oppaga Florida s Medicaid Home and Community-Based Services Waivers

Transcription

1 oppaga Florida s Medicaid Home and Community-Based Services Waivers JULY 009 Report No. 09- Office of Program Policy Analysis & Government Accountability an office of the Florida Legislature

2 Florida s Elder and Disabled Medicaid HCBS Waivers Year Implemented 98 AGED AND DISABLED ADULT SERVICES be age 60 or older or age 8 to 59 and determined disabled by the Social Security Administration meet Nursing Home Level of Care reside in home Services Provided adult companion adult day health care attendant care caregiver training case aide case management chore services consumable medical supplies counseling escort services financial assessment and risk reduction home-delivered meals Waitlist Department of Elder Affairs (DOEA), ages 60 or older Department of Children and Families (DCF), ages 8 to 59 Agency for Health Care Administration (AHCA), Aging Out program Total DOEA DCF AHCA 9,05 8, Waitlist,0 7,05,606 None home accessibility adaptations homemaker nutritional assessment and risk reduction personal emergency response system pest control physical risk reduction rehabilitation engineering skilled nursing specialized medical equipment and supplies therapies: occupational, physical, respiratory, speech Total Waiver Approved, Funding DOEA Total Appropriation Federal Appropriation State Appropriation $85,85, $6,67,6 $8,87, Average Beneficiary DCF Total Appropriation Federal Appropriation State Appropriation $,9,0 $6,98,07 $5,56,9 AHCA Total Appropriation Federal Appropriation State Appropriation $,799, $9,,70 $,65,0 DOEA Average Monthly Cost FY Expenditures FY Enrollee Months $755.8 $8,7, ,0 DCF Average Monthly Cost FY Expenditures FY Enrollee Months $96.97 $8,7, ,75 AHCA Average Monthly Cost FY Expenditures FY Enrollee Months $9,05.8 $7,75, Fee-for-Service: Florida Medicaid approved rate or the provider s customary fee, whichever is lower. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. The Aging Out Program is for beneficiaries age or older who no longer qualify to receive home-based medical services through the Department of Health s Children s Medical Services (CMS) program and thus age out of CMS. All enrollment and waitlist information is provided as of February 8, 009. Delays in moving beneficiaries from the waitlist to enrolled status are due to attrition, the availability and amount of services a beneficiary may need, and funding limits. Due to funding limits this waiver was closed to new enrollees in February 007 and reopened in October 008, at which time the department authorized additional limited beneficiary enrollment. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months.

3 ADULT DAY HEALTH CARE : Lee and Palm Beach counties Year Implemented 00 be age 75 or older and live with a caregiver meet Nursing Home Level of Care not reside in an institutional setting Services Provided All services are provided within an Adult Day Health Care facility and include assistance with daily living activities case management counseling health care monitoring intake and assessment medical direction medication management nutritionally balanced meals/snacks assistance therapeutic social and recreational activities therapies: occupational, physical, speech transportation Department of Elder Affairs Waitlist Waitlist: None Funding Total Appropriation Federal Appropriation State Appropriation $,96,858 $,07,0 $87, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $5.9 $5,595 7 Contracted Negotiated Rate based on either a half-day or full-day stay. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. All enrollment and waitlist information is provided as of November 008. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months.

