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Contents
This booklet is protected by copyright under United States law and by international copyright laws and treaty provisions. You may copy and distribute the work provided that you use the work for personal, noncommercial use; do not add the work to a collection or use it with any other text, photographs, artwork, etc; do not modify or alter the work in any way or delete or modify any copyright; and do not publish or post all or any part of the work on any Internet site or in or on any other media without obtaining the prior written consent of Ohio Legal Rights Service. Copyright © 2005 Ohio Legal Rights Service. All rights reserved. IntroductionThis paper outlines how to improve Ohio's Medicaid Program so that it is successful, and makes Medicaid more available, more effective and more meaningful for those who need it. To be successful, we, as Medicaid stakeholders, believe the program must be simple, fair and equitable, neutral, effective and competitive. The essential ideal of the Medicaid Program is to help Americans who are economically disadvantaged get medical care they need. In this paper, we identify practical strategies which support this ideal. Over the years, the Medicaid ideal has been increasingly difficult to implement because the number of people who need Medicaid is increasing, their needs are greater, and the costs of medical care are rising. The way Ohio currently runs the Medicaid Program cannot keep pace with these realities. But, Ohio's Medicaid Program can keep pace with reality, and function effectively to provide medical care to those who need it. And this can be done without jeopardizing those instances in which Medicaid is currently ensuring health for many Ohioans. The strategies we suggest have proven successful in other states, and are rooted in practicality — they will help Ohio structure a smarter Medicaid program — a program that meets reality head on, influences the health care market to correct current imbalances, and does the noble work it was intended to do. Finally, while we acknowledge the practical challenges and political ramifications of the Medicaid program's increasing costs, we nevertheless encourage you to keep the ideal of Medicaid a priority. Why? Because the Medicaid ideal is predicated on the value of health. Whatever concern the "bottom line" imposes upon decision making, we must be guided by the value of health. Who We AreWe are people:
Ohio's Improved Medicaid Program: SimpleThe Medicaid Program must be simple for Ohioans to find out about, and simple for Ohioans to understand. The process for getting Medicaid, including the application process, should also be simple. Thus, Ohio's Medicaid Program must be improved so it is:
Goal: Make Medicaid Simple to Find Out About and Simple to UnderstandFinding out about Medicaid should be simple. Information about the Medicaid Program should be readily and easily available to anyone who needs it. All service agencies should have the same information about Medicaid, in standardized formats that are easily recognizable as Medicaid related. Information should be available in print and on the internet, as well as in other places people would go to get information. Ohio should coordinate its information systems so that a person can access necessary information from multiple service venues, including disability service venues, elder services venues, children's services venues, and any other public service venue from which inquiries from a potential Medicaid recipient might arise. Because the laws and regulations which establish and regulate the Medicaid Program are written in "legal-ese," they are often difficult to decipher by people who need this information. However, the laws and regulations affect people's lives, and so should be explained in language that is simple to understand. Ohioans who are trying to get or keep Medicaid should have information which helps them personally and independently understand the Medicaid Program. In addition, any information about the Medicaid Program should be written and/or explained in language that is simple to understand, no matter who reads it, including people with disabilities, the elderly, families in crisis, and those for whom written or spoken English is not their primary language or mode of communication. Ohio should use "People First Language" in literature, brochures, or any materials it develops and disseminates about the Medicaid Program. "People First Language" acknowledges the person first, and refers to the person's capacity, ability or nature as simply descriptive. For example, material written in "People First Language" might say, "an individual who is vision impaired," or "a person who is elderly." Ohio should also make Medicaid information available in alternative formats so they are usable by people who have vision or hearing impairments, people who speak limited or no English, and people with limited cognitive abilities. Examples of alternative formats could include materials in braille and large print, materials readable by computer screen readers, materials in languages popularly used in Ohio such as Spanish, and materials which use pictures or icons to express meaning. Goal: Make the Process for Getting Medicaid (Applying) SimpleFor those who are eligible for Medicaid, the process for getting it, i.e. applying for Medicaid, should be simple. A basic application form should trigger the process, so that people are initially encouraged by the application process, rather than frightened off by it or dissuaded from continuing with it. Further application forms and materials should be streamlined and simplified. Application information should be stored and maintained in an electronic data base which eliminates or lessens the need to recreate "lost files." The process for determining eligibility, including any application process, also should be integrated and/or compatible with eligibility processes of other benefit programs. An applicant for Medicaid should not have to fill out multiple application forms for Medicaid and other public benefits. Ideally, the application and eligibility process should be singular and unified, and should determine eligibility for the myriad of public benefit programs and assistance for which the person is applying. Integrating information and/or eligibility systems can be done in a number of ways and many states have begun the process through "Aging and Disability Resource Centers." In collaboration with the federal Administration on Aging (AoA), the Centers for Medicare and Medicaid Services (CMS) awarded 12 states grants of up to $800,000 each to help them develop one-stop shopping centers for seniors and people with disabilities who need long-term care information.