Wednesday, November 22, 2017

Update on Medicaid Home and Community-Based Services

The final implementation of the controversial 2014 Federal Home and Community-Based Settings rule has been delayed by the Centers of Medicare and Medicaid Services (CMS) until 2022, but that has done nothing too allay the fears of many people with disabilities and their families that it may be used as an excuse to discontinue funding for needed services and programs.

State Transition Plans (STP) are important for protecting the rights of people with disabilities to appropriate services in settings of their choice that assure integration into the larger community appropriate to the needs of the individual.

Michigan has identified settings that will undergo “heightened scrutiny” to assure that they meet the conditions of the settings rule before they are finally approved or rejected for HCBS funding. There are also grounds for legal challenges to the rule and commentary that explains why the Federal rule has been so controversial.

The following are links to resources and information to better understand what is at stake in the implementation of the federal settings rule:


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HCBS Advocacy

This is a Website supported by the Association of University Centers on Disabilities (AUCD).

From here you can find information regarding your state, including State Transition Plans that have received initial or final approval from CMS. So far only five states - Tennessee, Washington, Oklahoma, Kentucky, Arkansas - and the District of Columbia have final approval for their STPs.


According to HCBS Advocacy, although implementation of the rule has been extended to 2022, the deadline for final statewide transition plan approval is still March 2019.

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The Michigan Health and Human Services Website on the “Home and Community-Based Services Program Transition”

“As the Department develops new opportunities for stakeholders to provide feedback on this project, information about these events and opportunities will be published on this webpage. If you have any questions about this project, please send an email to HCBSTransition@michigan.gov.”

“Heightened Scrutiny”:

from CMSHome and Community-based Setting Requirements” - Heightened Scrutiny:

“Importantly, any setting regardless of location that has the effect of isolating individuals receiving Medicaid home and community-based services (HCBS) from the broader community of individuals not receiving HCBS is also presumed to be institutional, and therefore requires information from the state to overcome that presumption and describe how the HCBS settings requirements are met. States have an obligation to identify settings that are presumed institutional. …[The] final regulation …describes the process of “heightened scrutiny” that states can use to rebut or overcome this presumption. In particular, the regulations indicate that a settings described above “will be presumed to be a setting that has the qualities of an institution unless the Secretary determines through heightened scrutiny, based on information presented by the state or other parties, that the setting does not have the qualities of an institution and that the setting does have the qualities of home and community-based settings.”

Heightened Scrutiny in Michigan: 

In Michigan: Providers have been notified if they are subject to heightened scrutiny. Family members are encouraged to ask their provider about their status with regard to state implementation of the federal rule. 

from the HHS HCBS Transition Program:

“For those providers whom the department may submit for further review by the Centers for Medicare and Medicaid (CMS) there will be a public comment period. During this time all members of the public, including family members, will have an opportunity to share their opinions about whether the setting is home and community based. These comments will be taken into consideration before the department makes the final decision regarding submission to CMS.”

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May 9, 2017 letter from CMS extending the deadline for full implementation of the settings rule:

Extension of Transition Period for Compliance with Home and CommunityBased Settings Criteria”


“In recognition of the significance of the reform efforts underway, CMS intends to continue to work with states on their transition plans for settings that were operating before March 17, 2014 to enable states to achieve compliance with the settings criteria beyond 2019. Consistent with the preamble language, states should continue progress in assessing existing operations and identifying milestones for compliance that result in final Statewide Transition Plan approval by March 17, 2019. However, in light of the difficult and complex nature of this task, we will extend the transition period for states to demonstrate compliance with the home and community-based settings criteria until March 17, 2022 for settings in which a transition period applies. We anticipate that this additional three years will be helpful to states to ensure compliance activities are collaborative, transparent and timely.”

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From Together For Choice Blog, 11/14/17

Together for Choice Meets with CMS Administrator Seema Verma


"Together for Choice was invited to meet with Seema Verma, CMS Administrator, on November 1, to discuss the future of Medicaid. Approximately twenty other organizations participated in this invitation only meeting. The focus of the discussion was CMS’s Settings Rule which defines what constitutes a “community” setting and is therefore eligible for Medicaid waiver funding. I was the only person at the meeting who advocated for choice. I argued that the Settings Rule should be changed to honor the choices of individuals and their families regarding where to live and spend their days and to expand residential and day programming options. All of the other participants said that they did not want any changes to the Settings Rule or the CMS guidance under the Rule.

