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The Idaho Health Care Plan Using State Innovation Waivers to Increase Access to Health Care

The Idaho Health Care Plan (IHCP) is a unique and innovative approach to extending opportunities for affordable health insurance coverage to some Idahoans in the health insurance gap, and to provide Medicaid coverage for Idahoans with certain diagnoses. IHCP requires two State Innovation Waivers, a Medicaid waiver under §1115 of the Social Security Act, and a waiver under §1332 of the Affordable Care Act.

The §1115 Waiver would allow Idaho to extend Medicaid coverage to people who have certain conditions which result in very high medical costs. Removing these people from the Idaho health insurance exchange and transferring their coverage to Medicaid will reduce costs and risk for the insurance carriers selling plans on the exchange. This in turn will result in lower premiums for insurance exchange customers, and also in lower federal premium assistance costs.

The §1332 Waiver would use some of those savings to extend premium assistance to households with incomes below the Federal Poverty Level making insurance affordable for about 30,000 Idahoans currently in the “gap”.

This helps Idahoans with disabilities in two ways:

  1. People with one or more of the listed diagnoses (which include e.g., spinal cord injuries, cerebral palsy, several forms of cancer, Multiple Sclerosis, Osteogenesis Imperfecta) will have access to the full range of Medicaid covered services. Some of these people are currently without coverage, and some currently have a policy on the exchange. Medicaid covers long term services and supports (LTSS) which are not covered by private insurance policies. Even people who are currently covered by insurance will benefit from coverage of these services, and more comprehensive coverage from Medicaid.
  2. Many people with disabilities, living below the FPL, who don’t have one of the listed conditions (e.g. people with mental illness) will at least have access to affordable health insurance on the exchange.

The IHCP is not a complete solution to the Idaho’s Health coverage problems. At least 20,000 Idahoans will still be left in the insurance gap. The IHCP does not provide premium assistance to people who do not have taxable income. Medicaid Expansion under the Affordable Care Act would provide much better coverage for Idahoans with disabilities, especially people with serious mental illness. It would also provide significant savings to the state of Idaho, not realized by the IHCP ( https://disabilityrightsidaho.org/idaho-health-plan-position-paper/ )

However, an estimated 5,000 Idahoans with serious health conditions would gain access to Medicaid coverage under the IHCP. Another 30,000 Idahoans living below the poverty level will have access to affordable coverage on the Idaho insurance exchange (Your Health Idaho). Many of these people also have disabilities and serious health conditions. These factors make the IHCP a significant step forward and a great improvement on the status quo. The IHCP is an opportunity to move Idaho in the right direction by making affordable health care available to Idahoans with low incomes, including many Idahoans with disabilities.

James R. Baugh, DisAbility Rights Idaho, 4477 Emerald St. Ste. B-100, Boise, ID 83706 phone (208)336-5353

Email: jbaugh@disabilityrightsidaho.org 

 

Comments on Idaho State Innovation Medicaid Waiver (§1115) Application for People with Complex Medical Needs.

DisAbility Rights Idaho is Idaho’s Protection and Advocacy System for people with disabilities.  We provide advocacy, legal assistance and public policy analysis on behalf of Idahoans with disabilities.

We recognize that this waiver, in conjunction with a proposed §1332 Affordable Care Act, State Innovation Waiver, seeks to provide health care coverage for about 35,000 Idahoans who are currently without coverage, and to provide Medicaid eligibility for Idahoans with certain diagnoses. We support the waiver application as a significant first step in shrinking the coverage gap and providing an appropriate range of long term services and supports for some Idahoans with disabilities.

The last comprehensive attempt to quantify the number of Idahoans without access to affordable health coverage fond approximately 78,000 people in the insurance gap1. Several years of improved economic conditions and increased employment have probably substantially reduced that number. Current estimates using SNAP data and other sources suggest that the population is currently around 54,000. It is likely that the people who remain in the gap are even more disproportionately people with disabilities, and chronic health conditions, since these people are the least likely to benefit from increased job availability.

