regulations CCR Title 22:

Service approval criteria for medical necessity

• Demonstrations• Waivers

MedicaidRoles and Responsibilities

Federal CMSMedicare & MedicaidCMS part of federal HHS Oversight of State Single

State AgenciesCentral & Regional OfficesApproves/monitors/audits

state policy, benefits, expenditures and operations

State DHCSMedicaid is called Medi-CalDHCS is Single State AgencyMedi-Cal State Plan – Benefits

modified by State Plan Amendments (SPA)

Develops demonstrations and waivers subject to CMS approval

Policy & Payment AccountabilityQuality & Audits

Some Basic Medicaid Requirements

Privacy: States and providers may not reveal (without their permission) that any individual is eligible for Medicaid and must implement HIPAA requirements for protection of Personal Health Information(PHI)

Informed Choice: Individuals must have information in order to have choice among qualified providers (unless choice is waived with approval from CMS); e.g. mandatory enrollment into a managed care plan

Quality: States must have protocols to monitor quality of serviceUtilization Review: State accountability for medical necessity (utilization

review) and fiscal responsibilityConsumer Due Process: Consumers must be informed of due process (Fair

Hearing) if there is denial or reduction of benefits Provider Appeals: Providers may appeal the state’s denial or reduction of

services requested via the TAR process

Medicaid Benefits(Federal Law)

Mandatory Benefits• Doctor Visits• Hospitalization• Lab & X-Ray• Inpatient Hospital• EPSDT • Rural Health Clinics• Family Planning• And others

Optional Benefits States Decide• Personal Care• Home & Community Based

Services• Prosthetics• Clinics• Dental• IMD (Institution for mental

disease)• And OthersAre we having fun yet?

Medi-Cal Benefits

• Described in the Medi-Cal State Plan • All Mandatory benefits• Optional benefits – for example, personal care services (aka

IHSS), drugs, prosthetics, therapies (PT, OT), home health and others

• Several Waivers• Several Demonstrations

Medi-Cal Service Delivery & Financing

Fee For Service -- each authorized service provider is reimbursed per Medi-Cal rates set by DHCS

Medi-Cal Managed Care (MCMC) County Operated Health System (COHS) – one

plan 2 Plan Model (in a county, 1 non-profit and 1

commercial plan) Geographic Managed Care (GMC) competitive

procurement for many plans in a county

What is a TAR? Treatment Authorization Request (TAR) Medi-Cal system for obtaining “prior authorization” Submitted by a provider on behalf of the person who needs service Provider must be approved Medi-Cal provider of a specific type Submitted to Medi-Cal Field Offices or to DHCS Types of services requested Quantity and frequency of services (for example, Home Health Agency

services - One 2/hour visit each week) Documentation of need (conditions, diagnosis, labs, doctor orders (RX) Treatment Plan in some situations New providers can get training on Medi-Cal systems New providers must sign agreement to Medi-Cal rules

TAR

FF

MEDI-CAL ALPHABET SOUP

COHSSPA

EPSDTHCBS

GMC

IMD

LOC

MCM

TAR

ICF

NF

SOC

IHSSADRC

FI

What About Long-Term CareUnder Medi-Cal?

Nursing Facility • State Plan Benefit• DHCS sets rates for Fee For Service

(FFS) NF services• DPH/L&C Monitors State Licensure

and Federal Certification • Some Medi-Cal Managed Care

Plans (MCMC) plans include inpatient NF care (COHSs for example)

• FFS NF TARs go to San Bern FO• Typically, Medicare for short rehab,

then Medi-Cal if eligible for long-term

Home & Community• Several HCBS Waivers, each for a

consumer profile• Personal Care Services/IHSS

through County DSS• Primary Care and Therapies that

the person needs• Mostly FFS• TARs to office specified in waiver

(more later)• Demonstrations• MFP – California Community

Transitions • TARs to DHCS in Sacramento

Medicaid Demonstrations

• Enables flexibility for states• States apply to CMS to prove efficiency, quality or

other benefit to consumers• Allowed under SSA § 1115 • Complex application describing benefits, quality

monitoring and multi-year budget showing cost neutrality

• CA Example: Money Follows the Person Demonstration

California Community Transitions

More about Medicaid Waivers

• Waives a specific federal Medicaid requirement in a sub-section (§)of SSA (CMS must approve)

• Waives choice, comparability, or statewideness • For example, Sec 1915(b) waiver of choice enables

states to have mandatory enrollment of members into managed care plans

• States must apply to CMS and describe what is being waived, how many people can be served, services are available, and among other things, how the state will ensure quality

Home & Community-Based Services (HCBS) Waivers

• Authorized under SSA § 1915©• Specific population profile• Specifies a menu of services• HCBS services in lieu of inpatient nursing facility services• Uses same T22 Level of Care (LOC) criteria as inpatient

facility services to prove cost neutrality and “medical necessity”

• Services “prior authorized” by Medi-Cal employees (Field Offices or in Sacramento) via Treatment Authorization Requests (TAR)

Medi-Cal HCBS Waivers

Title• Assisted Living• AIDS Waiver• Developmentally Disabled (DD) • Multipurpose Senior Services

Program (MSSP)• Nursing Facility/Acute Hospital

(NF/AH)• Traumatic Brain Injury (TBI)

(pending)

Administered by DHCS and:• DHCS (directly)• DPH/Office on AIDS• DDS• CDA

• DHCS (directly)

• DOR

** DSS administers Personal Care Services -- IHSS is not

a waiver) ** All Medi-Cal oversight is by DHCS

How Does a Person Apply for HCBS Waiver Services ?

• Currently HCBS entry points differ We’ll talk about this in a minute• Application by TAR (prior authorization of services

and documented need -- establishes need aka LOC)• Major components of a home plan not covered by

Medi-Cal Housing Non-medical transportation Meals (unless medical modified diet)

Eligibility for HCBS Waivers Level of Care (LOC)

• Consumer’s level of need (acuity)

• CCR Title 22 (State regulations)

• Used to authorize, modify or deny the TAR

• Establishes a consumer’s eligibility for NF

• Establishes cost neutrality of HCBS in lieu of inpatient NF services

NF LOC = CCR T22

• ICF (NF-A) = CCR/T22 51120 Intermittent need for medical

professional assessment & treatment; needs some assistance with ADL/IADLs*

• NFB = CCR/T22 51124Ongoing, long-term need for

professional assessment & treatment & ongoing need for assistance with ADLs/IADLs*

*Ridiculously over simplified

Review the List of

Medi-Cal LTC Options

But What About Someone in MCMC?

• Authorization system depends on the managed care plan and included benefits

• HCBS usually “carved out” • Either the person must:

disenroll from MCMCget the HCBS service as FFSPACE and SCAN are not typical MCMC – both include some HCBS

So Not The End….

HEALTH CARE

COMMUNITY SUPPORTS