(1) The centers help states provide a single, coordinated system of information and access for all persons seeking long term support. The goal is to minimize confusion, enhance individual choice, and support informed decision-making. Simplicity is an attribute that should characterize Ohio's Medicaid Program. A person in medical need who cannot afford to pay for medical care already must handle two enormous challenges: (1) being compromised by illness, and (2) not having the money to get and pay for medical care. The Medicaid program should not give people a third challenge by requiring him or her to understand and manipulate, while in medical and financial crisis, an unwieldy system. Making the Ohio Medicaid Program simple will help make it work for all of Ohio's citizens, including adults and children with disabilities. Ohio's Improved Medicaid Program: Fair and EquitableThe Medicaid program must be fair and equitable. Medicaid policy and practice must reflect compliance with legal mandates of Olmstead v. L.C., decision-making based on impartiality, and commitment to principles of self-determination. Thus, Ohio's Medicaid Program must be improved to:
Goal: Comply with the Mandates of Olmstead v. L.C.The United States Supreme Court decision in Olmstead v. L.C. requires each state to administer programs in the most integrated setting appropriate to the needs of individuals with disabilities. A basis of this decision is the idea that people are unique individuals, with individual desires and aspirations in life, and that uniqueness and individuality must be respected and honored. Any Medicaid policies, practices or decision making must be in compliance with this decision. Thus, Ohio's Medicaid program must comply with the Olmstead v. L.C. mandate, which requires that individuals with disabilities be given choice of where they want to live. Medicaid policies and practices should not restrict, directly or indirectly, a person's opportunity to choose where she or he wants to live. Medicaid waivers allow a state to pay for covered Medicaid services in a variety of settings, giving people the opportunity to choose where they want to live and helping fulfill the mandate of Olmstead v. L.C. Thus, to achieve fair and equitable distribution of Medicaid benefits, Ohio should use Medicaid Waivers as a primary tool to address needs of Ohioans with disabilities. In order to be successful and effective, however, Ohio must move to eliminate multiple waivers/eligibility criteria and offer integrated service options based on need: benefits should be based on need. Ohio should not accept fiscal relief in the form of block grants, which cap federal matching funds, and which serve simply to exclude people who have individual needs by allowing them only generalized benefits, which may be unnecessary and useless.(2) Goal: Make Decisions ImpartiallyA strong Medicaid Program, one the public can stand behind, is one based on impartiality. Ohio must restructure the state's program to overcome its historic failure to provide funding for individuals with disabilities who have been unserved or underserved, such as people with mental illness, and children with disabilities whose working parents make them ineligible for Medicaid under Medicaid's income requirements. Ohio should not, for example, restrict access to medications through prior authorization requirements and preferred drug lists which in turn serve to limit Medicaid benefits to historically excluded populations such as people with mental illness.(3) Ohio should revise or eliminate dated or arbitrary limits which restrict the access of persons with mental illness to necessary residential and acute hospital inpatient treatment services.(4) Ohio policymakers should also encourage and plan for the passage of the Family Opportunity Act, which would give states the option to expand Medicaid coverage for children with disabilities up to age 18 in families with incomes up to 250 percent of the federal poverty level (or $46,000 per year for a family of four). Among other important provisions, the proposed bill would also grant immediate access to Medicaid services for those children with disabilities who are presumed eligible for SSI.(5) Goal: Commit to Principles of Self-DeterminationOhio's Medicaid Program must commit to principles of self-determination. As noted above, distribution of Medicaid benefits should not restrict a person's opportunities to choose where to live. But Ohio, must go further: Ohio must structure its program so benefit recipients have opportunities for choices of many kinds, including the choice of where to live, the choice of with whom to live, the choice of care provider, the choice of the kind health care to have, and the choice to be employed. Many of these choices can be supported through the "money follows the person" concept, which is discussed in detail on page 18. Ohio should adopt this strategy which has proven successful in Medicaid programs across the United States. By revising Medicaid spending formulas to permit money to "follow the person," funds can be allocated for services which are based upon individual choices and self-determination. Ohio should also develop a "Cash & Counseling" consumer-directed care program to give Ohioans options for budgeting and planning their supports and services. Arkansas, New Jersey, Florida and other states have already demonstrated that self-directed planning and choice in providers is yields consumer satisfaction with care and increases in quality of life.