mary sowers nasddds july 14, 2014 nasddds national association of state directors of developmental...
TRANSCRIPT
Mary SowersNASDDDS
July 14 2014
NASDDDSNational Association of State Directors of Developmental Disabilities Services113 Oronoco Street Alexandria VA 22314Tel 7036834202 Fax 7036841395Web wwwnasdddsorg
Medicaid Basics Medicaid HCBS Basics Medicaid Authorities Opportunities for
Assistive Technology Coverage New HCBS Regulations Questions
2
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Medicaid can be an important source of public financing for assistive technology
In addition to medical and rehabilitative uses AT can also play a key role in assisting individuals return to or remain in their homes and communities and avoid institutional utilization
To understand how AT is covered in Medicaid it is important to understand some Medicaid basics
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Established in 1965 as a companion program to Medicare
ldquoGrants to States for Medical Assistance Programsrdquo ndash Medicaid
FederalState entitlement partnership program
Medicaid mandates some eligibility groups and services States may elect to include other groups and benefits
4
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Medicaid State Plan has historically referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute
With additions to the SSA a statersquos Medicaid State Plan can include more services and benefits than those in 1905(a)
There are now HCBS state plan benefits described more fully below at 1915(i) and 1915(k) of the SSA
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Under the traditional Medicaid State Plan states often cover some AT through Home Health Services andor Durable Medical Equipment
Coverage and payment for items varies by state Medically-necessary DME for use in the home or to
function in the community States may have a list of preapproved items with established process for modifications or exceptions
Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid Basics Medicaid HCBS Basics Medicaid Authorities Opportunities for
Assistive Technology Coverage New HCBS Regulations Questions
2
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Medicaid can be an important source of public financing for assistive technology
In addition to medical and rehabilitative uses AT can also play a key role in assisting individuals return to or remain in their homes and communities and avoid institutional utilization
To understand how AT is covered in Medicaid it is important to understand some Medicaid basics
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Established in 1965 as a companion program to Medicare
ldquoGrants to States for Medical Assistance Programsrdquo ndash Medicaid
FederalState entitlement partnership program
Medicaid mandates some eligibility groups and services States may elect to include other groups and benefits
4
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Medicaid State Plan has historically referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute
With additions to the SSA a statersquos Medicaid State Plan can include more services and benefits than those in 1905(a)
There are now HCBS state plan benefits described more fully below at 1915(i) and 1915(k) of the SSA
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Under the traditional Medicaid State Plan states often cover some AT through Home Health Services andor Durable Medical Equipment
Coverage and payment for items varies by state Medically-necessary DME for use in the home or to
function in the community States may have a list of preapproved items with established process for modifications or exceptions
Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid can be an important source of public financing for assistive technology
In addition to medical and rehabilitative uses AT can also play a key role in assisting individuals return to or remain in their homes and communities and avoid institutional utilization
To understand how AT is covered in Medicaid it is important to understand some Medicaid basics
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Established in 1965 as a companion program to Medicare
ldquoGrants to States for Medical Assistance Programsrdquo ndash Medicaid
FederalState entitlement partnership program
Medicaid mandates some eligibility groups and services States may elect to include other groups and benefits
4
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Medicaid State Plan has historically referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute
With additions to the SSA a statersquos Medicaid State Plan can include more services and benefits than those in 1905(a)
There are now HCBS state plan benefits described more fully below at 1915(i) and 1915(k) of the SSA
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Under the traditional Medicaid State Plan states often cover some AT through Home Health Services andor Durable Medical Equipment
Coverage and payment for items varies by state Medically-necessary DME for use in the home or to
function in the community States may have a list of preapproved items with established process for modifications or exceptions
Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Established in 1965 as a companion program to Medicare
ldquoGrants to States for Medical Assistance Programsrdquo ndash Medicaid
FederalState entitlement partnership program
Medicaid mandates some eligibility groups and services States may elect to include other groups and benefits
4
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Medicaid State Plan has historically referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute
With additions to the SSA a statersquos Medicaid State Plan can include more services and benefits than those in 1905(a)
