Office on Disability

Report on Constituency Expert Input Meeting—December 12, 2006

Department of Health and Human Services
Hubert H. Humphrey Building
Office on Disability  Room, 637D
200 Independence Avenue SW
Washington, DC 20201
www.hhs.gov/od/


CMS greatly appreciates all of the help that organizations are providing to meet the needs of people with disabilities.

Introduction

The U.S. Department of Health and Human Services (HHS) Office on Disability (OD) held its sixth Quarterly Constituent Meeting in the Hubert H. Humphrey Building on Tuesday, December 12, 2006. The meeting, which was attended by over 40 constituents in-person and by phone,[1] was an opportunity for representatives from organizations serving America’s 54 million citizens with disabilities to receive updates and discuss concerns with a number of HHS administrators. Kitty Kobert and Tina Vay from the Office of Personnel Management (OPM), Laurence Wilson, Director, Chronic Care Policy Group, Centers for Medicare and Medicaid Services (CMS), and Leslie Norwalk, Esq., Acting CMS Administrator were all present for this informational meeting facilitated by Dr. Margaret Giannini, M.D., F.A.A.P., Director of the Office on Disability.

The OPM representatives reported on the current status of and improvements in Federal employment of persons with disabilities, giving detailed insight into progress and remaining challenges in the job application process from the perspectives of applicants as well as Federal agencies.

Mr. Wilson framed this year’s changes to Power Mobility Device (PMD) rules in the history of fraud and rising expenditures, and elaborated on the corrections to this year’s rules that have resulted in a more effective reimbursement scheme.

Ms. Norwalk addressed two issues, the Prescription Drug Benefit and Money Follows the Person. She provided updates on these programs and highlighted areas in which constituent input and outreach would be particularly helpful. 

Dr. Giannini opened the meeting by welcoming those in attendance and asking participants to introduce themselves.  She explained the format of the meeting: each of the presenters would provide an update on the issue at hand, and would then respond to constituents’ questions.

Meeting Summary

The following provides a summary of the updates, as well as the questions and comments of the disability constituency organization representatives who attended the meeting.

Kitty Kobert and Tina Vay
Office of Personnel management

Ms. Kobert and Ms. Vay provided information on the present state of Federal employment of persons with disabilities, as well as prospects for improving employment. One of OPM’s goals is to make Federal employment policies known to the public so that applicants are better able to take advantage of them.

The OPM session began with a discussion of hiring policy, which was followed by a presentation on employment process. For the content of the policy presentation, please refer to the PowerPoint in Appendix B.

Following the policy presentation, Ms. Kobert spoke about OPM and institutional supports for hiring people with disabilities. She first directed the meeting’s participants to the “Hiring Authorities” link at OPM’s disability site: www.opm.gov/disability. That page has helpful information addressing which disabilities are covered under Federal law and an explanation of job readiness.

Federal hiring and employment rates for people with disabilities are quite low, and Ms. Kobert suggested poor utilization of Schedule A as a possible cause. This underutilization may occur for a number of reasons: people simply are not aware of Schedule A; vocational rehabilitation may not take advantage of Schedule A; Agencies may not know how to use Schedule A.

To improve Schedule A utilization, OPM is implementing a community of practice/social learning approach among interested parties. This strategy consists of fostering collaboration over time among groups with a common interest or problem. This 3-year pilot project will start at the front lines of Agencies—the people who receive Schedule A employees, such as Selective Placement Program Managers and Service Officers. OPM wants them to have access to the Schedule A community and be connected to applicants, as hiring quickly is a win-win situation. 

A key effort in creating this community of practice is making important information and resources easily available online. For example, the participants in the Community of Practice are creating a database of key leadership resources and existing example documents that demonstrate leadership support, such as letters from the Department of Homeland Security (DHS) and the Department of Defense (DoD). The goal is to make this role an active position involving placing applicants, not just waiting.

In addition, the Federal Disability Workforce Consortium supports people with disabilities working in the Federal Government through workshops and information sessions. These efforts are not as intensive as the community of practice is envisioned to be, but are a good resource. OPM’s hope is to include people who have been leaders in the disability community many years. With their involvement in the community of practice, disability professionals can standardize procedures, such as the timeframe for letters and types of medical practitioners accepted across Agencies.

As an example of how Agencies can take initiative on these ideas, DHS asks managers if they are considering hiring, and provides applicants with disabilities if they are.

These supports are greatly needed to help people with disabilities apply for positions in the Federal Government. With these supports, there are two important considerations to remember: first, certification letters should be general and not specific to one job announcement. Second, Schedule A is not the only way for a person with a disability to apply for a job in the Federal Government. Veterans with disabilities have additional options, and the standard job openings posted are open to anyone who chooses to apply.

OPM Questions and Answers

Q: ONE CHALLENGE AGENCIES FACE WHEN USING SCHEDULE A IS HANGUPS IN THE PERSONAL BACKGROUND, SUCH AS CREDIT ISSUES. IS THERE A WAY AROUND THOSE BARRIERS?

A: That concern illustrates the primary benefit of Schedule A. Because Schedule A is non-competitive, it allows flexibility, as in the case of two applicants, one with 10 years’ experience and one with 7 years of experience who had been in a severe car accident and has debt. 

Q: HOW DOES THIS WORK WITH JOB POSTINGS? HOW DO YOU FIND A JOB TO APPLY FOR?