4 ASSISTED LIVING FOR THE ELDERLY Year Implemented 995 be age 65 or older or age 60 to 6 and be determined disabled by the Social Security Administration meet Nursing Home Level of Care reside in an Assisted Living Facility (ALF) meet one or more of the following: a. require assistance with four or more activities of daily living (ADLs), three ADLs plus supervision or administration of medication, or total help with one or more ADLs b. have a diagnosis of Alzheimer s or other dementia and need assistance with two or more ADLs c. have a diagnosed degenerative or chronic medical condition requiring nursing services that cannot be provided in a standard ALF, but are available in an ALF that is licensed for limited nursing or extended congregate care d. be a Medicaid-eligible beneficiary who meets ALF criteria e. be awaiting discharge from a nursing facility and unable to return to a private residence because of a need for supervision, personal care, and/or periodic nursing services Services Provided All services are provided within an Assisted Living Facility and include case management incontinence supplies expanded Assisted Living services which may include the following: o attendant call system o attendant care o behavior management o chore services o companion services o homemaker o intermittent nursing o medication administration (within the ALF license) :,76 Department of Elder Affairs Waitlist Waitlist: 9 5, Funding Total Appropriation Federal Appropriation State Appropriation $,668,6 $7,67,7 $5,0, Average Beneficiary 5 o personal care o specialized medical equipment and supplies o therapeutic social and recreational activities o therapies: occupational, physical, speech Average Monthly Cost FY Expenditures FY Enrollee Months $87.7 $7,80,5.0,89 Mixed: Medicaid reimburses for assisted living services at a daily rate and case management services at a monthly rate. Medicaid reimburses incontinence supplies separately, on a monthly basis, based on use. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. Examples of activities of daily living are cooking, cleaning, grooming, and bathing. This waiver is designed to provide extra support to frail elders residing in assisted living facilities in an effort to delay or prevent nursing facility admission. All enrollment and waitlist information is provided as of February 8, 009. Delays in moving beneficiaries from the waitlist to enrolled status are due to attrition, availability and amount of services a beneficiary may need, and funding limits. Due to funding limits this waiver was closed to new enrollees in February 007 reopened in October 008, at which time DOEA authorized additional limited beneficiary enrollment. 5 Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months.

5 Miami-Dade and Broward counties Year Implemented 985 CHANNELING FOR THE FRAIL ELDER be age 65 or older meet Nursing Home Level of Care have two or more unmet long-term care services needs reside in home or with a caregiver in Miami-Dade or Broward counties have a cost of care that does not exceed 85% of the Medicaid nursing home payment in Broward or Miami-Dade counties Services Provided adult day health care adult companion case management chore services counseling (in-home) family training financial assessment and risk reduction home health aide :,07 Department of Elder Affairs Waitlist Waitlist:, Funding Total Appropriation Federal Appropriation State Appropriation $5,5,800 $8,55,.0 $6,88, Average Beneficiary personal emergency response system skilled nursing special drug and nutritional assessment services special home delivered meals special medical equipment and supplies therapies: occupational, physical, speech Average Monthly Cost FY Expenditures FY Enrollee Months $9.9 $,08,0.9 5,7 Contracted negotiated per person daily rate with the Miami Jewish Home and Hospital in Miami-Dade and Broward counties. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. All enrollment and waitlist information is provided as of November 008. Delays in moving beneficiaries from the waitlist to enrolled status are due to attrition, the availability and amount of services a beneficiary may need, and funding limits. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months.

6 NURSING HOME DIVERSION counties: Alachua, Brevard, Broward, Charlotte, Citrus, Clay, Collier, Duval, Flagler, Hendry, Hernando, Highlands, Hillsborough, Indian River, Lake, Lee, Manatee, Marion, Martin, Miami-Dade, Nassau, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole, St. Johns, St. Lucie, Volusia Year Implemented 998 be age 65 or older be Medicare Parts A and B eligible meet Nursing Home Level of Care have two or more unmet long-term care services needs reside in own home, in their caregiver s home, or in an Assisted Living Facility (ALF) Services Provided Acute Medical Services community mental health services dental hearing and visual services (optional) independent laboratory and x ray, inpatient hospital outpatient hospital/emergency physicians prescribed drugs Long-Term Care Community Services adult companion adult day health care assisted living case management chore services consumable medical supplies escort services family training Department of Elder Affairs : 6,000 Waitlist Waitlist:,5, Funding Total Appropriation Federal Appropriation State Appropriation $06,7,0 $69,77,8 $6,600, Average Beneficiary Long-Term Care Community Services (continued) financial assessment and risk reduction home-delivered meals home health care homemaker nutritional assessment and risk reduction personal emergency response system therapies: occupational, physical and speech nursing facility services/long-term care transportation (optional) Some plans offer additional optional services listed at: nefit_grid.html Average Monthly Cost FY Expenditures FY Enrollee Months $, $6,, ,8 Capitated risk-adjusted monthly rate that varies by plan and county. 5 Nursing Home Diversion is authorized to expand to an additional 7 counties; however the waiver is not yet operational because no providers have contracted to provide services in those counties. Currently, seven counties are in the process of setting up provider networks. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. All enrollment and waitlist information is provided as of February 8, 009. In the absence of legislative authority to seek federal approval to increase waiver enrollment, the Department of Elder Affairs will reduce program enrollment to the approved level through natural attrition. DOEA closed the waiver to new enrollees in January 009. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months. 5 The Department of Elder Affairs risk adjusts base rates using several factors including level of assistance needed with activities of daily living, instrumental activities of daily living, the presence of specific chronic conditions, and level of cognitive impairment. 5

