Choice is important to the quality of life for Ohio's... citizens and as part of the solution to reduce the rising costs of long term care.
(T.W.)
Ohio Access envisions a fundamental alteration in Ohio's approach to long-term services and supports for people with disabilities. This transformation is necessary for seniors and people with disabilities to live with dignity in the settings they prefer and maximize their employment, self-care, interpersonal relationships, and community participation; and for government to honor and support the role of families and friends who provide care.
Progress toward this vision requires greater consumer participation and control in decisions about their care. It requires detaching funding from particular settings of care, and allowing those funds to follow people into the settings they choose. This concept is consistent with the Supreme Court's Olmstead decision, and in most cases highly cost effective. In order to give consumers meaningful choices, the Ohio Access cabinet will work to:
- Increase home and community based Medicaid waiver programs;
- Provide information consumers need;
- Financially support consumer choice; and
- Support informal caregivers.
A.1 Increase Home and Community Based Medicaid Waiver Programs
The federal government allows states to seek Medicaid waivers, or exemptions, to provide long-term services and supports to people in community settings rather than in facility-based settings. The provision of these services reflects a valuable taxpayer investment because the federal government requires that the cost of waiver services be less than or equal to the cost of providing similar services in a facility-based setting. [1] Furthermore, many elders and people with disabilities want to live in their homes, and waiver programs provide that opportunity.
Ohio has obtained a number of federal waivers in recent years to provide home and community based services in a number of delivery systems. It is important to continue to expand upon this progress in several ways:
- Expand current waivers for eligible Ohioans;
- Redesign current waivers in order to increase quality, greater consumer direction and satisfaction, and the efficiency of service delivery; and
- Propose new waivers to help Ohioans to live as independently and productively as possible.
This section discusses the Administration's plans for specific Medicaid waivers, both existing and proposed, during the next several years. Note that all strategies are subject to the availability of sufficient resources, and may need to be modified or prioritized to match budget realities.
The chart below contains an overview of Ohio's current and proposed Medicaid home and community based services (HCBS) waiver activities.
| System | HCBS Waiver | Expand | Redesign | Propose |
|---|---|---|---|---|
| ODA | PASSPORT | |||
| ODMR/DD | Level One | |||
| ODJFS | Home Care: Transitions | SFYs 04-08 | ||
| ODJFS | Home Care Redesign | SFYs 04-08 | ||
| ODMR/DD | Individual Options and Level Three | SFYs 04-07 | ||
| ODMR/DD | Residential Facilities Waiver (RFW) | SFYs 04-08 | ||
| ODJFS | CAFS Skills Development and Supports | SFYs 04-05 | ||
| ODA | Choices for Elders | SFYs 04-05 | ||
| ODMR/DD | Independence Plus | SFYs 04-05 | ||
| ODA | Assisted Living | SFYs 06-07 | ||
| ODJFS | Early Intervention and Autism | |||
| ODJFS | Cash and Counseling | SFYs 04-07 | ||
| ODMR/DD | Community Access Model Waiver | SFYs 04-07 | ||
| ODJFS | ICF/MR Conversion Waiver | SFYs 06-07 |
Expand Current Waivers
PASSPORT — A request was submitted to the federal government to extend this very successful waiver for elders for an additional five years. Additional expansion will depend on the availability of state GRF during the next biennium.
| A.1.1 | ODA will recommend PASSPORT funding levels in the SFY 2006-2007 budget that are sufficient to avoid waiting lists. |
Level One — This waiver, offering limited support such as respite services and home modification for persons with cognitive disabilities and their families, is funded with a combination of federal, state, and local dollars. ODMR/DD developed this waiver in FY 2003 to provide 6,000 waiver slots over the next three years to individuals for whom $5,000 per year in services and supports is enough for them to stay in a home or community setting.
| A.1.2 | By SFY 2006, ODMR/DD will release at least 1,000 additional Level One waiver slots to county boards of MR/DD, as funds are available to serve additional individuals. |
Transitions — This waiver serves Ohioans who have developmental disabilities that qualify them for ICF/MR services. ODJFS created this no-growth waiver as an alternative to the Home Care waiver, and has been serving individuals since SFY 2003.
| A.1.3 | ODJFS will request federal permission to reassign additional slots individuals from the Home Care Waiver to the Transitions Waiver as Home Care is redesigned. |
Redesign Current Waivers
Home Care and Core Plus — Ohio's Medicaid state plan includes the Home Care CORE and CORE Plus programs. CORE covers nursing and aide services for qualified beneficiaries up to 14 hours per week. CORE Plus is a state plan service that enables consumers to exceed CORE's 14-hour limitation on services. Due to the increasing utilization trends for CORE Plus, it is difficult for ODJFS to efficiently manage resources in this area of the Medicaid program.