A: Under Schedule A, an applicant should go to a Selective Placement Program Manager or vocational rehabilitation service. A vocational rehabilitation councilor will provide the letter of certification, though a letter can also be written by an employer. It can also be effective to contact Human Resources (HR) offices at Agencies directly. USAJobs provides information on vacancies for which people with disabilities can apply.

The process can be made easier by working with a professional who is familiar with disability employment issues. Centers for Independent Living are an example of providers of this type of support.

Q: THERE IS AN INITIATIVE AT THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION AROUND EMPLOYMENT RATES OF PEOPLE WITH DISABILITIES. IF THERE IS A TREND THAT PEOPLE WITH SPECIFIC DISABILITIES ARE LEAVING THE FEDERAL GOVERNMENT AT A HIGHER RATE THAN AVERAGE, IS THERE ANY ATTEMPT TO TALK WITH THESE PEOPLE AND FIND OUT WHY OR HOW TO RETAIN?

A: There are attempts to retain people with disabilities at the some specific Agencies, however there is no broad effort at the OPM level.

Q: HOW CAN ORGANIZATIONS’ MEMBERS STAY INFORMED AS OPM MAKES PROGRESS ON THE STANDARDIZATION OF THE APPLICATION PROCESS ACROSS AGENCIES?

A: Standardization is currently at the Agency level, and OPM cannot create a formal cross-agency process. Agencies are just starting to get on board with community of practice.

Q: WHAT HAPPENS IF AN AGENCY IS GEIVEN BUDGET CUTS AND HAS TO LET FULL TIME EMPLOYEES GO? DO EMPLOYEES ON SCHEDULE A HAVE PROTECTION? HOW DOES THEIR PROTECTION COMPARE TO THAT OF THE TYPICAL EMPLOYEE?

A: If there are budget cuts in Agencies, the first step is to decide which offices and positions get cut. Regulations determine which missions are critical. Schedule A folks do not compete with the competitive side; a competitive person cannot take a Schedule A person’s job. It would not be just a Schedule A person involved in a reduction, but a whole cadre of individuals, as people on Schedule A have the same protection as those in the competitive system. Who gets cut depends on each Agency's determination of its key functions and priorities.

Q: ARE ALL JOBS POSTED ON USAJOBS.COM AVAILABLE FOR SCHEDULE A?

A: Three lines down in every job description on USAJobs.com there is a statement of who can apply. If the description says “Status Candidates” or “Federal employee,” the position may not be available for Schedule A. The employers still can consider anybody they want, so the recommendation is to apply, but the decision depends on internal policy. If there are any questions, call the contact given on the posting for details.

Q: IS THERE A LIST AVAILABLE OF SCHEDULE A OPENINGS?

A:  No, but there is a list of Selective Placement Program Managers available. Go to www.opm.gov/disability and look under “Applicants and Employees.”

Q: IF YOU ARE A PERSON WITH A DISABILITY AND APPLY WITHOUT SCHEDULE A, THE EMPLOYER CANNOT REJECT YOU IF YOU ARE QUALIFIED, RIGHT?

A: Right. The employee does not have to disclose the disability. Agencies have stacks of applicants, and they have the right to consider some or all of those stacks.

Q: IF THE AGENCY SAYS THAT ONLY CURRENT FEDERAL EMPLOYEES CAN APPLY, THAT GOES AGAINST THE GOAL OF BRINGING IN NEW PEOPLE WITH DISABILITIES.

A: Agencies have always had the right to determine which categories of candidates to consider, such as allowing only “status” applicants, for example. Agencies may not want to open a job to the public and receive more applications than they have money to process. There are limits, but Agencies have the right to limit the applications to status based on their needs.

Dr. Giannini closed this portion of the meeting by suggesting that participants with remaining unanswered questions for Ms. Vay and Ms. Kobert send them to Eileen Elias, Deputy Director, HHS Office on Disability (eileen.elias@hhs.gov). She also recommended that meeting participants explore the OPM website, www.opm.gov/disability, and contact the OD if they have any questions or concerns. She thanked Ms. Vay and Ms. Kobert.

Laurence Wilson
Center for Medicare and Medicaid Services

Dr. Giannini introduced Laurence Wilson, Director, CMS Chronic Care Policy Group, and CMS PMD expert, and thanked him for coming.

Mr. Wilson began by describing the latest rounds of revisions to PMD rules. 4 years ago, CMS set out to address two issues: fraud and abuse; and expenditure growth ($45million in 1995 to $1.2billion in 2003). In 2003, CMS created 4 steps in its strategy to reduce fraud and costs:

• Update coverage policies. Previous to this update, CMS operated under an antiquated rule that did not translate into clinical determinants. The 2003 new National coverage decision was more clinically based and functionally driven to make sure patients got PMD’s.
• Implement oversight provisions. In 2006, CMS began requiring a face-to-face visit with the prescribing physician.
• Implement new pricing and coding. 90% of products fell into one code and price prior to Nov. 15, 2006.
• Implement local coverage determinants (LCD). LCD guide contractors when making specific coverage determinations for beneficiaries.

CMS received a number of comments on this strategy. They heard that the LCD’s pushed clients down to lower functioning chairs, making mailboxes and other important places inaccessible. CMS also heard that another rule, the stand-and-pivot regulation, denied complex chairs to beneficiaries who needed them and was a problem. CMS has now reduced those barriers.