There are now HCBS state plan benefits described more fully below at 1915(i) and 1915(k) of the SSA
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Under the traditional Medicaid State Plan states often cover some AT through Home Health Services andor Durable Medical Equipment
Coverage and payment for items varies by state Medically-necessary DME for use in the home or to
function in the community States may have a list of preapproved items with established process for modifications or exceptions
Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid State Plan has historically referred to the list of services (both mandatory and optional) identified in Section 1905(a) of the statute
With additions to the SSA a statersquos Medicaid State Plan can include more services and benefits than those in 1905(a)
There are now HCBS state plan benefits described more fully below at 1915(i) and 1915(k) of the SSA
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Under the traditional Medicaid State Plan states often cover some AT through Home Health Services andor Durable Medical Equipment
Coverage and payment for items varies by state Medically-necessary DME for use in the home or to
function in the community States may have a list of preapproved items with established process for modifications or exceptions
Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Under the traditional Medicaid State Plan states often cover some AT through Home Health Services andor Durable Medical Equipment
Coverage and payment for items varies by state Medically-necessary DME for use in the home or to
function in the community States may have a list of preapproved items with established process for modifications or exceptions
Sometimes access can be complex especially for individuals eligible for both Medicare and Medicaid
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
States may offer HCBS through a number of statutory authorities as well as some time-limited grant programs
Increased demand from individuals and families the Olmstead decision other litigation and DOJ enforcement has spurred significant growth in HCBS over the past decade
The two primary HCBS sources for AT include 1915(c) HCBS waivers and 1915(i) HCBS as a State Plan Option
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Section 1915(c) of the Social Security Act originally enacted in 1981 (with some amendments since then) remains the predominant vehicle for the delivery of HCBS More than 300 waivers serving more than 1
million people In federal fiscal year (FFY) 2011 total state and
federal expenditures for Section1915(c) waiver programs totaled nearly $38 billion1
1 CMS Truven Health Analytics Medicaid Expenditures For Section 1915(c) Waiver Programs In FFY 2011 Steve Eiken Brian Burwell Lisa Gold Kate Sredl Paul Saucier October 2013
8
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Title XIX permits the Secretary of Health amp Human Servicesto waive certain provisions required through the regular State Plan process For 1915(c) HCBS waivers the provisions that can
be waived are related to Comparability (amount duration and scope) ndash
provides ability to target benefit Statewideness Income and resource requirements
9
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Permits States to provide HCBS to people who would otherwise require Nursing Facility (NF) Intermediate Care Facilities for the Mentally Retarded (ICFsMR) or hospital Level of Care (LOC)
Serves diverse target groups ndash including individuals with intellectual and developmental disabilities individuals with physical disabilities individual who are aging and those with mental health support needs
Services can be provided on a less than Statewide basis
Allows for participant-direction of services
10
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Costs HCBS must be ldquocost neutralrdquo as compared to institutional services on average for the individuals enrolled in the waiver
LOC Institutional levels of care define waiver LOC and the populations that may be targeted
Choice HCBS participants must have the choice of all willing and qualified providers
11
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Home Health Aide Personal Care Case Management Adult Day Health Habilitation Homemaker Respite CareFor chronic mental illness Day TreatmentPartial Hospitalization Psychosocial Rehabilitation Clinic Services AND Other Services ndash can be State-
proposed service specifications
12
NASDDDSNational Association of State Directors of Developmental Disabilities Services
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
AT is commonly covered in 1915(c) waivers States cover a wide array of technology
including commercially available technology when it is addressing an identified need in an individualrsquos plan of care
States frequently include annual multi-year andor lifetime dollar limits on AT
Prior authorization is also common for technology costing over certain amounts
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
CMS offers the following Core Service Definition for Assistive Technology but states may amendchange as needed
Assistive technology device means an item piece of equipment or product system whether acquired commercially modified or customized that is used to increase maintain or improve functional capabilities of participants Assistive technology service means a service that directly assists a participant in the selection acquisition or use of an assistive technology device Assistive technology includes-- (A) the evaluation of the assistive technology needs of a participant including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant (B) services consisting of purchasing leasing or otherwise providing for the acquisition of assistive technology devices for participants (C) services consisting of selecting designing fitting customizing adapting applying maintaining repairing or replacing assistive technology devices (D) coordination and use of necessary therapies interventions or services with assistive technology devices such as therapies interventions or services associated with other services in the service plan (E) training or technical assistance for the participant or where appropriate the family members guardians advocates or authorized representatives of the participant and (F) training or technical assistance for professionals or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of participants
