Thursday, July 7, 2011

Michigan Medicaid comments on CMS proposed rules (CMS-2296-P)

Comments from Michigan Medicaid were submitted by Jacqueline Coleman here.  To view the document, scroll down the page to Attachments - "Comments on CMS Proposed Rule CMS-2296-P" and click on "PDF" to open the file.

The proposed regulations affect people who are elderly and live in Assisted Living Facilities and other settings as well as people with developmental disabilities. Michigan Medicaid is concerned with what will happen to people living in these ALF's and other licensed settings who have chosen them over care in a nursing home, if the proposed regulations do not allow waiver services to be provided in these settings. The MI Choice waiver mentioned here is another type of waiver that Michigan uses to provide services to people who are elderly or disabled.

Michigan Medicaid comments on this proposed rule: "441.301(b)(1)(iv) ...A setting is not integrated if it is: (A) Located in a building that is also a publicly or privately operated facility that provides inpatient institutional treatment or custodial care; in a building on the grounds of, or immediately adjacent to, a public institution; or a housing complex designed expressly around an individual’s diagnosis or disability, as determined by the Secretary; or (B) Has qualities of an institutional setting, as determined by the Secretary." 

The state agency makes an important distinction between "optimal community integration" and other options:
Michigan would agree that the description of acceptable settings represents optimal community integration. However, as described it would eliminate important options that now contribute to the array of settings available to adults with disabilities and the elderly. In 2009, Michigan amended its MI Choice HCBS 1915 (c) waiver to include services provided in licensed settings. Licensed settings in Michigan include Adult Foster Care (AFC) homes and Homes for the Aged (HFA). 

As of May 1, 2011, the MI Choice waiver was providing services to 529 participants in licensed settings. Of this group, 387 participants transitioned to the setting from a nursing facility. The other 142 were at imminent risk of entering a nursing facility when enrolled in MI Choice. These are participants who chose the setting and remain there even though they have the option to
return to a nursing facility or, in some instances, move to a more independent setting. The vast majority of these homes would not meet the criteria in the proposed rules. Virtually all of these MI Choice participants would move to a nursing facility. This move to a more restrictive setting would ignore the participant’s choice, diminish the participant’s quality of life and cost Medicaid 2-3 times as much per day.

The following examples describe existing situations that would not meet the proposed criteria: 
  • MI Choice waiver participants living in homes licensed as an AFC on the grounds of continuing care retirement communities that included a skilled nursing facility. The home may provide a high level of independence and community integration. Further, the resident very likely appreciates the proximity to the skilled nursing facility for situations when that level of care is necessary, e.g. recovering from an illness. In some cases, the AFC resident has a spouse in the skilled nursing facility and the proximity allows them far greater opportunities to maintain their relationship. 
  • An AFC or HFA that provides dementia care is a setting designed around a diagnosis, which would exclude it from approved settings under the proposed rules. For the MI Choice participants residing is such settings, the residence provides a more home-like setting and more independence than a skilled nursing facility. A move from such a home to a nursing facility would be extremely detrimental to the resident and would outrage the resident’s family. 
  • Many of the MI Choice participants in licensed settings are not elderly. The preamble to the proposed rules suggests that they would be excluded from the provision that certain assisted living facilities may permissible for older persons. 
  • There are a small number of MI Choice participants living in licensed settings who simply have no other place to live. These include individuals with behavioral problems, such as sexual acting out, that let to their denial of admission by nursing facilities and other settings. MI Choice services provided in a small, all male AFC resulted in a very satisfactory and successful setting. There are also individuals with Traumatic Brain Injuries that presented unique and significant behavioral issues. There are small AFC homes that specialized in care for this population and provide a far more successful and independent setting than any other option.
There are also comments on Person Centered Plans and other concerns that arise out of the CMS proposals. 

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