When CMS issued new prices it found that they were too low, and has increased prices since November 15, 2006. Although CMS is continuing to look at prices, the fees being paid now will probably be the final prices. CMS will continue to monitor prices and LCD.

Furthermore, the Medicare Modernization Act (MMA) requires that CMS implement quality standards measures. There will be specific standards for quality of service for wheelchairs.

Laurence Wilson Questions and Answers

Dr. Giannini opened the discussion for questions. She began herself by asking Mr. Wilson if he felt that CMS had adequately addressed concerns that the pricing scheme was denying beneficiaries access to appropriate chairs. Mr. Wilson responded that CMS had heard that complaint loud and clear, and that CMS has increased prices significantly (more than $1,000 in some cases). Manufacturers say the prices are now acceptable, and the problem appears to be adequately addressed.

Q: UNDER MMA, WHAT IS THE EFFECT OF THE FACE-TO-FACE VISITS WITH DOCTORS? HAVE THE VISITS CUT DOWN FRAUD?

A: Yes, the visits have cut down on fraud. The number of claims denials has gone down, while the number of chairs and total expenditures have gone up; the system is working, people understand the rules, and more chairs are going to the people who need them. CMS will continue to monitor this process that has played out over a number of years.

Q: MY ORGANIZATION IS RECEIVING CONFLICTING INFORMATION ON THE HOME ISSUE. WE HEAR FROM CMS THAT IT REQUIRES LEGISLATION, YET WE HEAR FROM POLICY EXPERTS THAT CMS DOES NOT NEED LEGISLATION. WHY ISN’T CMS MORE AGGRESSIVELY ADDRESSING THIS ISSUE? ALSO, MY CONCERN IS THAT THE PRODUCTS MANUFACTURERS ARE MAKING AT LOWER PRICES WILL NOT LAST FIVE YEARS, ESPECIALLY WITH ADD-ONS.

A: The majority of the cost and important features are the add-ons. CMS re-priced and re-coded the accessories. Prices for chairs are lower, generally, but when beneficiaries pay 20% coinsurance, it is a major cost to beneficiaries and CMS. CMS is confident that it addressed this issue with quality standards. Accreditation organizations provide quality oversight, price oversight, and protection against fraud.

The Home Rule is in the statute, and CMS cannot write a rule to get around it. Congress placed many other similar restrictions, such as only 3 days of nursing home care for hospital stays, etc. CMS is confident that it has obtained the best benefit for beneficiaries that meets this requirement. A person with a disability has to qualify by needing a wheelchair or mobility device in the home, but CMS provides a chair that meets the comprehensive needs once the person is qualified.

Q: REGARDING SERVICE BY MANUFACTURES, WHAT IS BEING DONE ABOUT LARGE REPAIR COSTS? HAS CMS EXAMINED THOSE COSTS, WHICH ARE OFTEN INFLATED? HOW ARE YOU HOLDING PROVIDERS ACCOUNTABLE?

A: CMS’ approach is through quality standards. Some things, like saying a battery is going when it is not, is simply fraud. CMS does data analysis with the Office of the Inspector General (OIG)—maybe a company is performing an abnormal number of motor repairs. Also, up to a point, CMS stops paying for repairs and just buys a new chair. Mr. Wilson agreed that CMS could put in place performance metrics around customer service in repair.

Q: YOU MENTIONED THAT YOU’VE BEEN MONITORING THE IMPACT OF CHANGES. HOW WILL YOU MAKE THAT INFORMATION PUBLIC? ALSO, WE DISAGREE WITH YOUR IN-HOME INTERPRETATION. YOU SAY YOU’RE BOUND, BUT MANY OF THE STATEMENTS FROM THE ADMINSTRATION ABOUT COMMUNITY INVOLVMENT, ETC. ARE INCONSISTENT WITH THAT APPROACH. FROM A POLICY PERSPECTIVE, WOULD THE ADMINISTRATION SUPPORT A CHANGE IN POLICY?

A: The Home Rule has been in existence for a number of years, and CMS is not in a position to change it. The Home Rule is a legal issue, not a conflict in policy.

For the first issue, CMS is going to do the typical breakdown—claims, denials, etc.—but would like to work with constituents to get feedback on what information would be beneficial to them.[2]

Leslie Norwalk
Acting Administrator, CMS

Dr. Giannini introduced Leslie Norwalk, Esq., saying that Ms. Norwalk would be talking about the Medicare Prescription Drug Benefit and Money Follows the Person.

Ms. Norwalk started by expressing her interest in working with people with disabilities and stating that she understands how important CMS is to that population.

Medicare Prescription Drug Benefit

Ms. Norwalk first gave an overview and update of the Drug Benefit. The open enrollment season was short, and CMS depended on disability constituent organizations to help beneficiaries understand the plans and have the enrollment period go so smoothly. CMS could not have done it without the organizations in attendance, as well as many others.

CMS has new Drug Benefit materials: a toolkit; DVD’s; handouts; and others. One concern over the last one and a half months is discussing changes for 2007.  CMS wants people to know that doing nothing puts you in the same plan—CMS does not want people to have to do something. At the same time, it is very important that beneficiaries do not get surprised in January. People must review plan changes sent to them from their plans. The message is that you should review and compare plans and changes, even if you don’t think you want to change.

Many people still have the question, “How do I choose?” They are paralyzed by the choices. The most important effort made to address this issue was the creation of a month-by-month bar graph so you can see monthly costs for the next year based on your drugs and plan. It is important to get knowledge of this tool out there, along with numbers people can call for help.