(6) Ohio can also support choice by assuring that all people have access to the system. Ohio can offer equal access to institutional and community services by providing information and outreach to inform people about their options, as has been done in other states.(7) Fairness and equity are attributes that should characterize Ohio's Medicaid Program. Ohio must look beyond where a person is, to what a person needs and what choices a person makes. Ohio should also recognize and discontinue its practice of excluding people from Medicaid coverage based on the nature of their need, or the reason the need exists. Making the Ohio Medicaid Program fair and equitable will help make it work for all of Ohio's citizens, including adults and children with disabilities. Ohio's Improved Medicaid Program: Setting-NeutralIllness and economic disadvantage finds people in every setting. Consequently, Ohio should improve its Medicaid Program, both policy and practice, so it will
Goal: Fund Services in a Setting-Neutral MannerOhio's Medicaid Program should not give financial preference to medical care which is provided in institutional settings. Rather, the Medicaid Program should fund services in a manner that is "setting-neutral." To achieve such neutrality, Ohio should adopt the strategy of "money follows the person." This system of flexible financing for long-term services lets available funds move with the person to the most appropriate and preferred setting as the person's needs and preferences change. By putting distribution of funds into the hands of the consumer, this strategy provides consumers greater choice of services, yielding greater consumer satisfaction. This strategy promotes the right to self-determination in long-term care and provides equal access to community-based services and supports to eligible individuals with disabilities.(8) There are different methods for applying the "money follows the person" strategy. Many states changed their long-term care budgetary practices to enable funds to follow people as they choose community supports. Some states allow funds allocated to one program to transfer to another as the individual moves within the system. Others have created a single long-term care budget instead of separating budgets between facility and community services.(9) Ohio should apply the "money follows the person" strategy, either by any of the above mentioned methods or, through another method - legislative mandate. A legislative mandate would not only work toward assuring a balanced system, but would also allow for consistent policies across state agencies. A successful example of such a legislative mandate is Texas' "Rider 37" (a rider added to a two-year state appropriations act) which allows the Texas Department of Human Services to move Medicaid funding from its nursing facility budget to its budget for state and Medicaid-funded HCBS when a Medicaid participant transitions from a nursing facility into a community-based residence. Over 1,900 Medicaid participants in Texas have transitioned from nursing facilities into the community under Rider 37.(10) Goal: Eliminate the Current Institutional BiasHistorically, the Medicaid program has exhibited an institutional bias which places individuals with disabilities in long term care facilities rather than community settings of their choice. Ohio's Medicaid program should eliminate the current institutional bias. One of the first steps toward doing this is to revise the nursing facility funding formula. Ohio should revise its Medicaid nursing home funding formula to include incentives that ensure and reward quality care. Changes should encourage the industry to improve staffing levels and adequately compensate workers to ensure residents are well served.(11) Another step toward eliminating Medicaid's institutional bias is to update public perception of nursing facilities. Ohio should open public discussion on the costs, financial and personal, of institutionalized long-term care. Ohio should also launch a public education program to educate Ohioans about the cost of long-term care, and encourage them to take personal action to prepare for those costs (e.g. long-term care insurance, etc.).(12) Ohio must also assess the impact of funding schemes on rural areas as compared to urban areas. For example, in rural areas, health care recipients often must travel long distances to visit qualified specialists, a transportation cost paid for solely by Medicaid. This travel can create also additional mental and financial burdens on the individual and her or his family. The increased use of telemedicine technology is one promising method for reducing this transportation burden and thus Ohio Medicaid should provide adequate reimbursement for telemedicine services.(13) Ohio must look closely at its Medicaid Program, which is, simply put, a funding scheme, to assure that it is operates based on neutrality. For different and numerous reasons, including financial and political, the culture of Medicaid has not been neutral. Rather, it has been weighted toward paying for health care in institutional settings. But the reality of illness is neutral - it affects people wherever they live. If we want Ohioans to maintain a community-based existence despite illness, Ohio's Medicaid Program should be improved to reflect this same neutrality. Making the Ohio Medicaid Program neutral will help make it work for all of Ohio's citizens, including adults and children with disabilities. Ohio's Improved Medicaid Program: EffectiveOhio's Medicaid program must be effective. Taxpayers fund this program with the expectation that it will secure the medical care Medicaid recipients need, within the care environment that exists. Thus, Ohio should improve its Medicaid Program so that it will:
Goal: Adequately Satisfy the Medical Needs of Medicaid RecipientsThe medical care services Ohio's Medicaid Program pays for should satisfy the medical needs of people who get Medicaid. First, Ohio's Medicaid program must maintain basic health care services for Ohioans with disabilities, and any changes in the program should not compromise or dilute this basic health care "safety net." Existing levels of services should be maintained, safety net providers should be supported, and Ohio should continue to fund services for current benefit recipients. Next, Ohio must further develop the infrastructure and systemic developments necessary for consumer-directed supports and services, self-determination and person-centered planning. This includes all the home and community-based waiver programs. The Ohio Medicaid Program finances a successful program of home and community-based services waivers for people who need health care and related services. Ohio should enhance, through increased fiscal support, the strategies/programs which have proven successful, including the Home and Community Based Waiver programs. Furthermore, Ohio should strive to eliminate waiting lists for individuals who are applying for or interested in home and community based waiver services. Goal: Function Productively Within the Service EnvironmentAny regulations which control Ohio's Medicaid Program should be written to minimize unnecessary administrative costs, and encourage innovation and flexibility at both the state and county levels so as to provide quality, cost effective services in the most efficient manner possible. Ohio should also explore new cost effective ways of delivering services (e.g. 1115 Waiver) by removing the restrictions on the types of services or providers who are eligible for payment.(14); Ohio's Medicaid policies and practices should seek to better coordinate Medicaid with other benefit programs, such as mental health care programs, early intervention programs, the State Children's Health Insurance Program (S-CHIP) and special education programs.(15) Along the same lines, merging administrative and regulatory responsibilities for Medicaid programs at the state and local levels should also help Ohio function effectively within today's health care environment. Finally, it is logical that federal efforts to improve Medicaid should seek better coordination of enrollment and benefits for dually-eligible beneficiaries. Ohio's policymakers should encourage and support this kind of coordination in their political dialogue.(16) Goal: Receive Value of ServicesOne size does not fit all. To receive value of services, Ohio must assure that the right service is getting to the right person. Offering a variety of service options provides flexibility to meet the variety of individual needs. Ohio must work actively to fund more services, supports and items, and to build provider capacity to provide new or underutilized services. Like other states, Ohio must expand its service options beyond traditional medically oriented, agency-based services to include self-directed service models and social models for services.(17) In addition to offering individuals a real choice among services, the long-term support system must provide quality services that meet the needs of individuals with chronic conditions. Ohio should actively seek out funding sources that support this, including any grants, etc., from the Centers for Medicare and Medicaid Services (CMS) which assist in implementing person-centered planning, getting feedback from medical care recipients, and ensuring stakeholder involvement.(18) Ohio's Medicaid Program should also have quality assurance mechanisms that work consistently and effectively. Ohio should establish consistent assessment processes for both institutional and community services. These processes should use the same tools and personnel to assess quality of the range of services Medicaid pays for, wherever they are delivered. Ohioans want a Medicaid Program which assures that Medicaid recipients are getting the health care services they need. We acknowledge that the Program has to operate within the realities of the day, and we expect that Ohio will take the steps necessary to work within those realities in an effective way. Making the Ohio Medicaid Program effective will help make it work for all of Ohio's citizens, including adults and children with disabilities. Ohio's Improved Medicaid Program: CompetitiveOhio's Medicaid Program must be competitive. Policies and practices should encourage the health care system to adjust to the needs of those who receive Medicaid, not the other way around. As a primary funder of health care services, Ohio's Medicaid Program can be the state's most effective vehicle for generating and improving health care services in Ohio. To that end, Ohio should improve its Medicaid Program so that it will:
Goal: Realize Cost Savings Through Long-Term Care That is Home and Community BasedLooking forward to the future, it is indisputable that the Medicaid program faces looming costs because of fiscal and demographic pressures. First, health care costs are rising. Second, medical technology is helping elders, as well as younger adults and children who have disabilities or are injured, live longer. Consequently, all these people will need greater medical support for longer periods of time. The "long-term care" that our population needs is increasing progressively. The experience of other states has consistently shown that providing long-term care that is home and community based is more cost-effective than care that is based within the four walls of an institution. For example, in Arkansas, the cost of caring for a person through home and community based services is one-third the cost of placing that person in a nursing home. And in Vermont, the cost of caring for a person at home is one-half the cost of care in a nursing home. By diverting spending on nursing facilities to home and community care, Oregon's overall long-term care costs are well below the national average: $604 per capita compared with the U.S. average of $996 per capita.