"Administrator Verma stated that she wanted Medicaid to be beneficiary focused and to put people first. She also said that she wanted to provide the states with more flexibility on administering Medicaid programs. In fact, she said that she wanted to give states an 'unprecedented level of flexibility.' She also acknowledged that individuals with disabilities receiving Medicaid should be viewed differently from non-disabled individuals receiving Medicaid. She wants the states to be creative and innovative in developing Medicaid programs and she repeatedly said that she wants less process and more focus on outcomes. In that connection, she said that CMS will be developing a Medicaid scorecard for states…

"Brian Neale, the head of Medicaid services at CMS also spoke. He indicated a preference for revising the CMS guidance to address the unintended consequences of the Rule rather than amend the Rule.

..."We will continue to advocate for choice by following up with Administrator Verma and Director Neale. Please join our voices to preserve choice and expand quality options by joining Together for Choice. Click HERE to join."

Scott Mendel
Chairman, Together for Choice


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Misericordia’s Developmental Training Program No Longer Subject to “Heightened Scrutiny”

2/2/2017

...“In early November, Illinois issued for public comment a draft of its transition plan. The plan listed all the facilities in the state that it believed should be subject to 'heightened scrutiny.' Misericordia’s DT program was one of the facilities on the list. The reason the state gave for subjecting Misericordia’s DT program to 'heightened scrutiny' was that it was located on a campus and was close to Misericordia’s ICF/DDs. We immediately asked all of our families with a family member living in a Misericordia CILA [Community Integrated Living Arrangement] (these are the individuals receiving “waiver” funding) to submit a public comment to HFS explaining how Misericordia’s DT program does not isolate their family member from the broader community.
  • We asked each family to include in its comment: all of the activities their family member engages in both on and off campus to show how full and integrated their life is. 
  • We asked the families to explain that their family member was engaging in the employment opportunities and other activities they choose. 
  • We also had the families point out that the state was applying the wrong standard in deciding that DT should be subject to heightened scrutiny. 
"We explained that the rule (quoted above) does not require heightened scrutiny just because a setting is located on a campus and is close to an ICF/DD. In fact, the CMS rule says nothing about location. Instead, heightened scrutiny is limited to settings that isolate individuals. By having each family explain how their family member is not isolated, we were able to show that DT did not come within the settings that required heightened scrutiny.”…

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Legal Vulnerabilities of CMS’s Regulation of Home and Community-Based Settings 

from Covington and Burling, LLP, 1/17/17

“We believe that both the regulations and subsequent CMS guidance can be challenged as exceeding CMS’s authority. The effect of the regulations is to limit the choices of living situations for individuals with disabilities, and to replace the preferences of individuals, families and guardians with the preferences of CMS as to which setting best suits the needs of a particular individual.” 

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The Federal Government’s Quiet War on Adults with Autism 

by Jill Escher, 4/19/16

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The Coalition for Community Choice and the Madison House Autism Foundation have been following the implementation of the Federal settings rule since 2014. They have extensive knowledge of State Transition Plans and the effort to preserve innovative housing solutions for people with autism and other developmental disabilities. For questions, see contact information here.

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Another threat to replacing the preferences of individuals and their families and guardians with the preferences of CMS and federally-funded advocacy organizations, is the promotion of Supported Decision-Making (SDM). SDM is based on the belief that all people with disabilities can make and communicate decisions for themselves regardless of the nature or severity of their disabilities. Many SDM advocates refuse to acknowledge that disability can impair an individual's capacity to make decisions and they support the total elimination of guardianship. 

See Guardianship vs. Supported Decision-Making

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"The idea that one residential model is appropriate for the entire spectrum of intellectual ​and developmental disability — from college-educated self-advocates to profoundly impaired individuals at risk of detaching their own retinas or bolting into traffic — is patently absurd."

by Amy Lutz in "Myth - Truth", an article on Pennsylvania's proposed bill to close all Intermediate Care Facilities for Individuals with Intellectual Disabilities

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The Americans with Disabilities Act and the 1999 Supreme Court Olmstead decision protect people with disabilities from discrimination in their choice of residential settings, but they do not exclude the choice of institutional settings necessary for individuals to receive the services they need, nor do they ban congregate settings of more than 4 individuals with disabilities receiving services in a group setting.