Some other suggestions:

• Enroll as soon as you can to avoid confusion in January.
• Get refills now
• If you have to get something at the pharmacy in early January, take a piece of paper with your plan name, policy number, and other essential information with you to the pharmacy.

CMS has also put state and county-level data on the website for people that did not enroll but do not have any coverage. These are the places CMS and constituent organizations need to target outreach together.

Communication with beneficiaries is another issue. Of particular concern are beneficiaries that had Dual Eligibility (DE) in 2006. About 600 of them have lost Deemed Status. That status may come back in 2007, but at least in January they do not have that extra help. This situation is very scary for beneficiaries, and it is important that beneficiaries that have lost Status fill out SSA applications to get extra help. CMS anticipates a problem at pharmacies with this population in January.

To help address this concern, this population will have a special election period. If an individual is in a plan that makes sense under DE, but turns out not to be acceptable once the change occurs, that individual can change plans in January.

Another group of concern comprises beneficiaries whose 2006 plans are no longer available for zero-cost Low-Income Subsidy (LIS). These people should switch plans, and they need to be comfortable with their new plans. They will have open enrollment all year.

Prescription Drug Question and Answer

Q: FOR DUAL ELIGIBLES WHO MAY NOW HAVE TO MAKE A COPAY, IS THERE PERSONAL CALLING OR OTHER DIRECT OUTREACH BEYOND LETTERS?

A: That type of outreach is the plan’s responsibility. Calls tend to scare beneficiaries, so there is a lot of outreach at the pharmacy level. My main concern, though, is those that lose DE status.

Q: ARE DE’S NO LONGER AUTOMATICALLY ENROLLED?

A: People on LIS and those enrolled in Medicaid while in Medicare are auto-enrolled. That will continue.

Money Follows the Person

There was a major need to update the Medicaid institutionalization bias dating back to 1965. Under the old system, payments followed an institution, and States had to come to CMS with waivers to pay for work in the home or community. Now, payments for home or community services can be part of the State plan.

The Deficit Reduction Act allows CMS to do demonstrations of this around match services, and 38 States have applied. It is very exciting to work with States, to make this work, and to help States improve the spectrum of services so they are more appropriate. This is a critically important rebalancing, and it is remarkable that it took this long to get here. CMS and the disability community need to make the most of this opportunity.

Money Follows the Person Question and Answer

Q: The general public does not have as much of a sense that the Money Follows the Person change is happening. We need more outreach. The State of the Union and other visible outlets would be great ways to get the word out about something concerning a huge constituency.

A: CMS is looking internally at some opportunities that follow Money Follows the Person themes. It is time that healthcare focus more on individual need, as does Money Follows the Person.

Q: PEOPLE ALSO DO NOT SEEM TO UNDERSTAND WHAT MONEY FOLLOWS THE PERSON MEANS TO THEM, INDIVIDUALLY.

A: MFP has diverse implications, depending on the State and an individual’s needs. Now the default is no longer that cash goes to the nursing home and the State has to get an exception. Constituent organizations could fill an important role by assisting CMS in distributing informational materials.

Dr. Giannini supported the idea of constituent organization involvement, offering that the groups present at the meeting could help distribute materials.

Ms. Norwalk concurred that materials explaining what Money Follows the Person means in different circumstances would be very helpful.

Q: IS THERE ANY FURTHER SUPPORT ONCE STATES HAVE BEEN AWARDED A GRANT? WILL CMS SEND OUT DIRECTIVES TO ENCOURAGE STATES TO WORK WITH THE COMMUNITY OR TO KEEP MEDICAID OFFICES FROM USING THE MONEY ON ADMINISTRATION, ETC.?

A: There are protocols for spending the money, including on administration. This type of open door cooperation is very productive, but it is not known whether the proposals requires long term community involvement. More information can be found in the Downloads section of CMS’ MFP website: http://www.cms.hhs.gov/DeficitReductionAct/20_MFP.asp

One possibility is a two-pronged approach. One part would be to provide a response form from CMS reminding States to be involved. The second prong is to have constituent organizations at the table to let CMS know when things are not working.

Closing

Dr. Giannini closed the meeting and thanked the participants and presenters for their attendance. She also asked that people with further questions or comments contact the OD through Eileen Elias, OD Deputy Director.

Appendix A

Constituent Groups Represented

ADAPT
American Association for the Advancement of Science
American Association of People with Disabilities
American Health Care Association       
American Physical Therapy Association
The Arc
Autism Society of America
Center for Medicare and Medicaid Services
Center for Workers with Disabilities
Council of State Administrators of Vocational Rehabilitation
Easter Seals
Exceptional Parents Magazine
ITEM Coalition
National Alliance for Caregiving
National Alliance for Hispanic Health
National Association of State Directors of Developmental Disabilities Services
National Council on Independent Living
National Downs Syndrome Congress
National Organization on Disability
National Spinal Cord Injury Association
NISH
Office on Disability, HHS
Office of Personnel Management
Paralyzed Veterans of America
Parent Advocate
The Scooter Store
United Cerebral Palsy
United Spinal Association
Voice of the Retarded

Appendix B

Tina Vay’s Presentation

Appendix C

S.193 Text

S.1932

Deficit Reduction Act of 2005 (Enrolled as Agreed to or Passed by Both House and Senate)

SEC. 6071. MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION.