NASDDDSNational Association of State Directors of Developmental Disabilities Services
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
CMS ReviewApproval Process CMS approves a new waiver for a period of 3
years (possible 5 years for programs serving MedicareMedicaid eligible individuals)
States may request amendments at any time States may request that waivers be renewed CMS
considers whether the State has met statutoryregulatory assurances in determining whether to renew
Renewals are granted for a period of 5 yearsEach of these opportunities for change or
renewal offers an opportunity to add or improve AT coverage
15
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Originally authorized under the Deficit Reduction Act of 2005 (effective 2007) 1915(i) permits states to offer HCBS as a state plan option
The Affordable Care Act of 2010 amended 1915(i) providing states opportunity to target benefit and to offer services entirely consistent with those available under 1915(c)
NASDDDSNational Association of State Directors of Developmental Disabilities Services
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
May target services to specific groups (waives comparability)
Evaluation to determine program eligibility
Assessment of need for services
Plan of care
Health and Welfare and Quality Requirements
Self Direction Same allowable services Both use a preprinted application format
17
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Financial Eligibility Criteria
Program Eligibility
Institutional care requirements
Length of time for operation
Financial estimates
Waiver of statewideness
18
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
1915(c)
Must have eligibility criteria at least as stringent as the institutions
LOC must beequal to or greater than institution but not less than institution
1915(i)
Needs based not tied to institutional criteria
But institutional criteria must be more stringent than 1915(i) needs-based criteria therefore
Needs-based eligibility criteria must be
less than institution
19
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
1915(c) Can cap the numbers
served May have a waiting
list Can cap individual
expenditures
1915(i) Cannot cap the
numbers served or individual expenditure
All eligibles are entitled to the program
May NOT have a waiting list
Eligibility assessment must be independent
20
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
1915(c)
3 years initial 5 years upon
renewal
1915(i)
If state targets 5 years until renewal
Indefinite if state does not target
21
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
1915(c)
Reasonable estimates of cost and utilization
Program must be cost neutral compared to institutional care
1915(i)
Reveal payment methodology on Attachment 419-B of the State Plan
22
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
1915(i) permits all statutory and ldquootherrdquo 1915(c) services
Under 1915(i) and (c) states can ldquotargetrdquo services to specific populations Example autism services recovery services
May have multiple iSPAs or HCBS waivers Same prohibitions on covering services
that otherwise would be covered through IDEA or the Rehabilitation Act
23
NASDDDSNational Association of State Directors of Developmental Disabilities Services
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
1915(c)
May waive statewideness
1915(i)
May not waive statewideness
24
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
As of June 2014 14 states have approved 1915(i) SPAs California Colorado Connecticut Florida Idaho Indiana Iowa Louisiana Michigan Mississippi Montana Nevada Oregon Wisconsin
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Many states are considering moving HCBS and other LTSS into a managed care environment
Assistive technology may be included in services covered by managed care entities
States may also allow managed care entities to provide cost effective alternatives to covered services ndash Assistive technology may play a key role in those alternatives
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
States may have a set array of technology they will pay for in their standard fee-for-service arrangements
In some states self-direction through the management of an individual budget may afford even greater opportunity for individualized AT
Self-direction is an option in both 1915(c) and 1915(i) HCBS programs
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c) 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate
To enhance the quality of HCBS and provide
protections to participants
28
NASDDDSNational Association of State Directors of Developmental Disabilities Services
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
States can now combine multiple target populations within one 1915(c) waiver
Gives CMS with new compliance options for 1915(c) waiver programs not just approvedeny
Establishes five-year renewal cycle to align concurrent authorities for certain demonstration projects or waivers for individuals who are dual eligible
Includes a provider payment reassignment provision to facilitate certain state initiatives (payment of health premiums or training costs for example)
29