Ohio's Home Care Waiver program is being redesigned at the same time as CORE Plus because both programs are critical to providing a safety net of services to individuals. Home Care is being restructured into several distinct waivers (Self-Directed Care, Community Resource, Sub-Acute) to better match available service levels and funding to individuals with high end needs, and to permit individuals with emergent needs to leave hospitals and access waiver services. One of the new waivers (Self-Directed Care) will permit consumers much more flexibility by providing a consumer directed design. The new waivers will improve clarity about available services and the specific program that best meets the individual's needs.
| A.1.4 | ODFJS will work with other Ohio Access agencies to determine the number of affected consumers receiving Core Plus benefits as well as services through the MR/DD and Aging systems, and how these consumers will continue to receive such services. |
| A.1.5 | ODFJS will request additional Home Care and Transitions Waiver slots to accommodate CORE Plus customers who are eligible for these programs. |
| A.1.6 | ODJFS will develop and request the following from CMS: a Self-Directed Care Waiver in SFYs 2005-2006; a Community Resource Waiver from CMS in SFY 2006-2007; and Sub-Acute Waiver in SFY 2006-2007. |
| A.1.7 | ODJFS will transfer eligible adult CORE Plus consumers to other waiver programs before SFY 2008. |
Individual Options (IO) and Level Three — The IO waiver serves approximately 7,000 Ohioans with developmental disabilities. Ohio recently received approval from CMS to serve an additional 2,000 individuals on the IO waiver. Reform efforts will result in two distinct waivers with different cost caps: a redesigned IO waiver which will serve individuals who rely on publicly funded services of approximately $5,001 to $79,500 per year, and the Level Three waiver, which will serve individuals with publicly funded service costs that exceed $79,501 per year. Individuals will be assigned to one of these waivers based on an assessment of their need and existing amounts and types of support that they receive.
| A.1.8 | IO will be renewed March 1, 2004. At that time, an individual cost cap will be equal to average cost of providing services to a person with similar needs in a licensed ICF/MR setting. Current waiver enrollees whose service costs are above the newly established cap will be grandfathered into IO in the first year. As Level Three is implemented, these consumers' needs will be evaluated to determine whether the Level Three waiver will meet their needs. |
| A.1.9 | ODMR/DD and ODJFS will establish timeframes for the Level Three waiver. ODMR/DD will involve County Boards, advocates, providers, and other stakeholders in the development of Level Three. ODMR/DD and ODJFS will submit a waiver proposal to CMS during SFY 2005. |
Residential Facilities Waiver (RFW) — This waiver serves approximately 2,500 Ohioans with developmental disabilities in licensed facility-based settings. RFW will be redesigned to enable money to follow the person, meaning that an RFW consumer can change service providers and retain their waiver "slot." (Currently, the "slot" belongs to the licensed facility, not the individual receiving services.) This is consistent with the Ohio Access goal of offering individuals meaningful choices.
| A.1.10 | ODMR/DD and ODJFS will redesign RFW to enable money to follow the person and, by SFY 2008, move all RFW consumers to the IO waiver and eliminate RFW. |
CAFS Skills Development and Supports — ODJFS and ODMR/DD are redesigning the Community Alternative Funding System (CAFS) state plan program to move some services onto ODMR/DD-operated waivers and to modify other services to better manage the program. These changes will make it easier for individuals and families to understand their options under CAFS and Medicaid. For example, CAFS covers skills development and supports provided through day services, but in order to access these services, a person must be enrolled in a Medicaid waiver. The redesign will make skills development and supports provided through day services available through waivers.
| A.1.11 | ODJFS and ODMR/DD will convert CAFS from a cost-based system to a fee schedule in SFY 2004. |
| A.1.12 | ODJFS will work with ODMR/DD to move Skills Development and Support services to other ODMR/DD-operated waiver programs during SFY 2005. |
Choices for Elders — Choices is a Medicaid model waiver that gives 200 PASSPORT-eligible consumers in central Ohio more direct control over service providers than currently allowed under PASSPORT. The Choices waiver is due to expire at the end of SFY 2004. ODA plans to expand this successful model to other Ohio counties, by converting the current model waiver to a home and community-based services waiver similar to PASSPORT.
