Federal Initiatives Impacting the Aging

Network

Sandy Markwood, n4aWRAAA Annual Luncheon

May 10, 2012

1. Long-Term Services and Supports Systems Transformation

2. Implementation of the Affordable Care Act3. Older Americans Act Reauthorization Update 4. The Federal Budget Process FY13 Appropriations

Outlook5. Advocacy Strategies- Letting Your Voice be

Heard!

Today’s Agenda

LTSS Systems Transformation

Medicaid Managed Care, Dual Eligibles, HCBS

State Agency Restructuring

State Agencies that have restructured since 2009

FL

Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

Population Growth Shifting Demographics Also Contribute to Increased Demand

Source: This table was compiled by the U.S. Administration on Aging using 2000 Census data

Population Growth

Page 6

2002 2003 2004 2005 2006 2007 2008 2009 20108,000,000

9,000,000

10,000,000

11,000,000

12,000,000

13,000,000

14,000,000

15,000,000

Below 200% FPL with Work Disability

Below 250% FPL with Work Disability

Year

Num

ber

of

Pers

ons

While the number of persons with disabilities is also increasing

Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

What is Medicaid Managed Long-Term

Care? Capitated MMLTC State Medicaid Agency and contractors enter into agreement

under which contractor accepts risk of providing defined Medicaid LTC services

Alternative types of MMLTC capitation packages: Medicaid-covered LTC services only All Medicaid-covered acute and LTC services All Medicare and Medicaid-covered services

(additional plan contract with CMS required for Medicare portion)

ManagedCareContractor

ManagedCareContractorCapitated

Payment

StateMedicaidAgency

StateMedicaidAgency

ProvidersProviders

NegotiatedPayments(FFS, Per Diem, etc.)

Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.

MMLTC is Delivery Model States Use in Lieu of Fee-for-Service

Three Basic MMLTC Models

Source: AARP Public Policy Institute Issue Brief, Medicaid Managed Long-Term Care, 2005.

MODEL 1: Medicaid LTC Only

MODEL 2: Medicaid-Only

MODEL 3: Medicaid-Medicare Integration

Medicaid Services for Which Managed Care Contractor is at Risk

Home and Community Based Services (HCBS)Nursing Home Care

HCBSNursing Home CareMedicaid-Covered Primary Care ServicesMedicaid-Covered Acute Care ServicesMedicaid-Covered Pharmacy

HCBSNursing Home CareMedicaid-Covered Primary Care ServicesMedicaid-Covered Acute Care ServicesMedicaid-Covered Pharmacy

Medicare Services for Which Managed Care Contractor is at Risk

None None Medicare Acute Care benefitsMedicare Prescription Drug Benefit

Dual eligibles may also be enrolled in Medicare managed care and receive Medicaid LTC services in either FFS Medicaid, or in MMLTC Models 1 or 2

Medicaid Managed Care

MI

AK

HI

CA

WI

WA

OR

ID

WY

UT

AZ

NM

NV

TX

MN

IA

MO

OK

NE

KS

SD

NDMT

AL

LA

FL

TN

IN OHIL

PA

WVVA

KY

NC

SC

GA

AR

MS

ME

NY

VTNH

MA

RI

CT

NJ

DE

MDCO

Nearly half of states have or are planning Medicaid Managed Long Term Care Programs

Percent Change

Existing Program(in 2010 or 2011)

Plan to Implement in 2012

Plan to Implement in 2013

On the Verge: The Transformation of Long-Term Services and Supports; NASUAD, AARP Public Policy Institute, HMA; February 2012.Source: On the Verge: The Transformation of Long-Term Services and Supports; NASUAD, AARP Public Policy Institute, HMA; February 2012.

Dual Eligibles

Dual Eligibles

Green States: Through the State Demonstrations to Integrate Care for Dual Eligible Individuals program , CMS provided design contracts of up to $1 million to 15 states to develop new approaches to better coordinate care for dual eligible individuals.

Maroon States: Thirty-eight states (including the 15 that received grants) submitted letters expressing interest in pursuing the demonstration program.