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Conflict-free case management Was just in guidance now it is in rule
Implements the final rule for 1915(i) State plan HCBSmdashsame requirements on HCB settings character person-centered planning
Makes clear HCB settings characteristics also apply to 1915(k) Community First Choice option
Sets conditions and timelines for filing transition plans and coming into compliance with the HCB settings requirements
30
NASDDDSNational Association of State Directors of Developmental Disabilities Services
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
HCB Settings Character What is NOT community What is likely not community What is community
Person-centered planning Codifies requirements
Transition planning-coming into compliance with the HCB settings requirements
31NASDDDS 41714
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
42CFR441310(C)(4)Is integrated in and supports access to the greater community
Provides opportunities to seek employment and work in competitive integrated settings engage in community life and control personal resources
Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services
32
NASDDDSNational Association of State Directors of Developmental Disabilities Services
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
As states identify strategies to meet the obligations of the new regulations they may look to technology to assist individuals to more effectively engage in their community get and maintain employment develop social networks and communicate with friends family and co-workers
NASDDDSNational Association of State Directors of Developmental Disabilities Services
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Determining whether what and how your state covers AT can be daunting
Building relationships becoming informed and educating others are key to having a voice in future AT coverage strategies
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
A key message to policy-makershellipAT may be the necessary difference for individuals to live work and meaningfully engage in community
NASDDDSNational Association of State Directors of Developmental Disabilities Services
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
A number of states such as Ohio and Indiana have made strides in expanding access to AT to increase community living and participation
To learn more about state activity and options wwwmedicaidgov Coleman Institute
httpwwwcolemaninstituteorg
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
wwwnasuadorg
2014 State of Aging and DisabilitiesAssistive Technology and Medicaid
July 14 2014
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
NASUAD Overview
bull Founded in 1964 to represent state agencies on aging
bull In 2010 changed name in recognition of the fact that most state agencies served aging and disability populations
bull 56 members Represents State and Territorial Agencies on Aging and Disabilities
bull Board of Directors ndash Executive Officers 10 regional representatives and 10 regional alternate reps
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Our mission
To design improve and sustain state systems delivering home and community based services and supports for
the elderly and individuals with disabilities and their caregivers
Page 39
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Key Resources
bull NASUADorgbull HCBSorgbull NASUADiQorgbull Friday Updatebull Integration Trackerbull Expansion Tracker
Page 40
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Join us at the 30th annual HCBS conferencebull September 15-18 2014 Crystal City VAbull 5 pre-conference intensivesbull 130 sessions covering all populations receiving LTSSbull 1000 attendees representing state policymakers
federal officials staff academics businesses etc
bull For more information wwwnasuadorg
Page 41
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Aging amp Disability Agencies
Page 42
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 43
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 44
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 45
Managing relationships identified as key job responsibility
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Medicaid HCBS Options
Page 46
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 47
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 48
Change in Waiver Caseload for Older Adults and Adults with Physical Disabilities Served by Medicaid HCBS Waivers
Compared to SFY 2012 in SFY 2013 the Waiver Caseload
Increased DecreasedStayed the
Same Not Applicable
of States of States of States of States
Alzheimers Disease 258 00 161 581
Autism 138 00 138 724
IntellectualDevelopmental Disabilities 333 00 167 500
Older Adults 629 00 143 229
Older Adults and Adults with Disabilities 545 91 212 152
Adults with Physical Disabilities 567 00 200 233
Severe Emotional Disturbance 179 00 107 714
Traumatic Brain Injury 214 36 250 500
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 49
Percent Change in State Medicaid HCBS Waiver Expenditures for Older Adults and Adults with Physical Disabilities
2012 - 2013 Percent Change in Waiver Expenditures
Less than 5 5-8 8-15 More than 15 Not Applicable
of States of States of States of States of States
Alzheimers Disease 125 00 00 00 875
Autism 80 00 40 00 880
IntellectualDevelopmental Disabilities 200 80 120 00 600
Older Adults 179 143 143 71 464
Older Adults and Adults with Physical Disabilities 296 37 148 185 333
Adults with Physical Disabilities 125 83 42 83 667
Severe Emotional Disturbance 83 42 00 00 875
Traumatic Brain Injury 42 125 00 42 792
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Assistive Technology Coverage
Page 50
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
2012 Survey of Assistive Technology and State Agencies