7 Florida s Disease-Specific Medicaid HCBS Waivers ALZHEIMER S DISEASE Broward, Miami-Dade, Palm Beach and Pinellas Counties Year Implemented 005 be age 60 or older have a diagnosis of Alzheimer's Disease made or confirmed by a memory disorder clinic, a board certified neurologist, or a physician with experience in neurology meet Nursing Home Level of Care live with a caregiver in a private residence Services Provided adult day health care behavioral assessment and intervention caregiver training incontinence supplies pharmacy/medication review wanderer alarm systems wanderer identification and location programs : 5 A case manager authorizes services based on the beneficiaries documented need. Department of Elder Affairs Waitlist Waitlist: Funding Total Appropriation Federal Appropriation State Appropriation $5,057,09 $,8,08 $,6, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $,5.08 $,779,8.7,08 Fee-for-Service: Florida Medicaid approved rate or the provider s customary fee, whichever is lower. Alzheimer s, the most common form of dementia, is a progressive and fatal brain disease for which there is no cure. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. All enrollment and waitlist information is provided as of November 008. Delays in moving beneficiaries from the waitlist to enrolled status are due to attrition, the availability and amount of services a beneficiary may need, and funding limits. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months. 6

8 ADULT CYSTIC FIBROSIS : 90 Year Implemented 005 be age 8 or older have a diagnosis of Cystic Fibrosis meet Inpatient Hospital Level of Care Services Provided acupuncture case management chore services counseling (individual and family) dental homemaker nutritional assessment and risk reduction personal emergency response service prescribed drugs skilled nursing specialized medical equipment and supplies therapies: exercise, massage, physical, and respiratory transportation vitamins and nutritional supplements Department of Health Waitlist Waitlist: None Funding Total Appropriation Federal Appropriation State Appropriation $,709,870 $98,9 $76, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $9.50 $, Fee-for-Service: Florida Medicaid approved rate or the provider s customary fee, whichever is lower. Cystic fibrosis is a genetic disease that primarily affects a person s lungs and digestive system and is chronic, progressive, and terminal. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for inpatient hospitalization. All enrollment and waitlist information is provided as of November 008. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months. 7

9 FAMILIAL DYSAUTONOMIA : 7 Year Implemented 007 be age or older have a diagnosis of Familial Dysautonomia meet Inpatient Hospital Level of Care Services Provided behavioral services consumable medical supplies dental durable medical equipment non-residential support support coordination Agency for Health Care Administration Waitlist Waitlist: None Funding Total Appropriation Federal Appropriation State Appropriation $8,000 $6,60 $7, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $77.7 $8,0. 75 Fee-for-Service: Florida Medicaid approved rate or the provider s customary fee, whichever is lower. Also known as Riley-Day Syndrome, this is a genetic disease that results in incomplete development of the nervous system. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for inpatient hospitalization. All enrollment and waitlist information is provided as of October 008. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months. 8