Source: National Senior Citizens Law Center Duals Advocacy Website

State Demonstrations to Integrate Care

HCBS Waivers

Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

HCBS Waiver Expenditures

10

6

9

2

0

2

4

6

8

10

12

Less than 5% 5%-8% 8-15% More than 15%

Nu

mb

er

of

Stat

es

Percentage Range of Increases in HCBS Expenditures2010 to 2011

HCBS Waivers

Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

HCBS Waiver Caseload

6

7

0

3

31

27

0 10 20 30 40

2012

2011

Number of States

Changes in HCBS Caseload From Previous Year

Increased

Decreased

Stayed the same

Source: On the Verge: The Transformation of Long-Term Services and Supports; NASUAD, AARP Public Policy Institute, HMA; February 2012.

Affordable Care Act1915(i), Community First Choice, BIPP, MFP,

Health Homes

Section 1915(i) State Plan Option was established in 2005 and amended by the Affordable Care Act.

Similar to §1915(c) HCBS waivers in flexible service and benefit design, but— No requirement that people meet institutional level of care to

qualify. While states may target HCBS to one or more specific

populations, they may not cap enrollment for the targeted population(s).

Few states have exercised this authority so far. However, in recent NASUAD survey: 22 states reported consideration of §1915(i). 3 states said they will implement—CA, IN, TX.

§1915(i) State Plan Option

Community First Choice Option gives states option to add new participant-directed state plan HCBS attendant services and supports benefit.

Participating states will receive enhanced FMAP of 6% for

enrollees.

There are two levels of eligibility: People eligible for Medicaid under State Plan with incomes up

to 150% of poverty who don’t need institutional level of care. People with incomes above 150% of poverty and up to 300%

of SSI who meet institutional level of care requirements.

NASUAD’s recent survey found: 18 states are considering participation. 5 states definitely plan to participate—AK, AZ, CA, NY, RI.

Community First Choice

State Balancing Incentive Payments Program (BIPP) is temporary, noncompetitive grant program to encourage states to balance Medicaid spending toward HCBS.

To be eligible, states must have spent <50% of total Medicaid LTSS dollars on non-institutional services in FY 2009. Through 10/1/2015: States that spent <25% on HCBS will receive 5% FMAP increase

for HCBS. States that spent <50% but >25% on HCBS will receive 2%

FMAP increase for HCBS.

NASUAD’s recent survey found: 21 states considering participation. 3 states definitely plan to participate—GA, NJ, NH. *

Balancing Incentive Payments Program

Health Homes are providers or a health team that coordinates care across settings for people: with 2 or more chronic conditions, or with one chronic condition and at risk for another, or with one serious and persistent MH condition

States may offer these services by amending their state plans, and participating states receive 90% enhanced FMAP for health home services for up to 8 quarters per enrollee.

NASUAD’s recent survey found: 14 states plan to implement (As of January 2012, 7 states had

submitted Health Home State Plan amendments to CMS —IA, MO, NC, NY, OR, RI, WA. Some approved; others pending)

10 are considering implementation

.

Health Homes

The Money Follows the Person Demonstration Program provides transition funds and enhanced FMAP for states to help Medicaid beneficiaries leave nursing homes for HCBS in community settings.

Began in 2007; extended to 2016 by Affordable Care Act.

43 states + DC are currently implementing MFP.

In February 2012, CMS issued invitation to the remaining states to apply for MFP planning grants.

Money Follows the Person

State Intention to Pursue ACA Options

Federal Budget and FY13 Appropriations Outlook

What’s In The Federal Budget?

(Source: Center on Budget and Policy Priorities)Interest on the National Debt

9%

Non-defense Appropriations

18%

Other Entitlement Programs

9%

Defense Appropriations

20%

Social Security,

Medicare, and Medicaid

44%Funding for these two parts of the budget must be renewed each year.

Winter: President’s Budget, blueprint for Congress to follow…or ignore

Early Spring: Congressional budget resolution sets broad parameters

Late Spring/Early Summer: Appropriations committees begin work

October 1: New fiscal year begins

Federal Budget Process

FED SPENDING = Entitlement spending (Medicare, Soc Sec), interest on the national debt, and then discretionary (foreign aid, domestic) funding

DISCRETIONARY SPENDING Congress has to act each year to continue

funding for domestic discretionary spending Sets up special appropriations committees by

federal agency (Labor/HHS/Education) These are the Members of Congress with great

power over how much $$$ we get for OAA!