See also, 

and

“The Olmstead Decision has been Misinterpreted”


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HCBS Update as a Word Document

Friday, November 17, 2017

Michigan Family Connections Fall 2017 News

Michigan Family Connections Fall 2017 newsletter is a publication of the Michigan Family to Family Health Information Center and the Family Center for Children and Youth with Special Health Care Needs Family [phone Line 800-359-3722]. Here are two items that will help families seeking medical and other benefits for their special needs children:

ACA OPEN ENROLLMENT IS GOING ON NOW—DON’T WAIT! 


With so much uncertainty around the Affordable Care Act, some individuals and families are waiting to see what happens. But it is important to note that there are important deadlines to meet if you need to purchase coverage. Don’t wait and take a chance on missing out on enrollment.

The Kaiser Foundation recently did an analysis on individuals eligible for Marketplace insurance. The results show that 54% or 5.9 million people who are uninsured and eligible to purchase coverage on the Marketplace would pay less in premiums than they would owe as a penalty for lacking coverage.

Within that, about 4.5 million (or 42%) could obtain a bronze level plan at no cost in 2018, after taking income-related premium tax credits into account. For more information on the results of this analysis, go to the Kaiser Foundation website here

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For more information, or for assistance in finding help with enrollment, please visit: www.healthcare.gov .

December 15, 2017—Enrollment closes

For individuals who enroll during this open enrollment period, coverage will begin on Jan 1, 2018.


MICHIGAN MILITARY FAMILY SPECIAL NEEDS COALITION

The Michigan Military Family Special Needs Coalition was recently formed as a partnership between the State Family Program Office, and Michigan military families with special needs. The purpose of the Coalition is to improve support and gather resources for all military and veteran families in Michigan requiring medical or educational consideration for family members. A family member with special needs is defined as a:

  • Spouse, child or incapacitated adult, who, regardless of age, has special medical needs and requires medical care for a chronic condition, receives ongoing services from a medical specialist or has significant behavioral health concerns. 
  • Child (birth through age 21) with special education needs who is eligible for, or receives, either early intervention services through an individualized family service plan, or special education services through an Individualized Education Program. 
The Coalition is seeking any Michigan military service members, veterans, or family members who want to assist in improving support and resources for our Michigan military and veteran families with special needs.

Please share this information with any military or veteran family with special needs that may be interested in participating. Any service members or family members interested may contact Jess Ulrey at (517) 481-8301. You can also visit their Facebook page at: https://www.facebook.com/mmfsncoalition/  .

Wednesday, November 8, 2017

2017 Election results: Washtenaw County millages supporting special ed and Community Mental Health win and other news

Both Washtenaw County millages won by a wide margin in yesterday’s election.

In other news, the Michigan legislature seems to be losing its mind depending on how you feel about guns in schools and protecting wildlife.

According to a Detroit Free Press article, “Michigan bills would allow concealed guns in schools, churches” by Kathleen Gray, 11/7/17:


“In the wake of mass shootings in Las Vegas and Texas that left dozens of people dead or injured, a Michigan Senate committee approved bills Tuesday that will allow gun owners to carry concealed weapons in gun-free zones such as schools, churches, day care centers, bars, dorms and stadiums.”

…”The bills taken up in the Senate Government Operations Committee passed on a party-line vote with Republicans supporting the three-bill package and Democrats opposing it. The bills would also close the open-carry loophole, effectively barring gun owners from openly carrying their weapons in gun-free zones.” This was a concession to school districts that claim that seeing people carrying weapons in school upsets students, parents, and staff to the point where they sometimes have to shut down.

Emily Durbin, Michigan chapter president of Moms Demand Action, responded:

”Two days after the latest shooting, we’re here not having a conversation about keeping guns away from domestic abusers, increasing background checks or banning bump stocks," she said. "Instead, we're urgently discussing what the gun lobby wants and that's a desire to have more guns in more places, no questions asked."

Governor Rick Snyder vetoed a similar bill in 2012, four days after a gunman slaughtered 20 children in an elementary school in Newtown, Connecticut.

