On the Verge: The Transformation of Long-Term Services and Supports - - PowerPoint PPT Presentation

On the Verge:

The Transformation of Long-Term Services and Supports

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AARP

Research Methodology

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AARP

Primary Findings

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• States on the verge of transforming the financing and delivery of

LTSS

• Many plan to or have implemented Medicaid Managed LTSS

State LTSS Transformations

• States using administrative tools at their disposal to curtail

expenditures

• Increased demand due to economic downturn

Budget Cuts and Increased Demand

• With 26 new governors in office in 2011, record number of new

state officials

• Staff reductions top the list of savings strategies for aging and

disability agencies

Staffing Changes and Reductions

• Litigation pending before the U.S. Supreme Court
• Many states are reluctant to commit to ACA programs

Uncertainty of The Affordable Care Act (ACA)

AARP

Budget Context

States Continue to Struggle through Tough Economy

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AARP

Recession Remains a Significant Factor

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Major General Fund revenue sources (PI, Corp, and Property Tax) below pre- recession levels for most states

28 states still project 2012 tax revenues below 2007 pre-recession levels 22 states are now projecting collections above 2007 levels

While revenues are down, states must contend with increasing service demand

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MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

Percent Change in State Tax Revenue

2007 (actual) to 2012 (projected) Personal Income, Corporate, and Property Taxes

Source: HMA analysis of data from National Association of State Budget Officers (NASBO), Spring Fiscal Survey of States, 2007-2010 reports, and Fall 2011 Report for 2012 Notes: 2012 figures are enacted. For Illinois, this map uses projected revenue from NASBO’s 2006 report because 2007 data was not available.

Percent Change

• 25.7% to -15%
• 14.9% to -10%
• 9.9% to -5.0%
• 4.9% to - 0.1%

0% to 9.9% 10%+

AARP

Medicaid

Impact of the Recession on Medicaid Funded LTSS

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AARP

States are Transforming LTSS Delivery and Finance

Increased interest in Medicaid Managed LTSS

• 12 states with existing programs
• 11 states plans to implement in 2012 or 2013
• Half plan to implement statewide
• About 2/3 have or will require mandatory enrollment – but half of

these will allow an opt out

Increased focus on Dual Eligible service integration

• At least 28 states report efforts to integrate Medicare and

Medicaid services for “duals”

Plans for HCBS Waivers Consolidation

• 15 states considering for administrative and programmatic

simplification

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AARP

U.S. Medicaid Enrollment Increases in Economic Downturns

Aged and Disabled enrollment largely unaffected by economic fluctuations, but….

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Enrollment increase in other groups creates fiscal stress may prompt states to curtail LTSS optional services

Enrollment increases likely contribute to LTSS policy decisions

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Source: “Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage and Policy Trends: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2011 and 2012;” Vernon K. Smith, Kathleen Gifford, Eileen Ellis, et.al.; Kaiser Commission on Medicaid and the Uninsured; October 2011. Note: Enrollment percentage changes from June to June of each year.

Annual growth rate FY 1998-FY 2012 (projected)

U.S. Medicaid Enrollment Growth Shows Signs of Slowing

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AARP

Loss of Federal ARRA FMAP Results in 24% Increase in FY 2012 State Medicaid Funding

AARP 11 Enhanced FMAP / Federal Fiscal Relief (2003-2005)

Source: “Moving Ahead Amid Fiscal Challenges: A Look at Medicaid Spending, Coverage and Policy Trends;” Vernon K. Smith, Kathleen Gifford, Eileen Ellis, et.al.; Kaiser Commission on Medicaid and the Uninsured; October 2011. NOTE: State Fiscal Years.

ARRA Enhanced FMAP (2009-2011)

8.7% 10.4% 12.7% 8.5% 7.7% 6.4% 1.3% 3.8% 5.8% 7.6% 6.6% 7.3% 2.2% 8.4% 9.9% 12.9% 5.5% 4.9% 10.1% 3.0% 4.0% 5.7%

• 10.9%
• 4.9%

10.3% 23.7%

• 0.12
• 0.07
• 0.02

0.03 0.08 0.13 0.18 0.23

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Total State General Fund

Adopted

Annual Growth in Total and State Medicaid Spending, 2000-2012

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MI AK HI CA WI WA OR ID WY UT AZ NM NV TX MN IA MO OK NE KS SD ND MT AL LA FL TN IN OH IL PA WV VA KY NC SC GA AR MS ME NY VT NH MA RI CT NJ DE MD CO

Percent Change Existing Program (in 2010 or 2011) Plan to Implement in 2012 Plan to Implement in 2013 New Hampshire released a request for proposal (RFP) in October 2011, after the survey was completed. Although the state did not indicate plans to implement an MMLTSS program on the survey, the RFP includes the nondual aged and disabled as a mandatory population in its managed care program, and dual eligibles as a voluntary population for July 1, 2012. The state is also seeking a waiver to include dual eligibles as a mandatory group in managed care. 12

Nearly half of states have or are planning Medicaid Managed LTSS Programs

AARP

Most states have or plan statewide implementation

13 6 5 5 2 1 4 1 2 3 4 5 6 7 Existing MMLTC Programs Planned MMLTC Programs Number of States

Geographic Area of Medicaid Managed LTSS Programs n = 23

Statewide Limited geographic area Pilot program only Undecided

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• Most states have

either voluntary enrollment or mandatory with

• pt out option
• However, 6

require enrollment with no opt out

14 35% 30% 15% 20%

Enrollment Requirements for MML TSS n = 20

Mandatory with an opt out Mandatory with no opt out Voluntary opt in Other

Note: One state is represented in data for both Mandatory with an opt

• ut, and Voluntary opt in.