1. PROGRAM PURPOSE AND AUTHORITY- The Secretary is authorized to award, on a competitive basis, grants to States in accordance with this section for demonstration projects (each in this section referred to as an `MFP demonstration project') designed to achieve the following objectives with respect to institutional and home and community-based long-term care services under State Medicaid programs: 
   1. REBALANCING- Increase the use of home and community-based, rather than institutional, long-term care services.
   2. MONEY FOLLOWS THE PERSON- Eliminate barriers or mechanisms, whether in the State law, the State Medicaid plan, the State budget, or otherwise, that prevent or restrict the flexible use of Medicaid funds to enable Medicaid-eligible individuals to receive support for appropriate and necessary long-term services in the settings of their choice.
   3. CONTINUITY OF SERVICE- Increase the ability of the State Medicaid program to assure continued provision of home and community-based long-term care services to eligible individuals who choose to transition from an institutional to a community setting.
   4. QUALITY ASSURANCE AND QUALITY IMPROVEMENT- Ensure that procedures are in place (at least comparable to those required under the qualified HCB program) to provide quality assurance for eligible individuals receiving Medicaid home and community-based long-term care services and to provide for continuous quality improvement in such services.
2. DEFINITIONS- For purposes of this section: 
   1. HOME AND COMMUNITY-BASED LONG-TERM CARE SERVICES- The term `home and community-based long-term care services' means, with respect to a State Medicaid program, home and community-based services (including home health and personal care services) that are provided under the State's qualified HCB program or that could be provided under such a program but are otherwise provided under the Medicaid program.
   2. ELIGIBLE INDIVIDUAL- The term `eligible individual' means, with respect to an MFP demonstration project of a State, an individual in the State-- 
      1. who, immediately before beginning participation in the MFP demonstration project-- 
         1. resides (and has resided, for a period of not less than 6 months or for such longer minimum period, not to exceed 2 years, as may be specified by the State) in an inpatient facility;
         2. is receiving Medicaid benefits for inpatient services furnished by such inpatient facility; and
         3. with respect to whom a determination has been made that, but for the provision of home and community-based long-term care services, the individual would continue to require the level of care provided in an inpatient facility and, in any case in which the State applies a more stringent level of care standard as a result of implementing the State plan option permitted under section 1915(i) of the Social Security Act, the individual must continue to require at least the level of care which had resulted in admission to the institution; and
      2. who resides in a qualified residence beginning on the initial date of participation in the demonstration project.
   3. INPATIENT FACILITY- The term `inpatient facility' means a hospital, nursing facility, or intermediate care facility for the mentally retarded. Such term includes an institution for mental diseases, but only, with respect to a State, to the extent medical assistance is available under the State Medicaid plan for services provided by such institution.
   4. MEDICAID- The term `Medicaid' means, with respect to a State, the State program under title XIX of the Social Security Act (including any waiver or demonstration under such title or under section 1115 of such Act relating to such title).
   5. QUALIFIED HCB PROGRAM- The term `qualified HCB program' means a program providing home and community-based long-term care services operating under Medicaid, whether or not operating under waiver authority.
   6. QUALIFIED RESIDENCE- The term `qualified residence' means, with respect to an eligible individual-- 
      1. a home owned or leased by the individual or the individual's family member;
      2. an apartment with an individual lease, with lockable access and egress, and which includes living, sleeping, bathing, and cooking areas over which the individual or the individual's family has domain and control; and
      3. a residence, in a community-based residential setting, in which no more than 4 unrelated individuals reside.
   7. QUALIFIED EXPENDITURES- The term `qualified expenditures' means expenditures by the State under its MFP demonstration project for home and community-based long-term care services for an eligible individual participating in the MFP demonstration project, but only with respect to services furnished during the 12-month period beginning on the date the individual is discharged from an inpatient facility referred to in paragraph (2)(A)(i).
   8. SELF-DIRECTED SERVICES- The term `self-directed' means, with respect to home and community-based long-term care services for an eligible individual, such services for the individual which are planned and purchased under the direction and control of such individual or the individual's authorized representative (as defined by the Secretary), including the amount, duration, scope, provider, and location of such services, under the State Medicaid program consistent with the following requirements: 
      1. ASSESSMENT- There is an assessment of the needs, capabilities, and preferences of the individual with respect to such services.
      2. SERVICE PLAN- Based on such assessment, there is developed jointly with such individual or the individual's authorized representative a plan for such services for such individual that is approved by the State and that-- 
         1. specifies those services, if any, which the individual or the individual's authorized representative would be responsible for directing;
         2. identifies the methods by which the individual or the individual's authorized representative or an agency designated by an individual or representative will select, manage, and dismiss providers of such services;
         3. specifies the role of family members and others whose participation is sought by the individual or the individual's authorized representative with respect to such services;
         4. is developed through a person-centered process that-- 
            1. is directed by the individual or the individual's authorized representative;
            2. builds upon the individual's capacity to engage in activities that promote community life and that respects the individual's preferences, choices, and abilities; and
            3. involves families, friends, and professionals as desired or required by the individual or the individual's authorized representative;
         5. includes appropriate risk management techniques that recognize the roles and sharing of responsibilities in obtaining services in a self-directed manner and assure the appropriateness of such plan based upon the resources and capabilities of the individual or the individual's authorized representative; and
         6. may include an individualized budget which identifies the dollar value of the services and supports under the control and direction of the individual or the individual's authorized representative.
      3. BUDGET PROCESS- With respect to individualized budgets described in subparagraph (B)(vi), the State application under subsection (c)-- 
         1. describes the method for calculating the dollar values in such budgets based on reliable costs and service utilization;
         2. defines a process for making adjustments in such dollar values to reflect changes in individual assessments and service plans; and
         3. provides a procedure to evaluate expenditures under such budgets.
   9. STATE- The term `State' has the meaning given such term for purposes of title XIX of the Social Security Act.