| A.1.13 | ODJFS will seek federal permission on behalf of ODA in SFY 2004 to convert the Choices model waiver to a home and community-based (1915c) waiver that will serve approximately 350 people in SFY 2005. |
Proposed New Waivers
Independence Plus for People with Developmental Disabilities — ODMR/DD received a three-year grant from the Centers for Medicare and Medicaid Services to develop an Independence Plus waiver. This waiver would enable individuals to self-direct some or all of their waiver services. Individuals would be assigned a "personal budget" based on an assessment of their medical need and existing amounts and types of support that they receive. After that, a "fiscal intermediary" would be appointed in order to provide assistance to consumers and their families as they choose specific services and providers.
| A.1.14 | ODMR/DD and ODJFS will develop an MR/DD Independence Plus waiver proposal and submit it to CMS in SFY 2005. |
| A.1.15 | ODMR/DD will identify five counties to participate in the approved waiver and, if approved by CMS, implement in SFY 2005. |
Assisted Living — Many elders do not need the more intensive medical services provided by nursing facilities, but lack the necessary informal supports that are essential to remain at home. Assisted living spans this gap, combining both supportive services and housing. Often it is the only alternative to nursing facility care for consumers who lack stable housing.
Ohio already has a well-developed assisted living market for private-paying individuals who need those services. Governor Taft's SFY 2004-2005 budget proposed expanding access to assisted living through a new Medicaid waiver program. Eligibility for the new waiver would have been limited to PASSPORT consumers who would otherwise have to move to a nursing facility because their need for services has become greater than their current environment can support, or seniors residing in nursing facilities who desire to live in a different setting and would be able to do so with a PASSPORT service package. Because the new waiver was designed to serve people already served by Medicaid, it would have required no new resources. The General Assembly rejected this proposal in its deliberations on the Governor's budget.
| A.1.16 | ODJFS will resubmit the Governor's SFY 2004 assisted living Medicaid waiver proposal (or a similar version) for consideration in the SFY 2006-2007 budget. |
Early Intervention and Autism — ODMR/DD was granted permissive authority in the SFY 2004-2005 budget to apply to CMS (through ODFJS) for a home and community based waiver for either early intervention services or autism services, or both. The budget also created an Ohio Autism Task Force to make recommendations to the Governor and the General Assembly. The Administration will rely on the Task Force, which includes families of individuals who would potentially use the new waivers, in the development of an early intervention or autism waiver.
| A.1.17 | ODMR/DD will work with ODJFS and ODH, and in cooperation with the Ohio Autism Task Force, to develop recommendations for the SFY 2006-2007 budget about developing an early intervention waiver, autism waiver, or both. |
Cash and Counseling — This initiative, related to Home Care reform, is a specific type of consumer directed care that provides a flexible monthly allowance (based on the consumer's care plan or on claims history) that consumers can use to hire their choice of workers, including family members, and purchase other goods and services. Cash and Counseling requires consumers to develop spending plans that show how they will use the allowance to meet their needs for supportive services. It also provides counseling to help consumers manage their allowance and their responsibilities as employers. Consumers who are unable or unwilling to manage their allowance themselves may choose another person, such as a family member, to help them or do it for them. These features make Cash and Counseling adaptable to consumers of all ages and with all types of impairments.
| A.1.18 | As part of the redesign of Ohio Home Care, ODJFS will apply for a grant from the Robert Wood Johnson Foundation in SFY 2004 to support the development of a self-directed care waiver. |
Community Access Model Waiver — As the Apple Creek and Springview Developmental Centers close over the next two years, ODMR/DD remains committed to self-determination strategies for residents who want to leave these facilities and live in a community setting. The Community Access Model Waiver will enable ODMR/DD to support these individuals as they opt to leave Developmental Centers in favor of smaller community settings.
| A.1.19 | Pending federal approval, ODMR/DD will implement the waiver during SFY 2004, enrolling 55 people during the first full year of waiver operation and approximately 200 people by the end of the third year. |
ICF/MR Conversion to Waiver — As was the case during the FY 2004-2005 budget development process, the Administration will seek to reform the Medicaid ICF/MR program during FYs 2006-2007. The goals are to enable consumers to receive services in cost-effective settings they prefer; to control expenditure growth in the long term; to mitigate the state's fiscal liability; and to achieve federal compliance.