By far the best option for Idaho and Idahoans with disabilities is to take advantage of the enhanced federal match associated with the Affordable Care Act’s expansion provision to provide coverage for everyone in the gap. The Legislature has not been willing to do that so far. This proposal is a positive step in that direction.

We recognize that the selection of conditions for the §1115 waiver are based primarily on the impact that these conditions have on private insurance costs, and the impact that those costs have on premiums. Our concern however, is the impact on people with disabilities. We are very supportive of the changes released on November 22, 2017 to the list of eligible conditions to include, spinal cord injuries, and others.

The Application for the Complex Medical Condition waiver (CMC) will provide Medicaid coverage for some people with disabilities, that is, people with the listed conditions. This is obviously a significant benefit for those people currently in the “gap”, but it is also a significant benefit for people with disabilities who have an insurance policy on the state exchange. Private health insurance policies do not provide significant coverage for either long term care or for Home and Community Based Services (HCBS). Under the CMC waiver, both are covered. This will improve the risk pool for the exchange plans while providing coverage better suited to the needs of people with complex health conditions. Appropriate HCBS can delay or eliminate the need for long term care facility placements, and can prevent deterioration in health conditions, thereby reducing preventable hospitalizations, surgeries and other high cost treatments.

The CMC waiver does not include any coverage for people with serious mental illness (SMI).  We strongly recommend that the department include people with SMI.

Although their inclusion will increase the cost of the Medicaid program, those costs to the state are offset by savings in the Division of Behavioral Health, the State Catastrophic Care fund, the county indigent programs, and  the regional crisis centers. Indirectly, there will eventually be savings to local law enforcement, emergency departments, jails, first responders and the courts. Medicaid coverage for people with SMI is an overall fiscal benefit to Idaho.

It may be argued that the 1332 waiver will provide an opportunity for coverage for Idahoans with SMI who are “in the gap”. First, it is not clear how people without taxable income will qualify for the 1332 waiver. This is likely to be a problem for people with SMI. Second, private insurance plans will cover psychiatrist visits, prescription drugs, and some level of hospitalization. But private policies do not cover the range of services that have been demonstrated to be needed to support people with SMI in the community. Some of the most critical services such as psychiatric rehabilitation, intensive outpatient, peer supports, case management, partial care, and medication management, are covered by Medicaid, but not by insurance. Without some of these supportive services many people with SMI will not be able to comply with their psychiatrist’s appointments, or their medication regime. DBH provides some supports like ACT teams, but only for people who are already in crisis, not as ongoing supports.

It may be the case that the inclusion of people with SMI, makes it more difficult to establish the budget neutrality component of the application, if the Medicaid costs are not offset by reduced premium credits. We do not have the actuarial information needed to assess this issue. However, if it is possible to develop a waiver application which includes people with SMI, we should not let the opportunity pass by.

Idaho has a broken and fragmented mental health system which provides few services for people with SMI until they are in a serious crisis, posing a risk to themselves or others. We have little to offer these Idahoans unless they qualify for Idaho Medicaid. This approach to mental health has filled our jails and clogged our courts with people whose only offense is having inadequately treated mental illness. By failing to implement the expansion offered by the ACA, we have refused funding which could help Idaho make significant improvements to our system. If there is any way that we can use this waiver to improve mental health services for Idahoans with SMI, it would be a shame to let another opportunity pass by.

 

Submitted by James R. Baugh, Executive Director, DRI

VEYO NON-EMERGENCY MEDICALTRANSPORTATION (NEMT) CONTRACT TERMINATION – TALKING POINTS

VEYO NON-EMERGENCY MEDICALTRANSPORTATION (NEMT)

CONTRACT TERMINATION – TALKING POINTS

Veyo, LLC has terminated its contract with the Idaho Department of Health and Welfare to provide Non-Emergency Medical Transportation Services (NEMT) for Medicaid beneficiaries in Idaho, effective March 5, 2018. The Department of Health and Welfare and the State Division of Purchasing (DOP) are working to secure the services of a new NEMT provider with no disruption in services to Medicaid participants.

