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NOTE: There will be no update, February
9, 2007
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Plan to Join Us!! VOR 2006 Annual Meeting and Washington
Initiative. See -
http://www.vor.net/VORAnnualMeeting2007.htm for
complete details, including
a registration form.
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VOR is the only national organization advocating for a
full range of
residential and support options for people with mental
retardation,
including Medicaid-certified Intermediate Care
Facilities for the Mentally
Retarded (ICFs/MR) and home and community-based care.
VOR supports choice.
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VOR Weekly E-Mail Update
February 2, 2007
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1. "Waiver without a Waiver": Congress approves major
changes to Medicaid
Home and Community Based Services (VOR reprint)
2. States Now Have More Flexibility to Adopt Personal
Care Programs Without
Waivers
3. Tax Legislation Makes Technical Corrections to DRA
4. Bipartisan Group in House, Senate Pushes Grants for
States to Expand
Health Insurance Access
5. Please contribute to VOR! Use form at the end of this
update to support
our effective advocacy.
Coming Up: There will be no update on Friday, February
9, 2007. The next
update will be distributed on February 16.
=======================================================
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1. "Waiver without a Waiver": Congress approves major
changes to Medicaid
Home and Community Based Services (VOR reprint).
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Summary: The following article first appeared in VOR's
newsletter, The
Voice, in Spring 2006. The referenced provision of the
Deficit Reduction
Act (DRA), Section 6086, became effective January 1,
2007. This article
shares VOR's perspective, including cautionary notes,
regarding the new
Medicaid community benefit. The next article gives
background information
about Section 6087, "Cash and Counseling", to which some
of VOR's concerns
also apply.
Source: The Voice, Spring 2006.
Section 6086 of the Federal Budget Deficit Reduction Act
of 2005
establishes major changes to how states can implement
home and
community-based services (HCBS). States now can provide
any of the services
covered under the HCBS waiver without going through the
waiver process.
What's good about the waiver process?
For a waiver to be approved, states historically have
had to submit their
proposals to the Centers for Medicare and Medicaid
Services (CMS) for
approval based primarily on the following state
assurances: health and
welfare of waiver participants; plans of care responsive
to waiver
participant needs; only qualified waiver providers;
State eligibility
assessment includes need for institutionalization; State
Medicaid Agency
retains administrative authority; and the State provides
financial
accountability (the waiver must cost less than the
institutional program).
HCBS waivers are reviewed every 3-5 years. In 2005, CMS
refined its method
of quality oversight, initiated with the release of The
Protocol in 2000.
In January 2004, CMS made mandatory the use of the
Interim Procedural
Guidance as the method for federal waiver review. The
Guidance requires CMS
staff to solicit evidence from the states as to their
quality management
strategy and implementation, including evidence that the
statutory and
regulatory assurance have been met. CMS also revised the
voluntary waiver
application template and the annual report form ("372
form") to gather
additional information about how states assure and
improve quality (Source:
The Voice, Winter 2004).
Although HCBS waivers did not afford the same level of
quality assurance
and oversight as the Medicaid Intermediate Care Facility
for Persons with
Mental Retardation (ICF/MR) program, the process
afforded beneficiaries
some protection.
What States gain with the new Section 6086 State Plan
Option benefit
The new HCBS State Plan Option provides states with even
more flexibility
than is available under the waiver, but with virtually
no federal
oversight. States are only required to submit to CMS
quarterly reports
(Form 64), showing the number of people served and the
cost to serve them.
Furthermore, States do not have to establish budget
neutrality, unlike the
waiver, which requires the HCBS benefit cost less than
institutional care.
States will also now be required to establish stricter
eligibility (level
of care) criteria for institutional services than for
community-based
services.
Like the waiver, States can restrict what, to whom and
where a covered
services are provided.
The new HCBS State Plan Option also expressly allows
states to cap
enrollment and maintain waiting lists for services now
covered under the
state Medicaid plan, such as personal care services and
rehabilitation
services, by moving them into the new HCBS State Plan
Option. This
provision is aimed at curbing the many waiting list
lawsuits that have been
filed against states 25 as of May 2005. Waiting list
lawsuits assert that
federal Medicaid law obliges a state to furnish home and
community services
to eligible individuals when needed.
What about people currently receiving HCBS waiver
services
The only requirement in the new benefit is that an
individual's current
HCBS waiver benefit expire. There is no requirement that
states continue to
provide the same or any benefits. In other words, as
states begin to
exercise their new found flexibility, a great many
people could find
themselves without services, or with reduced services,
and with virtually
no legal recourse to challenge these changes.