3. STATE APPLICATION- A State seeking approval of an MFP demonstration project shall submit to the Secretary, at such time and in such format as the Secretary requires, an application meeting the following requirements and containing such additional information, provisions, and assurances, as the Secretary may require: 
   1. ASSURANCE OF A PUBLIC DEVELOPMENT PROCESS- The application contains an assurance that the State has engaged, and will continue to engage, in a public process for the design, development, and evaluation of the MFP demonstration project that allows for input from eligible individuals, the families of such individuals, authorized representatives of such individuals, providers, and other interested parties.
   2. OPERATION IN CONNECTION WITH QUALIFIED HCB PROGRAM TO ASSURE CONTINUITY OF SERVICES- The State will conduct the MFP demonstration project for eligible individuals in conjunction with the operation of a qualified HCB program that is in operation (or approved) in the State for such individuals in a manner that assures continuity of Medicaid coverage for such individuals so long as such individuals continue to be eligible for medical assistance.
   3. DEMONSTRATION PROJECT PERIOD- The application shall specify the period of the MFP demonstration project, which shall include at least 2 consecutive fiscal years in the 5-fiscal-year period beginning with fiscal year 2007.
   4. SERVICE AREA- The application shall specify the service area or areas of the MFP demonstration project, which may be a statewide area or 1 or more geographic areas of the State.
   5. TARGETED GROUPS AND NUMBERS OF INDIVIDUALS SERVED- The application shall specify--
      1. the target groups of eligible individuals to be assisted to transition from an inpatient facility to a qualified residence during each fiscal year of the MFP demonstration project;
      2. the projected numbers of eligible individuals in each targeted group of eligible individuals to be so assisted during each such year; and
      3. the estimated total annual qualified expenditures for each fiscal year of the MFP demonstration project.
   6. INDIVIDUAL CHOICE, CONTINUITY OF CARE- The application shall contain assurances that--
      1. each eligible individual or the individual's authorized representative will be provided the opportunity to make an informed choice regarding whether to participate in the MFP demonstration project;
      2. each eligible individual or the individual's authorized representative will choose the qualified residence in which the individual will reside and the setting in which the individual will receive home and community-based long-term care services;
      3. the State will continue to make available, so long as the State operates its qualified HCB program consistent with applicable requirements, home and community-based long-term care services to each individual who completes participation in the MFP demonstration project for as long as the individual remains eligible for medical assistance for such services under such qualified HCB program (including meeting a requirement relating to requiring a level of care provided in an inpatient facility and continuing to require such services, and, if the State applies a more stringent level of care standard as a result of implementing the State plan option permitted under section 1915(i) of the Social Security Act, meeting the requirement for at least the level of care which had resulted in the individual's admission to the institution).
   7. REBALANCING- The application shall--
      1. provide such information as the Secretary may require concerning the dollar amounts of State Medicaid expenditures for the fiscal year, immediately preceding the first fiscal year of the State's MFP demonstration project, for long-term care services and the percentage of such expenditures that were for institutional long-term care services or were for home and community-based long-term care services;
      2.  
         1. specify the methods to be used by the State to increase, for each fiscal year during the MFP demonstration project, the dollar amount of such total expenditures for home and community-based long-term care services and the percentage of such total expenditures for long-term care services that are for home and community-based long-term care services; and
         2. describe the extent to which the MFP demonstration project will contribute to accomplishment of objectives described in subsection (a).
   8. MONEY FOLLOWS THE PERSON- The application shall describe the methods to be used by the State to eliminate any legal, budgetary, or other barriers to flexibility in the availability of Medicaid funds to pay for long-term care services for eligible individuals participating in the project in the appropriate settings of their choice, including costs to transition from an institutional setting to a qualified residence.
   9. MAINTENANCE OF EFFORT AND COST-EFFECTIVENESS- The application shall contain or be accompanied by such information and assurances as may be required to satisfy the Secretary that--
      1. total expenditures under the State Medicaid program for home and community-based long-term care services will not be less for any fiscal year during the MFP demonstration project than for the greater of such expenditures for--
         1. fiscal year 2005; or
         2. any succeeding fiscal year before the first year of the MFP demonstration project; and
      2. in the case of a qualified HCB program operating under a waiver under subsection (c) or (d) of section 1915 of the Social Security Act (42 U.S.C. 1396n), but for the amount awarded under a grant under this section, the State program would continue to meet the cost-effectiveness requirements of subsection (c)(2)(D) of such section or comparable requirements under subsection (d)(5) of such section, respectively.
   10. WAIVER REQUESTS- The application shall contain or be accompanied by requests for any modification or adjustment of waivers of Medicaid requirements described in subsection (d)(3), including adjustments to the maximum numbers of individuals included and package of benefits, including one-time transitional services, provided.
   11. QUALITY ASSURANCE AND QUALITY IMPROVEMENT- The application shall include--
       1. a plan satisfactory to the Secretary for quality assurance and quality improvement for home and community-based long-term care services under the State Medicaid program, including a plan to assure the health and welfare of individuals participating in the MFP demonstration project; and
       2. an assurance that the State will cooperate in carrying out activities under subsection (f) to develop and implement continuous quality assurance and quality improvement systems for home and community-based long-term care services.
   12. OPTIONAL PROGRAM FOR SELF-DIRECTED SERVICES- If the State elects to provide for any home and community-based long-term care services as self-directed services (as defined in subsection (b)(8)) under the MFP demonstration project, the application shall provide the following:
       1. MEETING REQUIREMENTS- A description of how the project will meet the applicable requirements of such subsection for the provision of self-directed services.
       2. VOLUNTARY ELECTION- A description of how eligible individuals will be provided with the opportunity to make an informed election to receive self-directed services under the project and after the end of the project.
       3. STATE SUPPORT IN SERVICE PLAN DEVELOPMENT- Satisfactory assurances that the State will provide support to eligible individuals who self-direct in developing and implementing their service plans.
       4. OVERSIGHT OF RECEIPT OF SERVICES- Satisfactory assurances that the State will provide oversight of eligible individual's receipt of such self-directed services, including steps to assure the quality of services provided and that the provision of such services are consistent with the service plan under such subsection.  
          