Enrollment Requirements

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Indication of strong interest to integrate MMLTSS programs for people enrolled in Medicare and Medicaid (“Duals”)

15 22.7% 22.7% 9.1% 45.5% Program currently integrates both State plans to integrate both No integration currently or planned Under consideration

Integration for People Enrolled in Medicare and Medicaid in MMLTSS n = 23

AARP

Most states increased HCBS waiver expenditures in 2011

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10 6 9 2 2 4 6 8 10 12 Less than 5% 5%-8% 8-15% More than 15% Number of States

Percentage Range of Increases in HCBS Expenditures 2010 to 2011

AARP

Most states increased the number of individuals served through HCBS waivers…

17 6 7 3 31 27 5 10 15 20 25 30 35 2012 2011 Number of States

Changes in HCBS Caseload From Previous Year

Increased Decreased Stayed the same

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….while Medicaid nursing facility census is expected to decrease or remain static

18 17 15 5 2 4 6 8 10 12 14 16 18

States Reporting Nursing Facility Census Change: FY 2011 to FY 2012 n=37

Increase Stay the Same Decrease

Number of States

AARP

Aging and Disability Programs

Impact of the Recession on non-Medicaid Funded LTSS

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AARP

Source: AARP, HMA, NASUAD Economic Survey, FY 10, FY11. FY09 data is from NASUA Economic Survey, December 2009.

Reductions in non-Medicaid State Aging and Disability Agency Budgets, SFY 09 - 12

20 2 4 6 8 10 12 14 16 18 5% or less 6-10% 11-15% 16-20% 21-25% Over 25% Number of States Percent Reduction from Previous Year SFY 09 (n=36) SFY 10 (n=31) SFY 11 (n=14) SFY 12 (n=11)

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SFY 2012 Non-Medicaid State Aging and Disability Agency Budget Actions

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Current and Planned Savings Strategies, SFY 11 –12

22 0% 10% 20% 30% 40% 50% 60% Percent of States 2011 2012

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Programs with Increased Service Demands, SFY 2011

23 5 10 15 20 25 30 Traumatic Brain Injury Program Housing Assistance Low-Income Home Energy Assistance Program (LIHEAP) Assisted Living Emergency response systems Environmental Modifications Kinship Care Senior Farmers' Market Nutrition Program (SFMNP) Senior Medicare Patrol Congregate Meals Disease Prevention/Health Promotion Home health care Supplemental Nutritional Assistance Program (SNAP) Elder Abuse Prevention SCSEP Chore Senior Centers Adult Day Services Community Transition from Nursing Homes Legal Assistance Development Homemaker State Health Insurance Assistance Program (SHIP) Case Management Personal Care/Assistance Alzheimer's Support Program Family Caregiver Support Long Term Care Ombudsman Adult Protective Services Home-Delivered Meals Transportation Respite Aging and Disability Resource Center Information and Referral Number of States

AARP

Decreased Service Expenditures for Non-Medicaid Programs, SFY 10-11 and SFY 11-12

24 5 10 15 20 25 Number of States SFY 10-11 SFY 11-12

AARP

Affordable Care Act

Many states report uncertainty about pursuing provisions within the Affordable Care Act due to pending litigation in the U.S. Supreme Court and lack of final federal guidance on implementation.

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AARP

Indications of Intent to Pursue Selected Affordable Care Act Options

26 6 7 6 9 6 8 10 21 22 18 16 2 3 5 14 5 10 15 20 25 30 35 40 45 Balancing Incentive Payments Program Section 1915(i) State Plan Option Community First Choice Option Health Home State Plan Option Number of States Definitely Plan to Implement Under Consideration Don't Know Definitely Plan Not to Pursue

AARP

State Outlook

What to expect in 20122

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AARP

State LTSS Priorities

28 5 10 15 20 25 30 No change Scaling back

• f services

has become a priority Expanding services is not a priority Developing HCBS is more

• f a priority

Creative use of technology is more of a priority Maintaining current service levels is now a priority Number of States 2010 2011

AARP

Conclusion

• The sluggish economy and increased demand for publicly-

funded LTSS are putting pressure on state policymakers to redefine the way LTSS are financed and delivered.

LTSS Transformations

• Many state officials are new to their jobs and many state

agencies have less staff due to staff reductions.

State Officials

• Many service delivery system changes are still unfolding.

The next few years will be critical as we go from policy and demonstrations to full implementation.

Reforms

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