bull Types of assistive technology funded by 20 surveyed state agencies on aging and disabilities ndash Seventeen states fund some type of personal
emergency response system (PERS) ndash Six states fund technology to support home andor
vehicle modifications ndash Three states (Colorado Iowa and Minnesota) use
telehealthtelemedicine ndash Three states (Colorado Maine and Minnesota) use
telemonitoring or wander locating ndash Two states (Minnesota and Texas) use remote
medication management automated medication dispensing
Page 51
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 52
State Services Available to Specified Populations through Medicaid HCBS Waivers
Older AdultsIndividuals with Physical
Disabilities Individuals with IDD Individuals with TBI
of States of States of States of States
Adult Day Health (includes health component) 28 23 14 12
Adult Day Social (does not include health component) 26 16 15 11
Adult Foster Care 14 15 12 5
Assisted Living 28 25 5 7
Assistive Technology 27 27 27 19
Behavioral Supports 10 12 26 12
Environmental Modifications 31 32 27 16
Home-Delivered Meals 31 23 10 8
Personal Assistance Services 32 32 27 17
Personal Emergency Response Systems 34 28 21 11
Physical Therapy 12 13 18 8
Recreation Therapy 2 3 4 0
Residential Habilitation 3 4 25 9
Respite 35 30 27 14
Specialized Equipment and Supplies 28 30 23 16
Speech Therapy 10 11 15 6
Supported Employment 4 6 28 10
Transportation 32 28 27 16
Extended State Plan Waiver Benefit Personal Care 9 9 6 4
Extended State Plan Waiver Benefit Nursing 8 10 8 4
Extended State Plan Waiver Benefit Home Health 7 7 4 4
Extended State Plan Waiver Benefit Other 4 3 6 3
N=40
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Examples Oklahoma (IDDD)
bull Remote Monitoring service is the monitoring of an adult member in his or her residence by staff using one or more of the following systems ndash live video feedndash live audio feedndash motion sensing systemndash radio frequency identificationndash web-based monitoring system or ndash other device approved by OKDHSDDSD
bull The system shall include devices to engage in live two-way communication with the member being monitored as described in the memberrsquos Plan
Page 53
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Examples Oklahoma (IDDD)bull Assistive devices for members who are deaf or hard of hearing
ndash visual alarms
ndash telecommunication devices (TDDs) telephone amplifying devices and
ndash other devices for protection of health and safety
bull Assistive devices for members who are blind or visually impaired
ndash tape recorders
ndash talking calculators
ndash lamps magnifiers
ndash Braille writers paper and talking computerized devices and
ndash other devices for protection of health and safety
bull Augmentativealternative communication and learning aids such as language boards electronic communication devices and competence based cause and effect systems
bull Mobility positioning devices such as wheelchairs travel chairs walkers positioning systems ramps seating systems lifts bathing equipment specialized beds and specialized chairs
bull Orthotic and prosthetic devices such as braces and prescribed modified shoes
bull Environmental controls such as devices to operate appliances use telephones or open doors
Page 54
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Examples Pennsylvania (Seniors)
bull TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence quality of life and reduce the need for nursing home placement By utilizing in-home technology more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization TeleCare services are specified by the service plan as necessary to enable the participant to promote independence and to ensure the health welfare and safety of the participant and are provided pursuant to consumer choice
bull TeleCare includes ndash 1) Health Status Measuring and Monitoring TeleCare
Servicendash 2) Activity and Sensor Monitoring TeleCare Service and ndash 3) Medication Dispensing and Monitoring TeleCare
Services
Page 55
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Example New York (Aged and Physical Disabilities)
bull Assistive Technology Supports are specialized equipment and supplies that enable a client to increase maintain or improve hisher functional capabilities It includes the evaluation and purchasing (not leasing) of the assistive technology It includes selecting designing fitting customizing adapting applying maintaining repairing or replacing the assistive technology device and any training or technical assistance for the client and family members guardians etc
Page 56
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State Example South Carolina (TBI or Spinal Cord Injuries)
bull Supplies Equipment and Assistive Technology means medical supplies and equipment and specialized appliances devices or controls necessary for the personal care of a HASCI Waiver participant or to increase his or her ability to perform activities of daily living or interact with others It includes items needed for life support and ancillary supplies and equipment necessary for the proper functioning of such items Excluded are items not of direct medical or remedial benefit to the participant
Page 57
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid and Managed LTSS
Page 58
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid Managed Care bull Managed Care in Medicaid can mean different things
includingndash Comprehensive contracts with health plansndash Contracts with limited benefit plans such as
bull Prepaid Inpatient Health Plans (PIHPs)bull Prepaid Ambulatory Health Plans (PAHPs)
ndash Primary Care Case Management and other ldquomanaged fee-for-servicerdquo
ndash Program for All-inclusive Care for the Elderly (PACE) Plans and
ndash Others
Page 59
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Managed Care and MLTSS Growth Continues but Slows