Approximately 100,000 NEMT trips are provided each month for Idaho Medicaid participants who need transportation to access their Medicaid-covered services.

Participant and Stakeholder Callers

  • Veyo will continue to provide NEMT services for Medicaid participants through March 5, 2018.
  • You should not experience a break in your NEMT benefits. Please continue to contact Veyo at 1-877503-1261 to schedule your transportation. If you do experience any problems, please contact us immediately at 1-800-296-0509 or Medicaid transport adhw.idaho.gov.
  • Medicaid has established a Transportation Advisory Committee (TAC) to improve the NEMT program. The TAC includes Medicaid participants, transportation providers, behavioral health and developmental disability representatives, key Medicaid staff, advocacy agencies and legislative representation. This group will continue its work through the contract transition period.
  • Questions can be directed to key Medicaid staff at 1-800-296-0509 or Medicaidtransport@adhw.idaho.gov

NEMIT Provider Callers

  • Veyo will continue to provide NEMT services for Medicaid participants through March 5, 2018. Medicaid’s expectation is that Weyo will continue to provide NEMT services and assist in facilitating a transition to the new NEMT broker.
  • The new NEMT broker will be responsible for setting rates. Medicaid will share the rate structures used by both Weyo and the previous NEMT broker.
  • Providers will be required to enroll with the new NEMT broker in order to be paid for services provided after March 5, 2018. More information will be provided once the new NEMT broker has been determined and enrollment criteria have been developed.
  • Questions related to the contracting process can be directed to DOP at (208) 332-1600.
  • Questions can be directed to key Medicaid staff at 1-800-296-0509 or  Medicaidtransport@dhW.idaho.gov

Vendor/Lobbyist Callers

  • Weyo will continue to provide NEMT services for Medicaid participants through March 5, 2018.
  • For questions related to the contract process, please contact the Division of Purchasing at (208) 332 1600.

2018 Idaho Election Calendar

February 16, 2018 Last day to pre-register to vote for the March 13 election.

March 2, 2018 Last day for an application for a mail-in absentee ballot to be received by the County Clerk for the March 13 election.

March 9, 2018 Last day for in-person absentee voting and for early voting for the March 13 election.

March 13, 2018. Election 8:00am to 8:00pm (*) At clerks option, polling places may be opened at 7:00am. Absentee ballots must be submitted to the County Clerk’s
Elections office by 8:00pm.

April 20, 2018 Last day to pre-register to vote for the May 15 Primary Election.

April 30, 2018 Last day to begin Early Voting for the May 15 Primary Election at the Early Voting Polling Place for the Primary Election for those counties who elect to conduct Early Voting.

May 04, 2018 Last day for an application for a mail-in absentee ballot to be received by the County Clerk not later than 5:00pm for the Primary Election May 15.

May 11, 2018 Last day for in-person absentee voting and for early voting for the May 15 Primary Election.

May 11, 2018 Last day for Early Voting until 5:00pm for the Primary Election (May 15) at the Early Voting polling place.

May 15, 2018 Primary Election – 8 am-8 pm (*) At clerks option, polling places may be opened at 7:00am. Absentee ballots must be submitted to the County Clerk’s
Elections office by 8:00pm.

August 13, 2018 Last day to begin Early Voting at the Early Voting polling place for the August 28 election for those counties who elect to conduct Early Voting.

August 17, 2018 Last day for an application for a mail-in absentee ballot to be received by the County Clerk not later than 5:00pm for the August 28 election.

August 24, 2018 Last day for in-person absentee voting until 5:00pm for the August 28 election at the absent elector’s polling place.

August 24, 2018 Last day for Early Voting until 5:00pm for the August 28 election at the Early Voting polling place.

August 28, 2018 Election – 8am-8pm pm (*) At clerks option, polling places may be opened at 7:00am. Absentee ballots must be submitted to the County Clerk’s Elections office by 8:00pm.

