Health and Disability Policy Briefing

1
Health and Disability Policy Briefing

• The American Public Human Services Association
• July 2007

2
Disability The Numbers

• Approximately 50 million Americans
• (19.3 percent) have a disability of some type.
• Many individuals have more than one type of
  disability.
• The likelihood of disability increases with age.
• Nearly 70 percent of people with disabilities are
  children or working age adults.
• Source Access of Health and Long-Term Services
  for People with Disabilities, Jeffrey S. Crowley,
  Health Policy Institute, Georgetown University,
  April 2006

3
Overview Work Health Coverage Interaction

• People who work use their health insurance less.
• Employer-sponsored health insurance is declining
  and becoming less comprehensive.
• Many people with disabilities have health-related
  needs that are not covered by private insurance.
• Private coverage is often unavailable or
  unaffordable to people with disabilities.

4
Medicaid The Basics

• Medicaid provides coverage for designated groups
  of low-income individuals and individuals with
  disabilities.
• Jointly financed by the federal and state
  governments.
• States determine services covered, provider
  payments, and certain eligibility qualifications,
  within federal guidelines.

5
Medicaid Mandatory and Optional Services

• Mandatory Services
• Physicians services
• Laboratory and x-ray
• Inpatient and outpatient hospital services
• Early and periodic screening, diagnostic, and
  treatment (EPSDT) services for individuals under
  21
• Nursing facility services
• Home health services (for those entitled to
  nursing home care)

• Optional Services
• Prescription drugs
• Dental services
• Physical therapy
• Prosthetic devices
• Intermediate Care Facilities for persons with
  Mental Retardation (ICF/MR) services
• Personal care services
• Rehabilitation services
• Private duty nursing
• Hospice services
• Home and community-based services

6
Ten Things to Know About Health and Disability
Policy

• Disability/chronic illness can affect all aspects
  of someone's life employment, education, health,
  housing, income, and the need for medical and
  support services.
• Nearly half of Medicaid expenditures cover
  services for people with disabilities.
• 17 percent of Medicaid enrollees are people with
  disabilities (2006)
• 46 percent of Medicaid expenditures are for
  people with disabilities (2006)

7
Medicaid Spending on Categories of Enrollees
Elderly 9
Elderly 23
Blind Disabled 17
Blind Disabled 46
Adults 26
Adults 13
Children 48
Children 19
2006 U.S. Total 59.7 million
U.S. Total 299 billion in 2006
Note Expenditure distribution based on spending
only on services. Excludes DSH, supplemental
provider payments, vaccines for children, and
administration. SOURCE Health Management
Associates estimates based on CBO Medicaid
Baseline, March 2006.
8
Ten Things to Know About Health and Disability
Policy

1. Medicaid provides a comprehensive set of acute
   and long-term care benefits to meet the needs of
   people with disabilities.

9
Medicaid Expenditures by Service
10
Ten Things to Know About Health and Disability
Policy

1. Disabilities include both physical and mental
   impairments. Medicaid provides coverage for both,
   and is the single largest payer of mental health
   services.

11
Ten Things to Know About Health and Disability
Policy

• Medicaid is leading the way in supporting
  employment for people with disabilities.
• Medicaid covers mandatory services that are
  essential to employment acute care, long-term
  care, and inpatient and outpatient hospital
  services.
• Medicaid Infrastructure Grants (MIG)
• Another critical support is retaining health
  coverage through the Medicaid Buy-In, SSI
  sections 1619 (a) and (b), and other options.

12
Supporting Employment (Continued)

• States have implemented Medicaid programs and
  demonstration projects to allow working people
  with disabilities to retain health coverage.
• Medicaid Buy-In program
• 1902(r)(2)
• 1115 waiver
• DRA Benchmark Benefits

13
Medicaid Buy-In Overview

• The Medicaid Buy-In program allows states to
  expand Medicaid coverage to working individuals
  with disabilities whose income and assets would
  otherwise make them ineligible.
• Currently 33 states have Buy-In programs.
• As of 2005, more than 161,000 people have
  participated in state Buy-In programs.

14
National Buy-In Enrollment by Quarter (2000-2005)

• Source The Interaction of Policy and Enrollment
  in the Medicaid Buy-In Program, 2005 Final
  Report, Mathematica Policy Research, Inc., May
  2007, Figure III.1
• Note Missouri rescinded its Buy-In program in
  August 2005 causing a drop in total enrollment.
  The program has been reinstated in 2007.