10 PROJECT AIDS CARE (PAC) Year Implemented 99 have a diagnosis of Acquired Immune Deficiency Syndrome (AIDS) documented by a physician have an AIDS related opportunistic infection be at-risk of hospitalization or institutionalization in a skilled nursing facility be determined disabled according to the Social Security Administration not enrolled in a Medicaid Health Maintenance Organization (HMO) unless residing in the Medicaid Reform areas Services Provided case management chore services day health care education and support home-delivered meals homemaker restorative massage skilled nursing specialized medical equipment and supplies specialized personal care services for children in foster care therapeutic management of substance abuse :,7 The PAC case manager, in consultation with the beneficiary and a registered nurse care manager, develops a plan of care and authorize services Agency for Health Care Administration Waitlist Waitlist: None 5, Funding Total Appropriation Federal Appropriation State Appropriation $8,7,8 $,8,06.5 $,890, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $6.90 $6,989,. 5,05 Mixed: Medicaid reimburses case management at a contracted negotiated monthly rate per beneficiary and all other services as fee-for-service based on the authorized fee schedule. All enrollment and waitlist information is provided as of November 008. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months. 9

11 TRAUMATIC BRAIN AND SPINAL CORD INJURY : 9 Year Implemented 999 be age 8 or older must have one of the injuries described below. o Traumatic Brain Injury, defined as an insult to the skull, brain, or its covering from external trauma, which produces an altered state of consciousness or anatomic, motor, sensory, or cognitive/behavioral deficits. o Spinal Cord Injury, defined as a lesion to the spinal cord or cauda equine resulting from external trauma with evidence of significant involvement of two of the following: motor deficit, sensory deficit, or bowel and bladder dysfunction. meet Nursing Home Level of Care be referred to the state s Brain and Spinal Cord Injury Program Central Registry in accordance with s. 8.75, Florida Statutes. Services Provided adaptive health and wellness assistive technologies attendant care behavioral programming adult companion consumable medical supplies counseling (personal adjustment) life skills training rehabilitation engineering evaluation support coordination Department of Health Waitlist Waitlist: Funding Total Appropriation Federal Appropriation State Appropriation $0,79,000 $5,79,966 $,69, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $,507. $6,957,6.09,775 Fee-for-Service: Florida Medicaid approved rate or the provider s customary fee, whichever is lower. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for Medicaid nursing home care. All enrollment and waitlist information is provided as of November 008. Delays in moving beneficiaries from the waitlist to enrolled status are due to attrition, the availability and amount of services a beneficiary may need, and funding limits. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months. 0

12 MODEL WAIVER PROGRAM : 5 Year Implemented 99 be age 0 or younger be determined disabled according to the Social Security Administration diagnosed with a degenerative spinocerebellar disease meet Inpatient Hospital Level of Care Services Provided assistive technology service evaluation Agency for Health Care Administration Waitlist Waitlist: Funding Total Appropriation Federal Appropriation State Appropriation $,95 $8,7 $6, Average Beneficiary Average Monthly Cost FY Expenditures FY Enrollee Months $6.7 $,98.50 Fee-for-Service: Florida Medicaid approved rate or the provider s customary fee, whichever is lower. This is a group of rare genetic disorders which affect the brain and nervous system. The Department of Elder Affairs determines that a beneficiary meets the medical and functional eligibility for inpatient hospitalization. All enrollment and waitlist information is provided as of November 008. Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures by total number of enrollee months.

13 Florida s Developmental Disabilities Medicaid HCBS Waivers Year Implemented DEVELOPMENTAL DISABILITIES TIER,,, and Tier Tier Tier Tier To implement Ch , Laws of Florida, the Agency for Persons with Disabilities created a four-tier waiver system in 008. This system comprises four waivers: two new waivers that define Tiers and with the existing Developmental Disabilities and Family and Supported Living waivers, implemented in 985 and 998, respectively. Each tier has specific need criteria that determine the tier under which beneficiaries will be served. In addition, with the exception of Tier, each tier has an annual per-client spending limit. All Individuals must be age or older be registered as an eligible beneficiary with the Agency for Persons with Disabilities or its contractor meet level of care criteria for intermediate care facilities for the developmentally disabled (ICF/DD) meet specific criteria for assignment to a tier o Tier, must have intensive medical, behavioral, or adaptive needs. o Tier, must live in a licensed residential facility and require greater than five hours a day of residential habilitation or reside in supported living arrangements and receive more than six hours of in-home support. o Tier, must not meet criteria for tiers or. o Tier, must live in their family home, foster home, or own home. Services Provided Tier,, and adult day training adult dental behavior analysis behavior assistant companion dietician services in-home support medication review personal emergency response system private duty nursing residential habilitation residential nursing skilled nursing special medical home care specialized medical equipment and supplies specialized mental health services support coordination supported employment supported living coaching therapies: occupational, physical, respiratory, speech transportation Tier adult day training behavior analysis behavior assistant in-home support personal emergency response system specialized medical equipment and supplies support coordination supported living coaching supported employment transportation The Agency for Persons with Disabilities assigns a beneficiary to a tier based on a needs assessment which determines the beneficiary s service needs, risk level, and the spending needed per year to address the beneficiary s needs. For information on additional requirements based on age, living arrangements, exceptional behavioral problems, and authorization for certain services see Florida Administrative Code, 65G

