New options could benefit community support services

p>There are several new opportunities for Minnesota to obtain both a federal demonstration grant and increased federal Medicaid matching funds to improve our state’s community support services and reduce the use of institutions for persons with disabilities of all ages. How the state takes advantage of these opportunities will play out in the weeks and months ahead.

Congress adopted a variety of provisions for long-term care as part of federal health care reform legislation in March 2010. Two sections appear to be very promising opportunities for Minnesota: a “Money Follows the Person” demonstration grant and a new state Medicaid option, “Community First Choice Option,” for home and community-based attendance services.

Money Follows the Person (MFP) grants were first available under the Deficit Reduction Act of 2005. Changes were made and the grant availability was extended by Congress last March. Minnesota is currently applying to secure a five-year MFP grant for our state to: 1) Assist persons who have been in an institution for more than 90 days to move to the community; 2) Provide critical service and supports to reduce crises and avoid institutional use; 3) Develop and provide initial services and/or referrals to high-risk individuals to avoid institutionalization.

The Department of Human Services has sought input from a variety of people on a very short timeline, since the grant application was to be submitted to the Center on Medicare and Medicaid Services by Jan. 7, 2011. Because of a significant federal effort to assist states in reducing institutional care, it appears quite likely

that Minnesota will join more than 30 other states and receive an MFP grant. The MFP demonstration grant will provide 25 percent extra federal Medicaid match for the first year that a person living in an institution for more than 90 days moves to the community; and provide funds to cover the costs of administering the grant. It will provide the money needed for infrastructure changes to support people who have moved from institutions or need services to prevent institutionalization or crises which could lead to institutional placement. Full information about Minnesota’s application for Money Follows the Person funds and plans to improve services will be posted on the DHS website.

The Community First Choice Option (CFCO), also titled 1915k, is a new Medicaid optional service included in the Affordable Care Act of 2010. The CFCO has several positive features which would improve Minnesota’s Personal Care Assistant (PCA) program. First of all, the CFCO requires that services and supports are provided in a manner that does not discriminate based on age, condition, disability,or type of diagnosis or help needed. This inclusive provision would mean that Minnesota would have to change its restrictive PCA criteria which disproportionately affects those with mental illnesses, behavioral challenges,cognitive limitations and brain injury. Also, CFCO provides six percent more in federal Medicaid match funds. The type of assistance which can be provided under the CFCO includes assisting a person to acquire, maintain or enhance skills or functioning, and is not limited to a maintenance level of service.

Room and board payments as well as medical supplies and home modifications are excluded under the CFCO. However, transition assistance to move from an institution level-of-care, including an institution for mental disease (IMD), including rent and utility deposits and technology which substitutes for human assistance, are covered.

The CFCO would require state legislation to authorize the Department of Human Services to submit a state plan amendment to implement it. The Department of Human Services is required to work with a stakeholder group composed of a majority of persons with disabilities, seniors, and their representatives. Also required is a comprehensive, continuous quality improvement program for services provided under CFCO.

In order to qualify for CFCO attendant care, an individual must meet a state’s institutional level-of-care criteria. Currently, Minnesota has rather broad institutional level- of-care criteria which cover nursing facilities, intermediate care facilities for persons with developmental disabilities, institutions for mental disease, as well as children and adult mental health residential treatment. It appears that most of Minnesota’s currently eligible PCA recipients would continue to be eligible under this institutional-level-of-care criteria. However, Minnesota has already adopted new institutional-level-of-care criteria for nursing facilities which will likely have to be delayed until 2014due to a federal maintenance of effortrequirement. Even under Minnesota’s stricter nursing facility-level-of-care criteria, it appears that the CFCO would be able to cover most current PCA recipients.

More restrictive PCA eligibility criteria will be imposed in Minnesota beginning July 1, 2011, requiring persons to be dependent in at least two activities of daily living (ADL). Beginning in July 2011, Level I behavior will no longer be considered a factor in qualifying for PCA service.

More than 2,500 current PCA recipients are at risk of being terminated from service due to the new criteria. It will be easier to qualify for a nursing facility than for Minnesota’s PCA service when the new criteria become effective.

Because the Community First Choice Option is brand new, there are many questions about how the new program will be implemented and regulatedby the federal agency in charge, Center for Medicaid and Medicare services (CMS).

It is essential that CMS provide specific guidance to states before Minnesota can proceed with a detailed analysis to determine whether Minnesota should seek a state plan option under CFCO. Some of the concerns stated by the Department of Human Services include assuring that eligibility would not expand financial eligibility or functional criteria beyond those currently eligible for PCA services.

Limits on expansion are needed because of the staggering state budget deficit Minnesota faces for the coming legislative session of $6.2 billion. However, Minnesota’s budget crisis is also a prime reason for pursuing both the

Money Follows the Person demonstration grant and the CFCO to obtain additional federal funding to accomplish long agreed-upon state policy goals of improving community support services for Minnesotans with disabilities of all ages.

Anne Henry is an attorney at the Minnesota Disability Law Center

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