          Nothing in this section shall be construed as requiring a State to make an election under the project to provide for home and community-based long-term care services as self-directed services, or as requiring an individual to elect to receive self-directed services under the project.
   13. REPORTS AND EVALUATION- The application shall provide that--
       1. the State will furnish to the Secretary such reports concerning the MFP demonstration project, on such timetable, in such uniform format, and containing such information as the Secretary may require, as will allow for reliable comparisons of MFP demonstration projects across States; and
       2. the State will participate in and cooperate with the evaluation of the MFP demonstration project.
4. SECRETARY'S AWARD OF COMPETITIVE GRANTS-
   1. IN GENERAL- The Secretary shall award grants under this section on a competitive basis to States selected from among those with applications meeting the requirements of subsection (c), in accordance with the provisions of this subsection.
   2. SELECTION AND MODIFICATION OF STATE APPLICATIONS- In selecting State applications for the awarding of such a grant, the Secretary--
      1. shall take into consideration the manner in which, and extent to which, the State proposes to achieve the objectives specified in subsection (a);
      2. shall seek to achieve an appropriate national balance in the numbers of eligible individuals, within different target groups of eligible individuals, who are assisted to transition to qualified residences under MFP demonstration projects, and in the geographic distribution of States operating MFP demonstration projects;
      3. shall give preference to State applications proposing--
         1. to provide transition assistance to eligible individuals within multiple target groups; and
         2. to provide eligible individuals with the opportunity to receive home and community-based long-term care services as self-directed services, as defined in subsection (b)(8); and
      4. shall take such objectives into consideration in setting the annual amounts of State grant awards under this section.
   3. WAIVER AUTHORITY- The Secretary is authorized to waive the following provisions of title XIX of the Social Security Act, to the extent necessary to enable a State initiative to meet the requirements and accomplish the purposes of this section:
      1. STATEWIDENESS- Section 1902(a)(1), in order to permit implementation of a State initiative in a selected area or areas of the State.
      2. COMPARABILITY- Section 1902(a)(10)(B), in order to permit a State initiative to assist a selected category or categories of individuals described in subsection (b)(2)(A).
      3. INCOME AND RESOURCES ELIGIBILITY- Section 1902(a)(10)(C)(i)(III), in order to permit a State to apply institutional eligibility rules to individuals transitioning to community-based care.
      4. PROVIDER AGREEMENTS- Section 1902(a)(27), in order to permit a State to implement self-directed services in a cost-effective manner.
   4. CONDITIONAL APPROVAL OF OUTYEAR GRANT- In awarding grants under this section, the Secretary shall condition the grant for the second and any subsequent fiscal years of the grant period on the following:
      1. NUMERICAL BENCHMARKS- The State must demonstrate to the satisfaction of the Secretary that it is meeting numerical benchmarks specified in the grant agreement for--
         1. increasing State Medicaid support for home and community-based long-term care services under subsection (c)(5); and
         2. ) numbers of eligible individuals assisted to transition to qualified residences.
      2. QUALITY OF CARE- The State must demonstrate to the satisfaction of the Secretary that it is meeting the requirements under subsection (c)(11) to assure the health and welfare of MFP demonstration project participants.
5. PAYMENTS TO STATES; CARRYOVER OF UNUSED GRANT AMOUNTS-
   1. PAYMENTS- For each calendar quarter in a fiscal year during the period a State is awarded a grant under subsection (d), the Secretary shall pay to the State from its grant award for such fiscal year an amount equal to the lesser of--
      1. the MFP-enhanced FMAP (as defined in paragraph (5)) of the amount of qualified expenditures made during such quarter; or
      2. the total amount remaining in such grant award for such fiscal year (taking into account the application of paragraph (2)).
   2. CARRYOVER OF UNUSED AMOUNTS- Any portion of a State grant award for a fiscal year under this section remaining at the end of such fiscal year shall remain available to the State for the next 4 fiscal years, subject to paragraph (3).
   3. REAWARDING OF CERTAIN UNUSED AMOUNTS- In the case of a State that the Secretary determines pursuant to subsection (d)(4) has failed to meet the conditions for continuation of a MFP demonstration project under this section in a succeeding year or years, the Secretary shall rescind the grant awards for such succeeding year or years, together with any unspent portion of an award for prior years, and shall add such amounts to the appropriation for the immediately succeeding fiscal year for grants under this section.
   4. PREVENTING DUPLICATION OF PAYMENT- The payment under a MFP demonstration project with respect to qualified expenditures shall be in lieu of any payment with respect to such expenditures that could otherwise be paid under Medicaid, including under section 1903(a) of the Social Security Act. Nothing in the previous sentence shall be construed as preventing the payment under Medicaid for such expenditures in a grant year after amounts available to pay for such expenditures under the MFP demonstration project have been exhausted.
   5. MFP-ENHANCED FMAP- For purposes of paragraph (1)(A), the `MFP-enhanced FMAP', for a State for a fiscal year, is equal to the Federal medical assistance percentage (as defined in the first sentence of section 1905(b)) for the State increased by a number of percentage points equal to 50 percent of the number of percentage points by which (A) such Federal medical assistance percentage for the State, is less than (B) 100 percent; but in no case shall the MFP-enhanced FMAP for a State exceed 90 percent.
6. QUALITY ASSURANCE AND IMPROVEMENT; TECHNICAL ASSISTANCE; OVERSIGHT-
   1. IN GENERAL- The Secretary, either directly or by grant or contract, shall provide for technical assistance to, and oversight of, States for purposes of upgrading quality assurance and quality improvement systems under Medicaid home and community-based waivers, including--
      1. dissemination of information on promising practices;
      2. guidance on system design elements addressing the unique needs of participating beneficiaries;
      3. ongoing consultation on quality, including assistance in developing necessary tools, resources, and monitoring systems; and
      4. guidance on remedying programmatic and systemic problems.
   2. FUNDING- From the amounts appropriated under subsection (h)(1) for the portion of fiscal year 2007 that begins on January 1, 2007, and ends on September 30, 2007, and for fiscal year 2008, not more than $2,400,000 shall be available to the Secretary to carry out this subsection during the period that begins on January 1, 2007, and ends on September 30, 2011.
7. RESEARCH AND EVALUATION-
   1. IN GENERAL- The Secretary, directly or through grant or contract, shall provide for research on, and a national evaluation of, the program under this section, including assistance to the Secretary in preparing the final report required under paragraph (2). The evaluation shall include an analysis of projected and actual savings related to the transition of individuals to qualified residences in each State conducting an MFP demonstration project.
   2. FINAL REPORT- The Secretary shall make a final report to the President and Congress, not later than September 30, 2011, reflecting the evaluation described in paragraph (1) and providing findings and conclusions on the conduct and effectiveness of MFP demonstration projects.
   3. FUNDING- From the amounts appropriated under subsection (h)(1) for each of fiscal years 2008 through 2011, not more than $1,100,000 per year shall be available to the Secretary to carry out this subsection.
8. APPROPRIATIONS-
   1. IN GENERAL- There are appropriated, from any funds in the Treasury not otherwise appropriated, for grants to carry out this section--
      1. $250,000,000 for the portion of fiscal year 2007 beginning on January 1, 2007, and ending on September 30, 2007;
      2. $300,000,000 for fiscal year 2008;
      3. $350,000,000 for fiscal year 2009;
      4. $400,000,000 for fiscal year 2010; and
      5. $450,000,000 for fiscal year 2011.
   2. AVAILABILITY- Amounts made available under paragraph (1) for a fiscal year shall remain available for the awarding of grants to States by not later than September 30, 2011.
      