14 Waitlist Annual Maximum Allowable Spending Per Beneficiary Funding Tier,, and Funding Tier TIER Average Monthly Cost Per Beneficiary TIER Average Monthly Cost Per Beneficiary 6 DEVELOPMENTAL DISABILITIES TIER,,, and (continued) Agency for Persons with Disabilities Tier Tier Tier Tier Beneficiaries Pending Tier Assignment Total,,68 5,00,85 5,5 9,90 Waitlist 8,9 Tier Tier Tier Tier No maximum $55,000 $5,000 $,79 Total Appropriation Federal Appropriation State Appropriation $ 76,75,97 $ 7,76,59 $ 5,69, Total Appropriation Federal Appropriation State Appropriation $ 70,5,798 $ 8,907,97 $,6,50 Average Monthly Cost Per Beneficiary FY Expenditures FY Enrollee Months $,9. $88,, ,0 Average Monthly Cost Per Beneficiary FY Expenditures FY Enrollee Months $656.9 $,677,0.8 68,055 Fee-for-Service: Based on rates approved by the Agency for Persons with Disabilities and the Agency for Health Care Administration and incorporated into rule. All enrollment and waitlist information provided as of January, 009. All tiers share one waitlist and beneficiaries are placed in the appropriate tier based on a needs assessment which determines the individual s needs, risk level, and the spending needed per year to address the beneficiary s needs. These beneficiaries are receiving services and are awaiting a tier placement based on a needs assessment which determines the individual s needs, risk level, and the spending needed per year to address the beneficiary s needs. 5 Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures of Tier by total number of enrollee months. Tiers and were not operational until October Average monthly cost per beneficiary was calculated by dividing total Fiscal Year expenditures of Tier by total number of enrollee months.

15 The Florida Legislature Office of Program Policy Analysis and Government Accountability OPPAGA provides performance and accountability information about Florida government in several ways. OPPAGA reviews deliver program evaluation, policy analysis, and Sunset reviews of state programs to assist the Legislature in overseeing government operations, developing policy choices, and making Florida government better, faster, and cheaper. OPPAGA PolicyCasts, short narrated slide presentations, provide bottom-line briefings of findings and recommendations for select reports. Florida Government Accountability Report (FGAR), an Internet encyclopedia, provides descriptive, evaluative, and performance information on more than 00 Florida state government programs. Florida Monitor Weekly, an electronic newsletter, delivers brief announcements of research reports, conferences, and other resources of interest for Florida's policy research and program evaluation community. Visit OPPAGA s website at OPPAGA supports the Florida Legislature by providing evaluative research and objective analyses to promote government accountability and the efficient and effective use of public resources. This project was conducted in accordance with applicable evaluation standards. Copies of this report in print or alternate accessible format may be obtained by telephone (850/88-00), by FAX (850/87-80), in person, or by mail (OPPAGA Report Production, Claude Pepper Building, Room, W. Madison St., Tallahassee, FL 99-75). Cover photo by Mark Foley. Becky Vickers, Staff Director (850/87-6) Project supervised by Yvonne Bigos (850/87-90) Project conducted by Heather Orender (850/87-965) Gary R. VanLandingham, OPPAGA Director