(19) Like these states, Ohio should improve its Medicaid Program so that health care services are provided in homes and communities, and cost savings are realized for the program. A way to do this is to adopt the policy of "rebalancing" which means adjusting the state's publicly funded long-term supports — to increase the availability of community options and reduce reliance on institutions — so the supply of available services reflects the preferences of older people and people with disabilities. In states across the country, rebalancing long-term care systems at several levels of program and system design has shown not only decreased reliance on institutional services, but in some cases also short and long-term financial savings.(20) Several strategies can be used to achieve rebalancing, including legislative action, market-based approaches, and linkages that encourage rebalancing. Legislative action that establishes a policy of "money follows the person" was discussed above, and its benefits are clear. Employing the "money follows the person" policy will help Ohio realize cost savings because greater consumer choice results in greater consumer satisfaction which results in more effective use of Medicaid funds. Rebalancing can also be achieved through a fair market-based approach. With this strategy home and community based waiver usage is increased by 1) providing participants a choice of this option over institutionalization through equal access, service availability and quality, or 2) using managed care models to create incentives to serve people in less expensive community settings. Participants are offered a comprehensive selection of services and supports, with available traditional and independent providers and a variety of living environment options. Through fair market-based approaches, Ohioans can rebalance the supply of services available to them based on their demands (their choices) and help Ohio realize cost savings, as they choose home and community based waiver services over institutionalization.(21) Finally, linking funds and programs can help Ohio realize cost savings as well. Financial linkages build connections between funding streams, either by combining them or by linking an increase in the home and community based services budget to a decrease in institutional expenditures. Programmatic linkages increase coordination of services throughout the system, such as the establishment of local single access points for all long-term supports, or the introduction of person-centered planning processes throughout the system so people in any setting have the same tools to select services that meet their unique needs.(22) Another way in which Ohio can realize cost savings for its Medicaid Program is to realign financial incentives to allow county governments to access funds appropriated for intermediate care facilities for the mentally retarded (ICFs/MR) and nursing facilities services to cover the costs of community placements for persons leaving such institutional facilities.(23) Improving Ohio's Medicaid Program to realize cost savings will make the program more competitive among all the programs Ohio legislators have to choose from when making budgetary decisions. Goal: Implement a Medicaid Buy-In ProgramThe Medicaid Buy-In Program gives people with disabilities the option and opportunity to engage in meaningful employment and be productive members of their communities without the threat of losing access to health care. Medicaid Buy-In has proven to be a successful strategy across the United States.(24) For Ohio, Medicaid Buy-In not only means health coverage for more needy Ohioans, but also means increased state tax revenues, and decreased use of unemployment funds. Medicaid Buy-In brings money into our state by supporting employment. Goal: Redirect Cost Savings Within the Medicaid ProgramAny potential Medicaid cost savings realized through program changes must be redirected within the Medicaid Program to support a continuum of service in the most integrated setting. The need for health care is as critical for those who cannot afford it as it is for those who can. Health care for all must be a priority for Ohio. Healthy Ohioans make for a healthy Ohio, socially, economically and politically. Making Ohio's Medicaid Program competitive will help make it work for all of Ohio's citizens, including adults and children with disabilities. EndnotesSome links in this section are to documents created in Adobe® Portable Document Format (PDF). To view and print PDF documents, you need to have Adobe® Reader®, a free software program, installed on your computer. Download Adobe® Reader®
Funding for this PublicationThis publication was produced by the Ohio Legal Rights Service, 50 West Broad Street, Suite 1400, Columbus, Ohio 43215-5923. Telephone 614-466-7264/800-282-9181 TTY 614-728-2553/800-858-3542 Web site: http://olrs.ohio.gov This publication was funded in part by the Ohio Developmental Disabilities Council under the Developmental Disabilities Assistance and Bill of Rights Act, Public Law 106-402. Ohio Legal Rights Service and this publication are funded in part by grants under the following federal laws: Developmental Disabilities Assistance (DD) Act, administered by the Administration for Children and Families; Protection and Advocacy for Mentally Ill Individuals Act (PAIMI), administered by the Center for Mental Health Services of the U.S. Department of Human Services; and the Rehabilitation Act of 1973 as amended, administered by the Office of Education Services and the Rehabilitation Services Administration of the U.S. Department of Education. OLRS Vision, Mission, and Non-discrimination PolicyOLRS envisions a society in which people with disabilities enjoy the same rights and opportunities as all people. Everyone is entitled to make decisions about where, how and with whom they will live and work as full and equal members of their communities. OLRS' mission is to protect and advocate for the human, civil and legal rights of people with disabilities. OLRS accomplishes this mission by providing information, referral and educational services, individual case advocacy, policy analysis, legal representation and systems change. Ohio Legal Rights Service does not discriminate in provision of service or employment because of race, color, religion, sex, sexual orientation, national origin, military service, disability, or age. Related Topics:
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