“SB 584-586 — could come up for a vote in the Senate on Wednesday, and will likely pass the chamber, where Republicans hold a 27-11 majority.” 

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In addition,..."The state House of Representatives, in a voice vote and without debate, …passed a resolution urging the state Natural Resources Commission to establish a sandhill crane hunting season in Michigan." ---“‘Ribeye of the sky?' House recommends sandhill crane hunt in Michigan”, by Keith Matheny, Detroit Free Press, 10/18/17.

This has little to do with developmental disabilities, but a lot to do with how government fails to address important issues and sometimes seems to just want to aggravate the opposition for no particular reason. I doubt there has been a groundswell of support from hungry citizens who can’t wait to sample sandhill crane breast meat.

The Phyllis Haehnle Memorial Audubon Sanctuary near Jackson, Michigan has documented the successful repopulation of Sandhill Cranes in Michigan from near extinction to abundance throughout the Mississippi flyway. Since 2009, however, the fall population count has leveled off in Michigan and the birds reproduce in low numbers. The birds are protected under the federal Migratory Bird Treaty Act, but farmers can apply to the U.S. Fish and Wildlife Service for special permits to eradicate birds damaging their crops.

Is a Sandhill Crane hunt necessary, or could we all show a little restraint in the protection of native bird species?




Monday, November 6, 2017

Iowa privatization of Medicaid generates complaints

As Iowa experiments with the privatization of its Medicaid program, complaints have spiked. Is Michigan paying attention?

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As Medicaid Managed Care Proliferates, So Do Complaints


by Clay Masters, Iowa Public Radio | November 6, 2017

Iowa is one of 38 states that radically changed the way it runs Medicaid over the past few years. The state moved about 600,000 people on the government-run health program into care that is managed by for-profit insurance companies.

The idea is that the private companies would save the state money, but it has been a rocky transition in Iowa, especially for people like Neal Siegel.

Siegel is one of six Iowans with disabilities suing the state, alleging that Medicaid managed care, as it is known, deprives thousands of Iowans with disabilities the right to live safely in their homes.
Medicaid serves people with disabilities, low-income people and people in nursing homes. A combination of federal and state funds pays for it. It covers 74 million people across the country these days, about half of whom are in Medicaid managed care.

Siegel, a former financial consultant, was in a hit-and-run bicycle crash four years ago that left him with a severe brain injury. He uses a wheelchair and can barely speak.

“I would probably put Neal at about 98 percent cognitive (awareness) of what’s going on around him, but unfortunately (he’s) not able to articulate it,” said Siegel’s girlfriend, Beth Wargo. “So it’s being trapped inside your own body.”

After the accident, Siegel qualified for Medicaid. He lived in a rehabilitation center for a while, and the lawsuit, filed in U.S. District Court in June, says he was the victim of abuse and neglect while living there.

Eventually he moved home with Wargo, where he’s totally reliant on caregivers to assist him with all activities of daily life.

Then last year, Wargo said, they got a letter in the mail from AmeriHealth Caritas, the company that manages his care. Siegel’s budget for home help had been slashed by 50 percent, Wargo said. Siegel’s face lit up as Wargo talked about the lawsuit, and he managed to say, “Oh yeah,” when she mentioned how happy they were that they could be part of it.

Cyndy Miller is the legal director with Disability Rights Iowa, the advocacy group that spearheaded the lawsuit.

“The system is too stressed right now with the way it’s being managed, and it’s not healthy for individuals with chronic or serious disabilities,” said Miller.

According to the lawsuit, the company claimed that spending on Siegel’s case was cut because it had exceeded a limit set in state policy. A spokesman for AmeriHealth Caritas said the company could not comment on ongoing litigation. The state has asked for the lawsuit to be dropped.

In addition to the suit, complaints about Medicaid from hospitals, doctors and patients have spiked in Iowa.

Iowa’s Department of Human Services Director Jerry Foxhoven defended moving the entire Medicaid population to managed care. He said more taxpayer dollars will be saved under private management.

But he said his agency is willing to make changes, especially for people like Neal with serious disabilities.

“Everything’s always on the table. We’re always looking at everything to say, ‘How do we best serve the people we’re trying to serve and be the best stewards of taxpayer dollars?'” Foxhoven said.

