Some Questions About
the
Medicaid Community-Based
Attendant Services And Supports Act
MiCASSA (S. 971 and
H.R. 2032)
1. What are the community-based attendant services and supports in MiCASSA?
In MiCASSA, the term
community-based attendant services and supports means
help with accomplishing
activities of daily living (eating, toileting,
grooming, dressing,
bathing, and transferring) instrumental activities of
daily living (meal
preparation, managing finances, shopping, household
chores, phoning, and
participating in the community), and health-related
functions (which can
be delegated or assigned as allowed by state law).
These can be done
through hands-on assistance, supervision and/or cueing.
They also include
help with learning, keeping and enhancing skills to
accomplish such activities.
These services and
supports, which include back-up, are designed and
delivered under a
plan that is based on a functional needs assessment and
agreed to by the individual.
In addition they are furnished by attendants
who are selected,
managed, and dismissed by the individual, and include
voluntary training
for the individual on supervising attendants.
MiCASSA specifically
states that services should be delivered, "in the most
integrated setting
appropriate to the needs of the individual" in a home or
community setting,
which may include a school, workplace, or recreation or
religious facility.
2. If someone
can't manage their attendant services completely
independently are
they still eligible for MiCASSA services?
Yes! People who
have difficulty managing their services themselves, due to
a cognitive disability
for example, can have assistance from a
representative, like
a parent, a family member, a guardian, an advocate, or
other authorized person.
3. Do you have to be impoverished to be eligible for MiCASSA?
No. If you are
eligible to go into a nursing home or an ICF-MR facility you
would be eligible
for MiCASSA. Financial eligibility for nursing homes is
up to 300% of the
SSI level (roughly $1,500 per month for a single person).
In addition, with
the Ticket to Work and Work Incentives Improvement Act of
1999, TWWIIA, states
can choose to have a sliding fee scale for people of
higher incomes beyond
the current Medicaid eligibility guidelines.
4. Is MiCASSA biased towards an agency delivery model?
No. MiCASSA assumes
that one size does not fit all. It allows the maximum
amount of control
preferred by the individual with the disability. Options
include: vouchers,
direct cash payments or a fiscal agent, in addition to
agency delivered services.
In all these delivery models the individual has
the ability to select,
manage and control his/her attendant services and
supports, as well
as help develop his/her service plan. Choice and control
are key concepts,
regardless of who serves as the employer of record.
5. Will MiCASSA replace existing community-based programs?
MiCASSA does not effect
existing optional programs or waivers and includes a
maintenance of effort
clause to ensure these programs are not diminished.
Waivers include a
more enriched package of services for those individuals
who need more services.
With MiCASSA, people who are eligible for nursing
homes and ICF-MR facilities
can choose community attendant services and
supports as a unique
service that is a cost-effective option. The money
follows the individuals
not the facility.
6. Is MiCASSA a new unfunded mandate?
No. MiCASSA is
a way to make an existing mandate for nursing homes and
virtual mandate for
institutions for mentally retarded persons responsive to
the needs and desires
of the consumers of these services. MiCASSA says the
people who are already
eligible for these services will simply have a choice
of where they receive
services. MiCASSA would adjust the current system to
focus on the recipients
of service, instead of mandating funding for certain
industries and facilities.
7. Why is MiCASSA needed?
Our current long term
services system has a strong institutional bias.
Seventy five percent
of Medicaid long term care dollars go to institutional
services, leaving
25% to cover all the community based services. Every
state that takes Medicaid
funds must provide nursing home services while
community based services
are completely optional for the states. MiCASSA
says, let's level
the playing field, give the person, instead of government
or industry, the real
choice.
8. How does MiCASSA help states?
MiCASSA provides a
five year transformation period for the states by
providing both an
enhanced match and grants for the transition to Real
Choice before the
benefit becomes permanent. MiCASSA offers states
financial assistance
to reform their long term service and support system to
provide services in
the most integrated setting, and thereby helps with
compliance with the
Supreme Court's Olmstead decision as well.
9. Will MiCASSA bust the bank? What about the "woodwork" effect?
MiCASSA assures that
a state need spend no more money in total for a fiscal
year than would have
been spent for people with disabilities who are
eligible for institutional
services and supports.
There is a lot of discussion
about the people who are eligible for
institutional services,
would never go into the institution, but would jump
at the chance to use
MiCASSA. (This is called the woodwork effect.) The
states of Oregon and
Kansas have data to show that fear of the woodwork
effect is blown way
out of proportion. There may be some increase in the
number of people who
use the services and supports at first, but savings
will be made on the
less costly community based services and supports, as
well as the decrease
in the number of people going into institutions.
Belief in the woodwork
effect assumes a lot of "free care" is now being
delivered by caregivers.
There is a real question whether this care is
truly "free".
Research on the loss to the economy of the "free" caregivers
is beginning.
10. What are the transitional services?
Currently Medicaid
does not cover some essential costs for people coming out
of nursing homes and
ICF-MR facilities. These include deposits for rent and
utilities, bedding,
kitchen supplies and other things necessary to make the
transition into the
community. Covering these costs would be one of the
services and supports
covered by MiCASSA.
11. What about people who need more supports?
For people whose costs
are higher than 150% of the average nursing home
cost, MiCASSA will
provide additional federal support to the states, so that
people are not stuck
in institutions because they need more services and
supports.
12. What about
people who are dually eligible for both Medicaid and
Medicare?
MiCASSA includes a
national 5 to 10 year demonstration project in 5 states
to enhance coordination
of services for non-elderly individuals dually
eligible for Medicaid
AND Medicare. These individuals often fall through
the cracks now.
13. How is Quality Assurance addressed in MiCASSA?
States are required
to develop quality assurance programs that set down
guidelines for operating
Community-based Attendant Services and Supports,
and provide grievance
and appeals procedures for consumers, as well as
procedures for reporting
abuse and neglect. These programs must maximize
consumer independence
and direction of services, measure consumer
satisfaction through
surveys and consumer monitoring. States must make
results of the quality
assurance program public as well as providing an
on-going process of
review. Last but not least sanctions must be developed
and the Secretary
of Health and Human Services must conduct quality reviews.
14. What is the
purpose of the Real Choice Systems Change Initiatives
section of the bill?
MiCASSA brings together
on a consumer task force, the major stakeholders in
the fight for community-based
attendant services and supports.
Representatives from
DD Councils, IL Councils and Councils on Aging along
with consumers and
service providers would develop a plan to transition the
current institutionally
biased system into one that focuses on
community-based attendant
services. Closing institutions, or at least
closing bed spaces
must be thought through by the people that have an
investment in the
final outcome, the consumers. The plan envisions ending
the fragmentation
that currently exists in our long term service system.
In addition, the bill
sets up a framework and funding to help the states
transition from their
current institutionally dominated service model to
more community-based
services and supports. States will be able to apply
for systems change
grants for things like: assessing needs and gathering
data, identifying
ways to modify the institutional bias and over
medicalization of
services and supports, coordinating between agencies,
training and technical
assistance, increasing public awareness of options,
downsizing of large
institutions, paying for transitional costs, covering
consumer task force
costs, demonstrating new approaches, and other
activities which address
related long term care issues.
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