      

Appendix D

Consumer involvement and Money Follows the Person Rebalancing Demonstration

Administrative and national policy requirements under the Money Follows the Person Rebalancing Demonstration (MFP) require that “consumers and other stakeholders must have meaningful input into the planning, implementation, and evaluation of the project” (MFP solicitation CFDA 93779; subsection (i) on page 36).  Scoring of the State applications strongly support this and ten percent of the scoring for consumer emphasis were be broken down into two components. First, reviewers evaluated evidence provided in the application that consumers and consumer-run organizations will have a role in the design, development and implementation of the demonstration. To maximize scoring in this area, the consumer and/or consumer-run organization must participate in ways that go beyond advice giving. Maximum credit went to State proposals that showed evidence of some form of consumer decision making.  Second, in the demonstration itself,  preference was given to States that proposed mechanisms to track consumer satisfaction during the demonstration (MFP solicitation CFDA 93779 on page 33).

 
Appendix E

Outreach Data on People with Disabilities who are Part D Eligible

CMS has posted a summary of Part D enrollment data by state and county for Part D eligible people with disabilities who are under age 65. CMS is providing this data to assist organizations that are conducting outreach to people with disabilities to assist them in their drug plan selection process as swell as assisting them with applying for extra help through the Social Security Administration or state Medicaid offices.

State and county level data are available at the Partner Center:

http://www.cms.hhs.gov/partnerships/downloads/state_county_data_disabilities.zip

Please note that the number of people listed as not enrolled in Part D or Retiree Drug Subsidy in the chart is not the same as the number of people without drug coverage since many beneficiaries may have other sources of creditable coverage. However, these figures can be instructive to organizations that are targeting their outreach efforts to reach the most people.

CMS greatly appreciates all of the help that organizations are providing to meet the needs of people with disabilities.