For their part, the three companies with contracts in Iowa said in statements that the first 18 months of Medicaid managed care have been successful. But they also have said to state officials that reimbursement rates were based on deeply flawed cost estimatesprovided to them before the project began.

They are now negotiating to get millions of dollars more in state funding.

So where’s the savings? So far, no state has actually done a comprehensive review of whether private companies actually save Medicaid dollars, said Kelly Whitener, an associate professor with Georgetown University who studies managed care.

“You’d really need to be able to see, are you saving money overall or not, and if you are spending less money, are you suppressing services that are needed? Or are you really finding efficiencies and only delivering care that families really need?” said Whitener.

For the moment, those questions don’t have definitive answers.

Meanwhile, Iowa has to balance its books. Republican Gov. Kim Reynolds had to tap more than $260 million of the state’s reserve fund this year, and officials expect next year’s budget will be even tougher to negotiate. Medicaid funding is likely to continue to be a large part of the discussion.

This story is part of a reporting partnership with NPR, Iowa Public Radio and Kaiser Health News. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Elections Matter: VOTE November 7th, 2017


Washtenaw County, Michigan, has two important issues on the ballot affecting people with disabilities and people with mental illness.

Voting Information

The Ann Arbor League of Women Voters website can provide you with the information you need to vote. Enter your address and zip code and follow the links to check on your voter registration, the exact wording of ballot issues, and more.

Millage Elections

A mill is a property tax of one tenth of a cent ($0.001) or one-thousandth of a dollar of taxable value. A tax rate of one mill raises $1 per $1,000 of taxable value. The taxable value cannot be higher than 50% of the State equalized value (true cash value) of the property.


[For easily distractible people, who need to know more about this nowhere  is a link to a paper from the Michigan Senate Fiscal Agency.]

Washtenaw Intermediate Special Education Millage 

This is a proposal to renew a special education millage for another 8 years. See the Ann Arbor News report on the millage election:

“The millage would provide about $15.2 million in 2018 to fund special education services provided by Washtenaw County's public schools. Because this is a renewal of the existing millage, there is no additional cost to taxpayers.

“In all, Washtenaw County schools spend $124 million each year on special education services for more than 6,500 students, according to a presentation on the millage request from the WISD.”…


Washtenaw County Community Mental Health and Public Safety Preservation Millage


This is an NPR program by Jorge Avellan on 11/2/17 about the CMH millage: “Washtenaw County Voters To Decide Community Mental Health And Public Safety Proposal On Nov. 7th”

NAMI (National Alliance on Mental Illness), Washtenaw County supports the CMH Millage

NAMI Washtenaw County supports the Community Mental Health and Public Safety Preservation Millage on the November 7, 2017 ballot. NAMI WC focuses on mental health issues and their intersection with public safety, but we also support the complete millage, including the need for reliable funding for public safety operations and the need to rebate funds to communities which have their own public safety agencies.

Washtenaw County faces several crises among people with mental illnesses who are not eligible for Medicaid and who are unserved as a result of state budget cuts. State funding for Community Mental Health (CMH) has dropped by 60%, from $6.5 million to $2.7 million. CMH has lost 70 staff members. CMH has discharged 350 people and has turned away others seeking help. CMH cannot use other funds to make up for the cuts.

Here are the results from these cuts to the CMH budget:

1. CMH cannot respond to the demands from the deadly and growing mental health crisis from suicides and opioid use.

2. Lack of CMH services has resulted in costly hospital stays. Other services in the community have been stressed because they cannot serve such serious problems.

3. We see its effects of budget cuts on the homeless population.

4. People with mental illnesses are being incarcerated in the County Jail unnecessarily.

The millage will raise $5.86 million to fund:

1. Better coordination with the Sheriff’s Office and services which will divert people with mental illness from unnecessary jailing and harm.

2. Four specific types of service

  • Crisis services: including the suicide and opioid epidemics 
  • Stabilization services: for those who do not currently qualify for services— 
  • Prevention services: including mental health awareness, prevention, and early intervention programming with community partners, including schools, law enforcement and other first responders, and health care providers. 
  • Jail Services: Including mental health and substance abuse assessment and treatment inclusive of counseling and psychiatric services and prisoner re-entry. 
....Call or email NAMI WC at 734-994-6611, office@namiwc.org. Our website: namiwc.org