How long can we afford, as a state, to continue to relegate people with disabilities to not paying taxes, to not contributing to the economy of the state, to not buying goods and services that stimulate the economy?
(D.D.)
Most people with a disability between the ages of 21 and 64 work (77 percent according to the 2000 Census). Having a job and being economically self-sufficient are important aspects of personal independence and overall quality of life. However, many people with a disability who want to work cannot because additional income would threaten their health care benefits. Federal welfare programs were reformed in the 1990s to support people who work, but Social Security disability programs and Medicaid were not. In order to support the critical link between work and self-sufficiency, the Ohio Access cabinet will:
- Develop a Medicaid Buy-In program;
- Implement Supported Employment in the Mental Health System; and
- Implement the U.S. Department of Labor Employment Navigator.
F.1 Develop a Medicaid Buy-In Program
Recipients of Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) risk losing Medicaid coverage, which is linked to their cash benefits, if they work. Eliminating barriers to health care and creating incentives to work can greatly improve financial independence and well being. To support this goal, Congress included a Medicaid Buy-In (MBI) option in the Balanced Budget Act of 1997 (BBA) and enacted the Ticket to Work Incentives Improvement Act (TWWIIA) in 1999. These laws authorized states to create MBI programs to extend Medicaid coverage to persons with disabilities who go to work.
States have a great deal of latitude about if and how to construct various MBI models for people with disabilities. There are several models that have been discussed in Ohio. Each of these models assumed that personal care services would be only those services currently covered on the Medicaid State Plan. One model was constructed using a contractor for the Ohio Developmental Disabilities Council (ODDC). The Ohio Senate Finance and Financial Institutions Committee also recommended this model. The ODDC model was presented with a number of variations, including different cost sharing and eligibility assumptions. Fully implemented, the ODDC model was predicted to serve 12,542 people and cost approximately $22.3 million in new state dollars.
ODJFS contracted with The Lewin Group to further develop several aspects of MBI. Lewin presented five different models, the most conservative of which is described below. The Lewin models ranged from 3,451 to 9,056 participants with state funding ranging from $8.2 million to $29.6 million ($20.3 million to $74 million all funds). [1] The assumptions and costs associated with the ODDC model and the most conservative Lewin model are summarized below. [2]
| Medicaid Buy-In Cost Assumptions | ||
|---|---|---|
| ODDPC Model | Lewin most restrictive model | |
| Model 1. Assets 2. Earned Income 3. Income standard 4. Premiums |
1. $10,000 2. $20,000 3. 250 percent 4. 10 percent above 150 percent |
1. $2,000 2. $10,000 3. 200 percent 4. Varies from 2.5 percent to 7.5 percent depending on family income |
| People to be served | 12,542 (7,000 initially; 5,000 new to Medicaid) | 3,500 (less than 2,000 new to Medicaid) |
| Cost of Buy In | 1. Recommendation was that administration of $2.5m and $3m be given to JFS, but this was not passed by General Assembly 2. Buy-In for 12,542 people estimated $22.3 million state funds by the Finance Committee |
1. No administrative costs included 2. Buy-In in for 3,500 people estimated $8.2 million state funds by Lewin |
The Medicaid Buy-In proposals discussed above (including the ODDC model recommended by the Senate Finance Committee and the Olmstead Task Force) do not propose to add personal care to Ohio's Medicaid state plan. However, because this option is a priority for many individuals with a disability, it is important to address in this report.
Last year (SFY 2002) Ohio spent $505.2 million on personal care services through Medicaid waiver programs (PASSPORT, IO, RFW, Choices, Home Care and Transitions). In fact, personal care is primarily what these waivers cover. Adding personal care to the state plan would make that service an entitlement, which means that Medicaid would be required to provide it (up to the specified limit) to any Medicaid recipient who meets the functional definition of need for the service. Once on the state plan, qualifying for this service would not be limited to people seeking to maintain or obtain employment (the purpose of Medicaid Buy-In). The cost to add personal care to the state plan is significant — one preliminary ODJFS estimate pegs this cost from $171.7 million to $194.1 million in state funds only to serve all Medicaid eligibles who would need personal care services. A new commitment of that magnitude, given the state's current fiscal constraints, is not realistic. More work would be needed to update and refine this estimate. However, providing personal care services through waiver programs will remain a high priority.
| F.1.1 | ODJFS will develop a Medicaid Buy-In proposal for consideration in the SFY 2006-2007 budget; the proposal will address MBI model design (asset limits, premiums, etc.) and recommend a federal implementation vehicle (Ticket to Work Act, HIFA waiver, etc.); and the process will include active involvement of the Ohio Olmstead Task Force and others. |
F.2 Implement Supported Employment in the Mental Health System
Supported Employment is an evidence-based practice that has been shown to improve employment outcomes for people with disabilities compared to traditional job and vocational approaches. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) offers grants to help local providers "install" a Supported Employment toolkit in their agencies. The objective of this initiative is to increase economic self-reliance for people with mental illness and improve their overall quality of life. Research shows that employed consumers experience reduced disability and move from being consumers of tax-financed services to becoming taxpayers. Access to Supported Employment also improves access to other choices related to work, including choice of type and location of housing, networks of acquaintances and friends, and type and location of service providers.
| F.2.1 | ODMH will promote Supported Employment, establish four pilot sites during SFY 2004, and implement Supported Employment statewide during SFY 2006. |
| F.2.2 | ODMH will prioritize services to help consumers access income support and medical benefits through SSI/SSDI, Medicare, and Medicaid, and collaborate with ODJFS in the effort to expand Medicaid to support work. |
| F.2.3 | ODMH will promote the use of benefits counselors (advisers to consumers on navigating the complex world of health and income support benefits) to remove systemic barriers to employment for people with severe mental illness. |
| F.2.4 | ODMH will grow its partnership with the Ohio Rehabilitation Services Commission to improve consumer outcomes related to health and health care, economic independence, improved clinical outcomes, and meaningful participation in society. |
F.3 Implement the U.S. Department of Labor Employment Navigator
The Disability Program Navigator helps people with disabilities "navigate" through the enormous challenges of seeking work. Complex rules surrounding entitlement programs, along with fear of losing cash assistance and health benefits, can often discourage people with disabilities from working. U.S. DOL and the Social Security Administration established the Disability Program Navigator program to better inform beneficiaries and other individuals with disabilities about the work support programs now available at DOL-funded One-Stop Career Centers.
ODJFS is interested in applying for a DOL navigator grant at the next opportunity. The grant requires the state to work in collaboration with local One Stops and to use the grant to support, among other activities, hiring people in One Stops to assist people with disabilities to access programs that help them gain employment, or return to or retain a job.
| F.3.1 | ODFJS will immediately determine upcoming grant opportunities, promote the DOL Navigator initiative to all One Stops, and work directly with One Stops that are likely to be successful in pursuing this initiative. |
[1] Average annual Medicaid costs for MBI program participants were assumed to be equal to the average annual Medicaid expenditure for non-institutionalized Medicaid enrollees with a basis of eligibility of "Disabled." The majority of these individuals are between the ages of 18 and 64, which is the target population used for the enrollment estimates. Per capita Medicaid spending data for this group was used as a proxy for the expected average spending for MBI enrollees. Spending data from FFY 2001 was trended forward two years based on historical annual growth in per capita Medicaid spending for the ABD population in Ohio.
[2] The total estimated costs in Table 1 do not include the cost of administrative activities to implement MBI, which ODJFS estimates would be an additional $2.0 million in state funds for either model.
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