LTC Bullet:  Implementing a Medicaid and LTC Financing Study

Friday, June 14, 2013

Richmond, VA—

LTC Comment:  What goes into planning, implementing and completing one of the Center for Long-Term Care Reform’s state-level Medicaid/LTC financing studies, after the ***news.***
 

***  LTC COMMISSION will meet June 27, with Bruce Chernof of the SCAN Foundation as Chair and Mark Warshawsky of Towers Watson as Vice Chair.  Created January 1, 2013 by the fiscal cliff avoidance legislation (American Taxpayer Relief Act), the new commission is a consolation prize for the elimination, in the same statute, of the CLASS Act.  According to the law, members of the commission were to be appointed “not later than 30 days” after enactment.  Oops, missed that deadline by a couple months, with the White House making its three appointments, completing the membership, in mid-March.  “Not later than 6 months” after their appointment, the members of the commission are supposed to vote on a comprehensive “long-term care plan.”  With only three months remaining of the original six allotted to complete its work, the Commission begins handicapped by time pressures.  Expectations are low, but whatever the LTC Commission achieves or doesn’t will at least point public attention now and again toward the looming catastrophe of long-term care financing. ***

LTC BULLET:  IMPLEMENTING A MEDICAID AND LTC FINANCING STUDY

LTC Comment:  Over the past three years, the Center for Long-Term Care Reform has completed Medicaid and LTC financing studies in California, New York, Pennsylvania, Rhode Island and Maine.  We’ve reported to you faithfully on the results of those studies and our reports are readily available on the Center’s website here and on the sponsors’ websites as well.

So far, however, we have not described what goes into conducting one of our state-level studies.  Let’s correct that oversight today.  Following below the “fold” is a document, titled “Implementing a Medicaid and Long-Term Care Financing Study,” which we provide to each project sponsor at the beginning of the process.  

Over the years, study sponsors have included state governments, state Medicaid programs, LTC provider trade associations, and State Policy Network-affiliated think tanks.  Whoever the sponsor and whichever the state, we always proceed in the same, methodical way.  We gather information systematically from face-to-face interviews with key officials and experts.  We analyze germane current and archival documents, gleaning from them the history, status, and likely future course of Medicaid and LTC financing in the state.

We seek to understand the way Medicaid LTC eligibility actually works, irrespective of the conventional wisdom that it requires catastrophic spend down and total impoverishment.  We try to discern the challenges key stakeholder groups face and we gather their ideas and suggestions.  We analyze the politically realistic options for change.  And we recommend policies that improve the LTC financing system for all while reducing dependency on publicly financed care.

We are not always able to schedule all of the desired appointments.  Nor can we locate all desirable documentation in every state.  We’re usually limited to one intensive week onsite to do all of the face-to-face interviews.  This Summer, however, for the three studies we’re conducting in Virginia, New Jersey, and Georgia, I’m onsite for at least three weeks in each place.  That’s because we’ve taken the Silver Bullet of Long-Term Care on the road again and I’m living all Summer on the East coast.

As these three studies develop, we’ll keep you posted on our progress and results.  In the meantime, here’s how we begin each project and what we do in the process.

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Implementing a Medicaid and LTC Financing Study for [State Name]

Responsibilities

I'm counting on the [project sponsor name] to help me find key information and documents not easily accessible online and to help locate interviewees and schedule appointments for the site visit.  I anticipate scheduling the site visit for [dates].

I will provide guidance including a full briefing on the issue, suggestions on where and how to find documents and information, names of organizations and/or individuals to contact, draft letters describing our inquiry, documents and web links establishing my and the Center for Long-Term Care Reform's bona fides, etc.

After you look this document over, let’s talk by phone about how to begin the process.  There are several things we can do in the ensuing weeks which will save us time once we can begin in earnest.

Following is a list of organizations and individuals to interview during my site visit and a list of documents and information we need to begin collecting soon.

Interviews/Briefings to schedule for site visit

Governor:  if possible, a short briefing and interview on the issue, the proposed study and likely recommendations, 15 or 20 minutes

Governor's health policy specialist:  longer briefing and interview, up to one hour

Key state legislators and staff, especially chairs of germane committees and sub-committees:  short briefings for the principals, longer sessions with staff.  OK to set up one briefing for all legislators and staff, but also schedule personal briefings for key legislators who want them.

State Insurance Commissioner:  if possible, a short briefing on the issue, the study and likely recommendations, 15 or 20 minutes

Insurance commission LTC insurance specialist:  longer briefing and interview, at least one hour

Medicaid single-state agency head and State Medicaid Director:  together or separately, a short briefing on the issue, the study and likely recommendations, 15 or 20 minutes

State Medicaid LTC financial eligibility policy specialist:  intensive briefing and interview, two hours

State Medicaid lien and estate recovery program manager:  intensive briefing and interview, two hours

State Medicaid local offices (one urban, one suburban, and one rural):  in each of the three offices, two-hour briefings and interviews with a Medicaid financial eligibility supervisor and at least one, but preferably more, eligibility workers who actually take and process applications Medicaid LTC benefits. 

Proprietary (AHCA affiliate) and non-proprietary (Leading Age [formerly AAHSA] affiliate) nursing home/assisted living trade association representatives, including executive directors of the state affiliates, their government affairs directors, and a sampling of members (nursing home and assisted living owners or managers).

Home health agencies representatives from trade associations and members.

Long-term care insurance representatives including individual producers and people representing carriers and major brokers.

NAIFA, NAHU affiliates. 

Reverse mortgage specialists including representatives of lenders and individual producers

Elder law attorneys including Medicaid planners.

Senior advocates (AARP, NCOA, Area Agencies on Aging, LTC Ombudsman)

Business (Chamber of Commerce, etc) and/or taxpayer representatives who have an interest in long-term care financing issues.  (Employee absenteeism and presenteeism re family LTC responsibilities have become as big a problem as child care.)

Documents or Information:

Any data or reports on the current budgetary crisis especially as relates to funding Medicaid and long-term care. 

Details on measures (1) taken already and (2) anticipated, to cut Medicaid costs, especially cuts that affect LTC.

Break out of state spending on Medicaid vs other state programs, i.e. education, corrections, etc.

[State] Medicaid expenditures for long-term care for the elderly broken out by nursing home and HCBS (home and community-based care) for the past five years, more years if possible.

Any available reports on Medicaid financing of long-term care in [State], including studies bearing on advisability and potential savings from nursing home diversion to HCBS.

[State] Medicaid (TEFRA) lien and/or estate recoveries for the past five years, excluding recoveries for fraud.

Medicaid financial eligibility rules for nursing home and HCBS, e.g. asset limits, countable vs. non countable assets, income limits, spousal impoverishment protections, etc.

Any demographic studies related to aging of the [State] population and the likely impact of the Age Wave.

Medicaid reimbursement rates for nursing homes and home care providers and private pay rates in the state for comparison.

Any reports or data bearing on quality of care in [State] nursing homes and by home care providers.

Information on nursing home liability insurance issues, premiums, claims experience, etc.

Percent of nursing home residents in [State] covered by Medicaid, Medicare, private pay and other systems.

Summary of [State]'s Medicaid waivers that provide care for the elderly.

Any studies that document "Medicaid estate planning," the practice of artificially impoverishing people to qualify them for Medicaid LTC benefits.

Any studies documenting the use of private long-term care insurance or home equity conversion to fund long-term care in [State].

Insurance commission regulations bearing on long-term care insurance.

Data on home ownership and home equity of [State’s] residents especially for the age 62+ cohort that could qualify for reverse mortgages.

Status of "LTC Partnership" take-up and implementation in [State].