15
Medicaid Buy-In Program Basic Guidelines
Requirements

• The Medicaid Buy-In program was created in the
  Balanced Budget Act of 1997 (BBA).
• Must be below 250 percent of FPL.
• Cannot exceed Supplemental Security Income (SSI)
  resource standard.
• Section 1902(r)(2)
• Ticket to Work and Work Incentives Improvement
  Act of 1999 (TWWIIA) expanded the Medicaid Buy-In
  program.
• Added two new optional eligibility groups.
• States can establish their own income and
  resource standards.
• Do not have to be below 250 percent of FPL.
• Participants must be between the ages of 16 and
  64.

16
Other Work Incentive Programs

• Social Security Disability Insurance (SSDI)
  trial work period of 9 months
• Supplemental Security Income (SSI)
• gradual reduction in benefits
• 1619 (a)
• 1619 (b)
• Disability Program Navigators (DPNs) assist
  individuals with disabilities in accessing
  services at One-Stop Career Centers

17
Medicaid Infrastructure Grants

• Medicaid Infrastructure Grants (MIGs) were
  authorized by TWWIIA to provide funding for
  states to facilitate the employment of people
  with disabilities through
• Medicaid Buy-In programs
• Improvements to Medicaid services that support
  employment
• Coordinated, cross-programmatic approaches to
  remove barriers to employment
• 40 states, plus the District of Columbia,
  currently have a MIG.
• Most MIG states also have a Medicaid Buy-In
  program.

18
Ten Things to Know About Health and Disability
Policy

• Medicaid facilitates independent living in the
  community for people with disabilities.
• Medicaid support services include
• Home and Community-Based Services (HCBS)
• Rehabilitation services
• Personal care services
• Durable medical equipment
• Home and Community-Based Services (HCBS) are on
  the rise.
• In 1994, represented 19 percent of Medicaid LTC
  spending
• In 2004, represented 36 percent of Medicaid LTC
  spending

19
Ten Things to Know About Health and Disability
Policy

• The Deficit Reduction Act of 2005 (DRA) provides
  opportunities to expand new services to people
  with disabilities.
• Benchmark Benefit packages
• Self-Directed Personal Assistance Services
• New options to provide HCBS
• Cash and Counseling
• Money Follows the Person

20
Ten Things to Know About Health and Disability
Policy

• Medicaid fills in the gaps in Medicare coverage.
• 7 million dual eligibles low-income seniors
  and people with disabilities who qualify for
  Medicaid and Medicare.
• A person with a disability must wait 24 months to
  become eligible for Medicare. Medicaid provides
  coverage when Medicare is not immediately
  available.
• Medicaid provides long-term care services and
  wrap-around coverage for services not covered
  by Medicare.

21
Ten Things to Know About Health and Disability
Policy

• Medicaid provides comprehensive services for
  youth with disabilities.
• Half of the 1 million children with severe
  disabilities age 4 and under receive Medicaid
  benefits.
• 30 percent of the 5.3 million children ages 5 to
  17 with disabilities receive Medicaid benefits.
• Katie Beckett option (TEFRA option)
• States also cover children in foster care.

22
Ten Things to Know About Health and Disability
Policy

• Fluctuations in state fiscal conditions impact
  the ability of Medicaid to provide services for
  individuals with disabilities.
• Rate of growth in Medicaid spending slowed since
  2000 and hit record lows in Fiscal Year 2006.
• States are improving program efficiency and
  investing in new services, innovations, and
  provider payment rates.
• Medicaid also must respond to rising health care
  costs, erosion of employer-sponsored health
  coverage, enrollment growth, and pressure to
  increase provider rates.

23
Ten Things to Know About Health and Disability
Policy

• Demographic and enrollment trends are impacting
  Medicaid programs.
• Aging population
• Growth in disability rolls

24
Trend Aging Population
25
Trend SSDI Enrollment, 1970-2005

• Source Annual Statistical Report on the Social
  Security Disability Insurance Program, 2005
  Social Security Administration, September 2006,
  Chart 2

26
Challenges and Issues

• Some health services can only be obtained in the
  home and not in the workplace.
• Complexity of work incentive programs.
• Barriers posed by asset limits.
• Number and scope of definitions of work and
  disability.
• Sustainability of initiatives such as Money
  Follows the Person and Demonstration to Maintain
  Independence and Employment.
• Pressures on state budgets.
• Age of transition for youth with disabilities.
• Impending restrictions on targeted case
  management and the rehabilitation option.

27
For More Information

• APHSA web sites
• Center for Workers with Disabilities
• http//cwd.aphsa.org
• National Association of State Medicaid Directors
  http//www.nasmd.org
• Contact
• Martha Roherty, Director
• [phone] ext. 229
• mroherty_at_aphsa.org