October 12, 2018 Last day to pre-register to vote for the General Election November 6.

October 22, 2018 Last day to begin Early Voting at the Early Voting polling place for the General Election (November 6) for those counties who elect to conduct Early Voting.

October 26, 2018 Last day for an application for a mail-in absentee ballot to be received by the County Clerk not later than 5:00pm for the general Election (November 6).

November 2, 2018 Last day for in-person absentee voting until 5:00pm for the General Election (November 6) at the absent elector’s polling place.

November 2, 2018 Last day for Early Voting until 5:00pm for the General Election (November 6) at the Early Voting polling place.

November 6, 2018 General Election – 8am-8pm At clerks option, polling places may be opened at 7:00am. Absentee ballots must be submitted to the County Clerk’s Elections office by 8:00pm.

Combining the SILC, the DD Council & TBI Programs into a Single Council is a Bad Idea

DisAbility Rights Idaho, Comments on proposal for the Partnerships for Innovation, Inclusion and Independence (PIII)

The PIII proposal is one of those concepts that seems like a good idea to people in Washington D.C. examining the various laws and grants, but is obviously a very bad idea to people with disabilities in the states where the councils actually do their work. I do not believe that there is any way to combine the three councils without diminishing their effectiveness. I do not believe that a single council can have effective representation from all of the affected constituencies.

Combining the Councils will destroy their focus and dilute disability representation.

All three councils are concerned with some type of disability, all three councils are required to have some representation of people with disabilities or family members. All three councils have some role in recommending state policies concerning issues involving people with disabilities. Nothing else is the same. Even in these three areas, each council’s mission and makeup are very different. In theory, the councils’ activities could overlap. In practice they never duplicate but sometimes collaborate. In Idaho the DD Council has interacted with the State Independent Living Council (SILC) for thirty five years, complimenting each other’s activities without duplicating or overlapping.

  1. The State Independent Living Council (SILC) and Centers for Independent Living (CIL) are cross disability organizations, but they are exclusively focused on independent living in the community. The SILC’s activities are focused on adults and transition age youth, soon to enter adulthood. They are NOT directly concerned with conditions in facilities, early childhood services, family support, K-12 education (except for transition), abuse or neglect in facilities, diagnosis or treatment. By concentrating on independent living, the SILC can work on a wide variety of disabilities, although it is a challenge to maintain a board which fairly represents this variety.
  2. The DD Council is focused on people whose disability is severe and occurs at birth or during the developmental period, but mostly addresses people with Intellectual Disability, Autism Spectrum Disorders, and Cerebral Palsy. By keeping a narrower focus in terms of disability, DD Councils can address issues across the lifespan including prevention, infant and toddler, preschool, Education, medical treatment, abuse and neglect in homes and facilities, specialized skill development, job training and placement, benefits policies, rights protections, and community integration. By having a narrower disability focus, DD Councils can assure that they have representation for the variety of disabilities, different ages and issues, and can include parents of children with DD.
  3. Congress established the Traumatic Brain Injury (TBI) Programs for the specific reason that the unique problems of people with TBI were not being addressed by the various disability related programs and the medical and rehabilitation establishment. People with TBI found themselves without appropriate treatment, rehabilitation services, education or medical treatment. As the incidence of TBI increased due to combat injuries, and sports injuries, this lack of specialized services was exacerbated. Recombining the TBI program into pre-existing programs would defeat the purpose of the legislation.

There is no way that these councils can be efficiently combined into a single entity. To insure adequate representation of all of the different disability types, ages, and geographic and cultural groups would require a huge and unwieldy council. Maintaining a focus on all of the issues addressed by each of the councils would dilute the targeted efforts and make them less efficient and less effective.

PIII would dismantle a successful program of State and Local innovation, often leveraging private resources to create local solutions.