Conclusion
Despite strong opposition by disability organizations,
including VOR,
Section 6086 passed. Its passage represents perhaps the
most significant
reform to Medicaid law since the passage of the HCBS
waiver. Seriously
negative ramifications are predicted upon implement. It
is predicted that
the "waiver without a waiver" benefit will undermine the
availability and
quality of Medicaid home and community-based services.
Although States can
still opt to provide HCBS waiver services, overtime
there seems to be
little incentive for a state to pursue this more
"restrictive" process. V
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2. States Now Have More Flexibility to Adopt Personal
Care Programs Without
Waivers
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Source: BNA, 2007
States will now be able to more easily provide Medicaid
beneficiaries in
need of personal care services with a new
"self-directed" personal
assistance service option, a private group said Jan. 29.
Prior to Jan. 1, any state interested in introducing a
so-called Cash &
Counseling option was required to obtain a Section 1115
or 1915c waiver
from the Centers for Medicare & Medicaid Services,
according to an
announcement from the Cash & Counseling National Program
Office at the
Boston College Graduate School of Social Work. However,
Section 6087 of the
Deficit Reduction Act of 2005, which took effect Jan. 1,
now allows states
to offer a Cash & Counseling option within their regular
Medicaid states
plans without first obtaining a waiver.
Known as "Cash & Counseling," the program gives
beneficiaries eligible for
personal care services--frail elderly people and those
with
disabilities--the option to manage a flexible budget and
decide for
themselves what mix of goods and services will best meet
their care needs.
Cash & Counseling was created to help address the
serious barriers these
individuals can meet when seeking personal assistance
through the
traditional route, state-contracted home care agencies.
Typically, services chosen involve help at home with
daily activities such
as bathing, dressing, grooming, and meal preparation.
Cash & Counseling
participants may use their budget to hire their own
personal care aides,
including family members and friends, as well as buy
items or make home
modifications that help them live independently.
The Cash & Counseling program is jointly funded by the
Robert Wood Johnson
Foundation and the Department of Health and Human
Services.
"The new law will make it possible for Cash & Counseling
to become an
option in more states--giving thousands more elderly
adults and people with
disabilities choice and control over their Medicaid
personal assistance
services," said Kevin J. Mahoney, director of the Cash &
Counseling
National Program Office at Boston College.
Mahoney added that the federal waiver process is long,
cumbersome, and
difficult for states, and the new option will address
many of the issues
that currently hinder states that want to offer the
self-directed option.
The release said that based on the results, 12 more
states are now
implementing Cash & Counseling programs: Alabama,
Illinois, Iowa, Kentucky,
Michigan, Minnesota, New Mexico, Pennsylvania, Rhode
Island, Vermont,
Washington, and West Virginia.
More information on Cash & Counseling programs is at
http://www.cashandcounseling.org.
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3. Tax Legislation Makes Technical Corrections to DRA
---------------------------------------------------------------------------
--------
Note: VOR 2006 Washington Initiative participants called
on Congress to
pass a Deficit Reduction Act (DRA) technical correction
relating to cost
sharing. The article below relays that such a bill
passed late in December,
2006.
According to the National Association of State Directors
of DD Services
(NASDDDS, Jan. 19, 2007;
http://www.nasddds.org/publications), the Tax
Relief and Healthcare Act of 2006 (TRHA), passed shortly
before the close
of the 109th Congress, contains two technical
corrections to last year's
Deficit Reduction Act (DRA) important to advocates for
people with
disabilities:
* Medicaid recipients below 100 percent of the federal poverty line are
not subject to most of the new cost sharing requirements
of the DRA-a
protection that most legislators agreed was part of the
intent of Congress,
but which did not appear in the DRA due to a drafting
error [NOTE: VOR
called on Congress to make this technical correction
during the June 2006
Washington Initiative]. Congress also clarified that the
total cap on cost
sharing applies to the family, not on a per person basis
within a family.
* The TRHA codifies a CMS clarification that Medicare
and Supplemental
Security Income (SSI) recipients are exempt from the
citizenship
documentation requirements. TRHA extends citizenship
documentation
exemptions to recipients of Social Security disability
benefits.
One technical correction sought by advocates was not
included. The DRA,
which allows states to restructure their Medicaid
programs for certain
beneficiaries into "Benchmark Plans," does not specify
that those benchmark
plans must provide Early Periodic Screening, Diagnosis,
and Treatment
(EPSDT) services to enrolled children. Although it has
generally been
conceded that this was an error of omission, and a
technical correction was
included in the Senate version of the legislation, the
law as passed does
not address this issue.