bull Historically Medicaid Managed Care was largely limited to Children Parents Pregnant Women and other ldquoless complexrdquo populations
bull States began including primary and acute care for some seniors and individuals with disabilities which could include DME and other medically-oriented AT
bull A growing number of States are expanding managed care to encompass comprehensive benefits including LTSS
Page 60
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid Managed Care Statistics (FY 2011)
bull 41 percent of enrollees age 65+ were in some form of managed care
bull 87 percent of non-disabled children were in managed care
bull Comprehensive MCO enrollmentndash 14 of aged beneficiariesndash 33 of individuals with disabilitiesndash 48 of adults without disabilities andndash 63 of children without disabilities
Page 61
Source MACPAC June 2014
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 62
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 63
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 64
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 65
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 66
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Page 67
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Medicaid MCOs Bring Challenges and Opportunities
bull MCOs are frequently given latitude tondash Establish selective provider networksndash Negotiate rates and contractual requirements with providers
and suppliersndash Develop prior authorization and utilization controls
bull Medicaid MCOs are given strong incentives to provide care in a cost-effective manner creating a value-proposition dynamicndash AT providers can benefit when they demonstrate value by
reducing other costs such as hospitalization post-acute and nursing homes
ndash However this dynamic can be challenging for providers that are used to being paid directly by the State at predetermined rates and in many cases without performance standards
Page 68
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State AT Involvement and
MedicaidMarty Exline
Missouri Assistive TechnologyJuly 14 2014
Missouri Assistive Technology
Blue Springs Missouri 64015
816-655-6700
Martyexlineattnet
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Challenges amp Opportunities
What AT is covered in my statersquos HCBS waivers
bullStatersquos Waiver applications
bullState annual 372 report to CMS
bullContact your state waiver manager
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
ASSISTIVE TECHNOLOGY in HCB WAIVERS
CMS Technical Assistance Guide 35
bull Home Accessibility Adaptations
bull Environmental Accessibility Adaptations
bull Vehicle Modifications
bull Specialized Medical Equipment amp Supplies
bull Personal Emergency Response Systems
bull Assistive Technology
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
Source FY12 372 Reports
Comprehensive Support Autism MOCDD Partnership Total
Total Waiver Expenditures $512677539 $15588016 $1513136 $2421925 $5840897 $538041513
Total Unduplicated Participants 8126 1406 160 207 1314 11213
Total EAA Costs $238037 $85277 $0 $79516 $90612 $493442
Unduplicated Participants Receiving EAA 69 22 0 23 20 134
DD Waiver-Environmental Accessibility Adaptations (EAA)
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
OKLAHOMA Able TECH
Living Choice Advisory Committee
AT in my Life My Choice Waiver Policy to increase or maintain functional abilities
State plan coverage of iPads for communication
Provider for OK Medicaid
DME Re-use
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
VERMONT ASSISTIVE TECHNOLOGY PROGRAM
bull Piloting an MFP ldquoAT and Access Evaluationrdquo
bull 3 ndashStep Process
bull VATP reviews Eval Reportdevice loans for trialsreuse project
bull DD Technology Workgroup
bull State plan coverage for iOS devices for communication
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
MISSOURI ASSISTIVE TECHNOLOGY
bull AT in all DD HCB waivers
bull Developed guidelines for coverage
bull Provider of AT for DD waivers
bull Training
bull Money Follows the Person
bull Stakeholder Group
bull Training for MFP Contact Agencies
bull MFP training for nursing facilities
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
ASSISTIVE TECHNOLOGY PROGRAM of COLORADO
bull In regular meetings with Medicaid to reconfigure all HCBS waivers
bull Has hosted meetings at their facility
bull AT Advisory Committee Co-chair serves on MFP advisory board
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
NEBRASKA ASSISTIVE TECHNOLOGY PARTNERSHIP
bull Provider for NE Aged amp Disabled Waiver
bull Collaborated to develop referral process guidelines regulations forms etc
bull Provides assessments for home modifications and AT
bull $5000 cap on service so provides funding coordination
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-
State AT Considerations
bull Broad terminology
bull Watch exclusions
bull Evaluations amp training included
bull Waiver service cost maximums
bull State plan services
bull Help suggest language for guidelines
- NASUAD Overview
- Our mission
- Key Resources
- Join us at the 30th annual HCBS conference
- State Aging amp Disability Agencies
- Slide 43
- Slide 44
- Slide 45
- State Medicaid HCBS Options
- Slide 47
- Slide 48
- Slide 49
- State Assistive Technology Coverage
- 2012 Survey of Assistive Technology and State Agencies
- Slide 52
- State Examples Oklahoma (IDDD)
- Slide 54
- State Examples Pennsylvania (Seniors)
- State Example New York (Aged and Physical Disabilities)
- State Example South Carolina (TBI or Spinal Cord Injuries)
- Medicaid and Managed LTSS
- Medicaid Managed Care
- Managed Care and MLTSS Growth Continues but Slows
- Medicaid Managed Care Statistics (FY 2011)
- Slide 62
- Slide 63
- Slide 64
- Slide 65
- Slide 66
- Slide 67
- Medicaid MCOs Bring Challenges and Opportunities
-