These Councils have been productive laboratories for state innovation. Congress designed these programs to be focused on specific priorities, but to leave the implementation to the states to find innovative and local solutions. Within each council’s mission they are required to have consumer controlled processes for developing plans and projects. These projects in Idaho have often focused on developing and connecting people with disabilities to local, private or charitable resources to help people integrate more fully into community life, rather than promoting dependence on federal programs. For over 30 years these unique programs have been successful laboratories of innovation, responsive to their constituent communities. In those three plus decades, they have developed cooperative arrangements, collaborating when appropriate, but never duplicating services. In Idaho at least, this process is effective and efficient.

Each Council is an essential part of a State Network.

SILCs have a unique relationship with the state’s Centers for Independent Living (CIL). CILS receive guidance, public policy assistance, coordination and planning assistance from the SILC. CILs are the main focus of the SILC and this very beneficial collaboration could not be sustained at the same level with a broader, less focused, combined council. The SILC also provides a statewide point of contact for broader collaboration with Protection and Advocacy services, and the other two councils.

DD Councils are intimately associated with The University Centers for Excellence in DD (UCEDD), and with the Protection and Advocacy System (P&A). DisAbility Rights Idaho is the P&A system for Idaho. The UCEDD, through research training and dissemination helps to define evidence based “best practices” for people with DD. DD Councils provide planning coordination and public policy guidance to help the state adopt and implement those practices. P&As, in addition to protecting the rights of people with developmental disabilities, monitor the success of those practices and policies and provide important feedback and legal analysis to the Council and the UCEDD (See also NDRN”s comments on this issue, with which we concur). These three entities are required to collaborate on five or more priority issues every year.

TBIACs are integrated with the state TBI program and the Protection and Advocacy for people with TBI (PATBI). This combination of programs provides for collaborative planning and priority selection to help drive state level solutions to the lack of specialized services and treatment for people with TBI.

A combined council could not hope to achieve the level of joint planning and collaboration on the three areas of focus. This would make the process of planning and priority setting cumbersome at best and impractical in general. The focus which Congress placed on particular populations, like TBI, and on particular goals, like independent living, would surely be lost.

Reduced Funding will Reduce Effectiveness.

Since the merger of the councils will not increase efficiency, reduced resources will simply reduce effectiveness. The drastic reduction in overall funding will create destructive competition for shrinking and inadequate resources by diverse and deserving groups of people with disabilities. Making a single council choose between addressing abuse of people with DD in institutions, and finding transportation resources to enable people with disabilities to gain employment, or making web based services accessible for blind people, or improving access to mental health services for people with persistent mental illness, is not productive. These programs are in need of more funding, not less. (See also the comments of NDRN).

Conclusion

The PIII proposal has superficial appeal to people in Washington D.C. reviewing statutes and bureaucracies, but it discounts the collective experience of people with disabilities in the states where these programs have succeeded, and over thirty years, have found effective ways to achieve the Congressional purpose of each program, individually and collaboratively. PIII would destroy the focus of each program and dilute their mission across many dissimilar disabilities and goals. It would make adequate representation of different disabilities, geographic areas, and cultural concerns in a single council impossible. It would disrupt the three networks which improve the effectiveness of the councils. Reduced funding will reduce effectiveness.

If You Are Having Problems with Veyo – CID Wants to Hear About It.

The Consortium for Idahoans with Disabilities (CID) is collecting information regarding issues that people with disabilities (and/or parents of children with disabilities) may be experiencing with non-emergency medical transportation being provided by the new managed care organization Veyo.

CID is sharing these concerns with the Department of Health and Welfare, legislators, and VEYO in an effort to determine what problems may exist and how to provide immediate solutions.

Idaho Parents Unlimited (IPUL) is hosting a form on their website for you to share your story, as well as to be contacted for more information. Please click here to go to the form.

Medicaid Supported Living Rates for People with DD

Comments of DisAbility Rights Idaho on 

Medicaid Supported Living Rates for People with Developmental Disabilities.

Rate setting assumptions and base wage rate.