Specifically, the Administration will propose to convert the state plan ICF/MR entitlement system to a home and community based waiver. This reform will enable the state to eliminate the State Plan option over time and increase control over the number of beds and costs in the system. This plan provides two critical tools for the state, as well as consumers: the flexibility of waiver slots, and a new waiver reimbursement system.
| A.1.20 | During the SFY 2006-2007 budget process the Administration will resubmit its proposal (or a similar version) to remove the ICF/MR program from the state plan and replace it with a waiver. |
A.2 Provide Information Consumers Need
People with disabilities need timely, accurate, and complete information about available services in order to make informed decisions. In order to support the ability of consumers and their families to make meaningful choices, the Ohio Access cabinet will:
- Create a "No Wrong Door" website;
- Continue a long-term services and supports consumer guide;
- Redesign long-term services and supports consultations; and
- Expand the mental health network of care.
Create a "No Wrong Door" Website
Ohio's long-term services and supports are administered by several state agencies and, in some cases, multiple county boards. Individuals and families who need to access these services do not always know where to begin and the fragmented and sometimes contradictory information that is available to them can be the cause of enormous frustration. A project is already underway to assemble consistent, reliable, and up-to-date information about all of Ohio's services and supports for people with disabilities on one, easy-to-use website. No Wrong Door Ohio will include (but is not limited to) information about service providers, assistive technology, civil rights, community life, education, employment, financial benefits, health care, personal care, housing, transportation, and other resources. See: www.NoWrongDoorOhio.org.
| A.2.1 | ODA will select a contractor in March 2004 to develop and implement No Wrong Door Ohio for public use in July 2005. |
Continue the Long-Term Services and Supports Consumer Guide
ODA operates a successful Long-Term Care Consumer Guide website that includes information about nursing facilities and other services for frail elders (See: www.ltcohio.org). The site will be expanded to include more specific information about home health services; supportive services such as transportation, homemaker assistance, and meals; and residential supports such as assisted living, adult foster homes, adult family homes, adult group homes, and nursing homes. To the extent available, data will include regulatory compliance information, quality measures derived from consumer assessments, satisfaction scores, and detailed information provided by service and support providers about specialization, policies, rates, and staffing. The consumer guide is available on the Internet and allows consumers to compare multiple providers. Consumers who do not have Internet access are able to access the consumer guide through ombudsmen, case managers, and other professionals who can conduct searches and comparisons on their behalf.
| A.2.2 | ODA will coordinate the Ohio Access agencies and others to expand the Long-Term Care Consumer Guide to include the functionality described above by June 2007. |
Redesign Long Term Services and Supports Consultations
Many individuals face difficult decisions about their care without a full knowledge of available resources or the advice of others. Providing these individuals with the opportunity to discuss their situation with an expert improves the quality of their decisions and promotes better outcomes for individuals. Consultations can provide all individuals who are entering a nursing facility with the opportunity to meet with a professional consultant to discuss the options that are available to meet long-term care needs, including information about the full continuum of long-term services and supports, sources of public and private payment for services, factors to consider when making a decision, and opportunities to maximize independence and self-reliance.
| A.2.3 | ODA will implement a statewide consultation program in SFY 2004. |
| A.2.4 | ODA and ODJFS will assess the current pre-admission review process for nursing facility admission in SFY 2004 and make legislative recommendations (if needed) to ensure that individuals receive the information they need to make choices about their care. |
Expand the Mental Health Network of Care
The Network of Care is an Internet-based, consumer-friendly health resource, available at the local government level. It addresses system fragmentation by supporting the exchange of critical information among consumers, caregivers, case managers, local service providers, and county and state governments. The Network of Care integrates multiple information sources to create a one-stop resource for information, communication and advocacy. It offers consumers, families and caregivers a fast and accurate way of finding all services in a community from any computer with an internet connection. Individuals can also access databases about illnesses, treatments, programs, and legislation; use public and private communications mechanisms; and communicate concerns directly to policy makers.
