to know about . . .
Currently, nursing home services are provided on an entitlement basis, while personal assistance services and other home and community based services are not. Federal statutes must be changed so that they no longer provide incentives among the states to provide long-term care systems biased toward institutional services, says the Robert Wood Johnson National Blue Ribbon Panel on Personal Assistance Services.
Medicaid programs in place now currently allow states to offer in-home services. But there's no requirement in Medicaid law that they do so. Nursing homes are an "entitlement" -- but in-home services are not.
The Medicaid Community Attendant Services and Supports Act (MiCASSA) would change that.
Introduced into the U.S. Senate in Nov. 1999 by Sen. Tom Harkin (D. - Iowa) and co-sponsored by Senator Arlen Specter (R-PA), MiCassa is designed to reform the Medicaid program by allowing people a choice to remain at home rather than go to a nursing home: "The money follows the individual," says ADAPT's Bob Kafka.
Read a news story about MiCassa when it was introduced.
Prepared by American Disabled for Attendant Programs Today(ADAPT)
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, and give the person (instead of government or industry) the real choice."
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 for a single person). In addition, states can choose to have a sliding fee scale for people of higher incomes; MiCASSA specifically references this as an incentive for employment. This sliding fee scale can go beyond the current Medicaid eligibility guidelines.
In MiCASSA, the term "community 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.
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.
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.
MiCASSA does not affect existing optional programs or waivers; it 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 individual, not the facility.
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.
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.
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.
States are required to develop quality assurance programs that set down guidelines for operating Community 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 public results of the quality assurance program public as well as 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.
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.