The rates appear to be based on an assumption that the appropriate average wage for all of the levels of support should be $10.47/hr. This is based on the mean wage for personal care aide in the Bureau of Labor Statistics (BLS), Occupation Code 39-9021, Personal Care Aide. We think this assumption is flawed and that it will lead to undesirable consequences. Although direct support staff for all levels of support may share the same job title, the level of difficulty, and the level of responsibility, and the level of skill will generally be very different for example in hourly supported living versus intense support. The tasks involved and the qualifications for direct care staff are markedly different from those of a personal care aide. People who are approved for Intense Supports must have either a serious medical condition or a history of dangerous behavior (IDAPA 16.3.10.514.02 (b)). The skill level, training needs, and responsibility level for Intense Level direct care staff are markedly higher than for most participants receiving hourly supports. These disparities will likely impede delivery of high quality services, create perverse financial incentives, and may result problems with access to service for some individuals.

  1. Supported Living Direct Care staff have responsibilities beyond those of a personal care aide. While Residential Habilitation- Supported Living (hereafter, SL) includes personal care services, it also includes skill training, and some high levels of supervision and medically related care and monitoring which are not provided by personal care aides (PCA). Teaching independent living skills to people with developmental disabilities requires training and skill beyond those expected of personal care aides. Although there may not be an appropriate BLS category for Supported Living direct care staff, it is clear that the job title selected by Meyers and Stauffer, does not match the skill set for this position. If PCA is used as a basis for salary some premium should be added to account for the higher skill and responsibility level expected in SL.

Recommendation: Set a higher base wage for Supported living direct care staff

  1. Intense Supports will likely involve much higher levels of skill and responsibility than most Hourly Supports. Once an appropriate salary level is determined for basic SL direct care, a higher base rate should be used in Intense Supports. A reading of the standard used for approving intense support level will quickly reveal that the skill and responsibility of providing care and supervision for this population is on a much higher level than standard hourly supports. Idaho is unusual (possibly unique) in having developed a system for SL which serves the most complex participants in the DD System. Idaho has for decades utilized SL to serve the people previously served in the Idaho State School and Hospital/Southwest Idaho Treatment Center (SWITC). While in state custody Idaho spent over $900/day to care for these individuals. The most medically involved participants would qualify for placement in Long Term Acute Care Facilities at a similar or greater daily cost. In either case the individuals involved in their care are paid at much higher rates than PCAs. The work involved for some staff includes risk to personal safety. For others, it requires high levels of responsibility in the face of unpredictable and complex medical conditions. These are not job conditions faced by PCAs or by most hourly SL providers. In early meetings with M&S, and H&W representatives, I provided rationale for why direct care staff in intense supports, although having the same job title, needed a much higher level of training, responsibility, and reliability than in hourly SL. At that time, I was assured that this would be taken into consideration. That does not appear to have been the case. The effect of basing the Intense Supports level rates on the same base pay, will be to create a perverse incentive to avoid accepting people in this level of care.

Recommendation: Set a higher base wage for Intense support staff than for Hourly support staff

  1. High supports is set at exactly one half of the Intense Supports rate which will discourage any individual activities. “High Supports” allows for some of the billable hours for people in that level to be provided in groups of two or three. However, the service, and in particular the new HCBS rules, require that at least some of the hours are available to allow people to engage in individual activities with the help of staff. By setting the rate at half of the 1:1 rate, the department virtually guarantees that the HCBS rules will not be implemented. If two participants ever want to do different things, like attend different churches, the agency needs to have flexibility to staff some 1:1 time for both participants. An arbitrary ½ of the 1:1 rate makes this impossible without significant financial penalty to the provider. This is one more case of the Department creating perverse incentives by expecting providers to honor participant choice, and financially penalizing them each time they do so.

Recommendation: Create a rate that allows providers to provide 1:1 staffing for part of each day to allow for personal choice of participants in compliance with CMS/ HCBS regulations.

Submitted by DisAbility Rights Idaho

James R. Baugh, Executive Director