Appropriations Process

OAA Appropriations Have Not Kept Pace With Demand

2005 2006 2007 2008 20090

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

Age 60 and above & Below 250% FPL

Age 60 and above & Below 200% FPL

Number of Persons Receiving OAA Services

Year

Year

Nu

mb

er

of

Pe

rso

ns

Source: NASUAD Analysis of U.S. Census data (Current Population Survey) and AGid

Service DemandIncreased Demand for Services, SFY11

Source: NASUAD Economic Survey, FY11: State Aging and Disability Agencies in Times of Change.

OAA needs at least a 12 percent increase to keep pace with projected population growth and inflation in 2013 and begin to make up for years of stagnant funding;

Give special attention to three OAA programs, Title III B Supportive Services, III E NFSCP and Title VI Grants for Native Americans, which are particularly overdue for increases; and

See n4a 2013 Policy Priorities for other appropriations recommendations….

n4a Appropriations Advocacy

Advocacy Groups send letters to Appropriations Committees

As do Members of Congress, both individually and in groups Sanders OAA 12% Letter, 18 Signers

Requests from the field are important too!

Appropriations Advocacy

Aging Program Funding (FY 2013)

President’s Budget: hold the line + addition of SHIPs, Title V, APS

OAA program funding for the most part maintained Exception is Program Innovations

Status of FY 2013 Appropriations

Senate Labor/HHS bill marked up as early as late May, early June

But House starting from different spending level

Discretionary Levels Senate -- $1.047

trillion* House -- $1.028 trillion Current Year = $1.043

* Set by Budget Control Act, Summer 2011

Forecast:End-of-Year Storms

No floor votes for approps bills, no public conference committee

Continuing resolutions (CRs) until after the election at least

Lame Duck Session: approps, Medicare “doc fix,” Bush tax cuts and Jan. 2013 sequester!

OAA Appropriations

Budget Control Act: If Congress fails to act by the end of the calendar year, $1.2 trillion in automatic, across-the-board cuts would take effect through a sequestration process

Cuts expected to be 8-9% for programs like OAA Exempted programs: Social Security, Medicaid and

several low-income entitlement programs. (Medicare benefits could not be cut either, but provider payments could be reduced by up to 2 percent.)

Takes effect on January 2, 2013

Sequester!

Potential Impact of Sequester

IMPACT OF SEQUESTER ON FY13 OLDER AMERICANS ACT PROGRAMS

FY12 Estimated

FY13 funding after

automatic cuts

(CBO estimate

of 7.8%)

FY13 cuts based on CBO estimate

(Difference between FY13 funding after CBO 7.8% cuts and

FY12 estimated funding level)

FY13 funding after

automatic cuts

(CBPP estimate

of 9%)

FY13 cuts based on CBPP estimate

(Difference between FY13 funding after CBPP 9% cuts and

FY12 estimated funding level)