The Network of Care technology was developed in California, featured as a model program by The President's New Freedom Commission on Mental Health, and will be evaluated as a pilot for select Ohio counties beginning in 2004. Since the original system development costs of $2.5 million were borne by the State of California, Ohio's costs will only include adapting and applying the technology for our state.
| A.2.5 | ODMH will pilot the Network of Care in select Ohio counties in SFY 2004 and, based on evaluation results, implement an expansion strategy in SFY 2005. |
A.3 Financially Support Consumer Choice
Individuals want control over choices that impact their lives. Meaningful choices among long-term services and supports are nearly always linked to financial considerations—the types and quantities of services purchased, who provides the services, and in what setting. In order to increase independence and self-sufficiency for a number of Ohio's frail elders and people with disabilities, the Ohio Access cabinet will:
- Implement a cash and counseling program;
- Develop and implement an Independence Plus Waiver; and
- Provide institution to community support.
Implement a Cash and Counseling Program
About 1.2 million Americans receive disability-related supportive services at home through Medicaid state plan services or home and community based waiver programs. Under Medicaid state plan services, benefits are typically restricted to human assistance with personal care and homemaking provided by licensed agencies. Waiver programs offer additional services, but coverage is limited, with a case manager deciding whether or not services are needed. Increasingly, states are offering Medicaid beneficiaries and their families the opportunity to directly obtain services and supports from individual providers they choose. This alternative is called consumer directed care.
Cash and Counseling is a specific type of Medicaid funded consumer directed care. It provides a flexible monthly allowance (based on the consumer's care plan or on claims history) that consumers can use to hire their choice of workers, including family members, and purchase other goods and services. Cash and Counseling requires consumers to develop spending plans that show how they will use the allowance to meet their needs for supportive services. It also provides counseling to help consumers manage their allowance and their responsibilities as employers. Consumers who are unable or unwilling to manage their allowance themselves may choose another person, such as a family member, to help them or do it for them. These features make Cash and Counseling adaptable to consumers of all ages and with all types of impairments.
A national evaluation of the first Medicaid cash and counseling pilot program finds that participants are far more likely to receive the services authorized in their care plans than non-participants receiving traditional Medicaid personal care services because traditional agencies were not always able to provide services due to staffing shortages. Any additional costs were more than offset by the lower utilization of more expensive services (such as facility-based care) by participants.
The action step associated with Cash and Counseling is A.1.18.
Provide Institution to Community Support
Federal Medicaid policy now permits states to assist individuals who want to leave institutional settings and return to their communities. States may provide limited payments for items typically not covered by Medicaid when individuals are leaving institutional settings, including one-time costs such as rent deposits, utility deposits, and basic furniture. Soon, the Ohio Access Success Project, which was funded in the SFY 2004-2005 budget, will provide one-time financial assistance to cover relocation costs for people who are medically able to leave facility-based care but simply can't afford the one-time costs associated with moving.
| A.3.1 | ODJFS will implement the Success Project in SFY 2004 and provide payment for transition services for up to 250 nursing facility residents during SFY 2004-2007. |
| A.3.2 | Upon federal approval, which is pending, ODJFS and ODMR/DD will immediately implement a Community Access Model Waiver, which includes payment for transition services, for up to 200 residents who want to leave state-run developmental centers or other ICFs/MR. |
A.4 Support Informal Caregivers
Family caregivers provide the vast majority of the assistance that enables frail elders and people with disabilities to live independently in their homes and communities. In many cases, both the caregivers and care recipients are aging adults. Family caregivers face substantial stresses and burdens as a consequence of caregiving obligations. Because caregivers play such an important role, services that sustain a caregiver's role and maintain their emotional and physical health are an important component of any home and community-based care system.
The National Family Caregiver Support Program (NFCSP) provides funding for Ohio, which is added to funds from the State Alzheimer's Respite Program and local funds, to provide a package of services to support caregivers. These services include information about available services; assistance in gaining access to supportive services; individual counseling and training; respite care to provide temporary relief from caregiving; and supplemental services, on a limited basis, to complement the care provided by the caregiver.
| A.4.1 | ODA will include caregiver resource information in the Long-Term Services and Supports Consumer Guide and No Wrong Door website, which will be available to the public in June 2005. |
| A.4.2 | ODA will work with Ohio's 12 Area Agencies on Aging to publicize the NFCSP program during SFY 2006-2007. |
[1] The federal requirements regarding the expenditure "cap" may be aggregate or person-specific, depending on the waiver.