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4. Bipartisan Group in House, Senate Pushes Grants for
States to Expand
Health Insurance Access
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Source: BNA
ISSN 1091-4021
Volume 12 Number 11
Thursday, January 18, 2007
A bipartisan, bicameral group of lawmakers Jan. 17
introduced bills to
provide federal grants to states to carry out reforms to
reduce the number
of individuals without health insurance coverage.
The introduction of the legislation is an indication
that states have
become laboratories for health care reform efforts and
that Congress is
unlikely to consider sweeping reforms in the next two
years, sponsors of the measures said at a press
briefing.
The bills would establish a "State Health Innovation
Commission" that would
review state health reform proposals. The proposals then
would be subject
to approval by Congress. The review process would take
about six months,
bill supporters said.
Proposals spanning the political spectrum likely will be
spawned by the
bills, from single-payer types plans to those using the
tax code to provide
coverage to the uninsured, to expansion of
Medicaid or State Children's Health Insurance Program
plans, they said. The
number of Americans without health insurance reached
46.6 million in 2005,
according to the Census Bureau.
Congressional Approval Needed
The bill would provide as much as $4 million for the
operation of the
commission, but the amount of money available to states
would depend on the
type and scope of plans submitted by states, they said.
The commission would act in much the same way as the
Base Realignment and
Closure Commission does, as votes would be taken on
numerous state health
reform plans as part of a package, they added.
After five years, the commission would report to
Congress about state
efforts and recommend possible additional congressional
action.
The Senate bill, the proposed Health Partnership Act
(bill number
unavailable), was introduced by Sens. Jeff Bingaman
(D-N.M.) and George
Voinovich (R-Ohio). The House bill, the proposed Health
Partnership Through
Creative Federalism Act (H.R. 506), was introduced by
Reps. Tammy Baldwin
(D-Wis.), John Tierney (D-Mass.), and Tom Price (R-Ga.).
Both bills also
were introduced in the 109th Congress.
Health care lobbyists and policy analysts have said
helping reduce the
number of uninsured Americans may be a topic on which
Democrats and
Republicans could work together in the 110th Congress,
although the federal
budget deficit likely would prevent major proposals from
becoming law.
State Initiatives
A report issued Jan. 17 by the Robert Wood Johnson
Foundation said states
are motivated to provide coverage for the uninsured for
a variety of
reasons, including declines in employer-sponsored health
insurance,
improved state economies with increased state revenues,
and the lack of
national action.
The report, State of the States 2007, Building Hope,
Raising Expectations,
found that more than a dozen states have enacted
innovative policies to
expand coverage; they include comprehensive
health care reform (Massachusetts, Vermont, Maine) ,
public-private
partnerships (Arkansas, Montana, New Mexico, Oklahoma,
Rhode Island,
Tennessee, Utah), and initiatives to cover all
children (Illinois, Pennsylvania).
California Gov. Arnold Schwarzenegger (R) Jan. 8
unveiled a health care
reform plan that would require every one of the state's
6.5 million
uninsured residents to have health insurance, and use a
combination of funds from individuals, employers,
providers, hospitals, and
state and federal government to pay the $12 billion
price tag.
"States are facing a 'perfect storm' with health care,"
said State Coverage
Initiatives Acting Director Enrique Martinez-Vidal, "and
that has provided
governors and state legislators with the
political will necessary to tackle the problem. States
have been fertile
testing grounds for new reforms and have proven that
bipartisan compromise
is possible." The state coverage initiatives
program is a national program of the Robert Wood Johnson
Foundation.
Valuable Information
Lawmakers said while individually they may disagree with
the best way to
expand health insurance, funding state initiatives will
provide valuable
information about covering the uninsured.
"The truth is, dealing with this problem between now and
the [2008]
election is not realistic," Bingaman said of a
comprehensive solution being
considered by Congress.
"While there are many health reform bills on the table,
including my own
preference for a single payer plan, it's clear to me,
and has been for some
time, that no single approach has enough support to
become law," Baldwin
told reporters.
Price said he favored the bill because "one-size fits
all doesn't work in
health care . . . and it's not politically feasible.
What is right for one
state may not be right for another."
"For too many years, I have listened to my colleagues on
both sides of the
aisle talk about the rising cost of health care and the
growing number of
uninsured. And for too many years, I've seen
little progress here at the federal level," Voinovich
said.
The bill "aims to break the logjam and allow states to
experiment with
health care reform options," he added. "Our hope is the
bill will provide a
platform from which we can have a thoughtful
conversation about
comprehensive health care reform here in Washington."
The Robert Wood Johnson report is available on the Web
at
http://www.statecoverage.net/pdf/stateofstates2007.pdf
---------------------------------------------------------------------------
Tamie Hopp
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