Adult Protective Services 0 0 0 0 0

Aging and Disability Resource Centers 16 14.752 -1.248 14.560 -1.440

Aging Network Support Services 8 7.376 -0.624 7.280 -0.720

Alzheimer’s Disease Demonstration Grant 4 3.688 -0.312 3.640 -0.360

Chronic Disease Self-Management Program 10 9.220 -0.780 9.100 -0.900

Congregate Nutrition 439 404.758 -34.242 399.490 -39.510

Elder Rights Support Activities 4 3.688 -0.312 3.640 -0.360

HCBS Supportive Services 367 338.374 -28.626 333.970 -33.030

Home-Delivered Nutrition 217 200.074 -16.926 197.470 -19.530

Lifespan Respite Care Program 2 1.844 -0.156 1.820 -0.180

Long-Term Care Ombudsman Program 17 15.674 -1.326 15.470 -1.530

National Clearinghouse LTC Information 3 2.766 -0.234 2.730 -0.270

National Family Caregiver Support Programs 154 141.988 -12.012 140.140 -13.860

Native American Caregiver Support Program 6 5.532 -0.468 5.460 -0.540

Native American Nutrition and Supportive Services 28 25.816 -2.184 25.480 -2.520

Nutrition Services Incentive Program 160 147.520 -12.480 145.600 -14.400

Prevention of Elder Abuse and Neglect 5 4.610 -0.390 4.550 -0.450

Preventive Health Services 21 19.362 -1.638 19.110 -1.890

Program Administration 23 21.206 -1.794 20.930 -2.070

Program Innovation 0 0 0 0 0

Senior Medicare Patrol Program 9 8.298 -0.702 8.190 -0.810

Total, Program Level 2,005 1848.610 -156.390 1824.550 -180.450

Source: NASUAD analysis of projected cuts. www.nasuad.org

(In millions of dollars)

Older Americans Act in the 112th Congress

OAA Reauthorization

TIMELINE AoA Listening Sessions, Winter 2010 Groups survey members, write

recommendations, release by spring 2011 Senate HELP Subcomm holds listening

sessions, summer 2011 Act “expires” Sept. 30, 2011 Fall 2011: AoA shares tech asst for Hill

Reauthorization of OAA

Add parent caregiver of adult children with disabilities to NFCSP

Consolidate nutrition programs Expand the # of programs allowed to cost-share (would

still need waiver from AoA to test cost-sharing for nutrition and case management)

Incentive payments to enhance Aging Network capacity LTCOP updates Establish minimum Title III funds for State Legal Asst Devel

Program; states pick which if any AAAs to fund Transform Title IV

AoA Suggestions

Increase min amt of state admin from $500k to $750k, affects low-population states

Transfers Title V Senior Community Service Employment Program to AoA from Dept. of Labor

Establish Senior Medicare Patrol within Title VII; from competitive grants to formulas to states

III D: Allow states to fund disease prevention and health promotion services directly by grant/contract (aka not all AAAs will be funded); all programs must be evidence-based

AoA Suggestions

Preserve the Act’s flexibility and person-centered approach

Strengthen the Aging Network’s role and capacity in the coordination and provision of home and community-based services

Expand evidence-based health promotion and disease prevention

Improve community preparedness for an aging population

Set adequate authorization levels

n4a’s OAA Reauthorization Priorities

Cost-sharing Coordination (e.g., ADRCs, community health centers)

Smaller programs shifting to be state-run (e.g., legal services, III D)

Elder justice: APS, LTCOP

What are the issues under discussion?

Investment in workforce, specifically home care, direct care workers

Caregiver assessments Financial exploitation Home care ombudsmen programs and home

care consumer bill of rights

What are the issues under discussion?

Consolidates $ for C1 and C2 but sets floors: 40/35/25 Recommends increases of 50% in funding for nutrtion, supportive

services, SCSEP and HPDP Encourages collaboration with Federally Qualified Health Centers Add “economic security” to objectives, redefine “greatest

economic need” to 200% FPL Redefines “greatest social need” to include LGBT individuals and

older adults with HIV/AIDs or Alzheimer’s Senior Center Modernization encouraged Legal services: establishes new definition “integrated legal

assistance delivery system”; boosts state’s role over current local role for AAAs

And more…

S. 2037

TIMELINE Sanders Bill (S. 2037) Released, January 2012 Other Dem Senators followed with their bills

(Kohl/Mikulski, Franken, Casey, Blumenthal); more to come

Senate Mark-up in June? Merely in the queue in House

Reauthorization of OAA

S. 2037 Chairman Sanders (I-VT) S. 1750 Franken (D-MN) S. 1819 Kohl (D-WI) and Mikulski (D-MD) S. 1982 Casey (D-PA) S. 2077 Blumenthal (D-CT)Up next? Manchin, Bennet, others

OAA Bills

Advocacy Strategies

Reach out to freshman MoCs to educate them about your agencies and the work you do

Stay in regular contact with Members and staff

Invite your local congressional offices to do site visits, attend events

Participate in the federal regulatory process to make your voice heard

Grassroots Activities

Sandy Markwoodsmarkwood@n4a.org

www.n4a.orgwww.facebook.com/n4aACTION

www.twitter.com/n4aACTION or www.twitter.com/AmyGotwals

Questions?