The enrollment surge at the end of March in the health insurance exchanges, created by the Affordable Care Act (ACA), was widely covered in the news, as was the announcement that at least 8 million people have used the new marketplaces to sign up for coverage.  The news got a fair amount of attention from the public, with over half saying they followed the enrollment numbers “very” or “fairly closely.” But the latest Kaiser Health Tracking Poll finds that this news did little to change the public’s impressions of the law, with overall opinion remaining exactly where it was last month (46 percent unfavorable, 38 percent favorable). While over four in ten correctly identify the number of people who have signed up for insurance¹ , enrollment levels do not register as a success for most Americans. Nearly six in ten (including half of those who correctly identified the 8 million figure) believe enrollment fell short of the government’s expectations, and the same share believe the rollout problems indicate that the law is not working as planned. Still, more want the government to give the law a chance than want to scrap it and start over; nearly six in ten would prefer their representative in Congress work to improve the law, while just over a third want them to repeal and replace it. When asked why they haven’t gotten coverage yet this year, over a third of the uninsured say they tried to get coverage but it was too expensive, while smaller shares say they didn’t know about the ACA’s requirement to have insurance or didn’t think it applied to them. Just 7 percent of the uninsured say they would rather pay the fine than pay for coverage. This month’s tracking poll also finds public support for the ACA’s requirement that private health insurance plans cover the full cost of birth control, including a majority who believe that for-profit companies should be subject to this requirement even if their owners object to birth control on religious grounds.

Overall opinion remains unchanged from March

Despite the announcement that at least 8 million people have signed up for health insurance through the ACA’s new marketplace, overall favorability of the law remains exactly where it was in last month’s tracking poll, with 46 percent of the public saying they have an unfavorable view and 38 percent a favorable view. This is a slight improvement over polls taken from November through January, but still represents a more negative tilt to opinion than was measured in Kaiser tracking surveys before the troubled launch of the exchanges last October.

As it has been since the start, opinion remains highly polarized by political party, with three-quarters of Republicans having an unfavorable view of the law and two-thirds of Democrats viewing it favorably.

“8 million” registered with many, but majority don’t view first enrollment period as a success

Just over four in ten Americans (43 percent) were correctly able to identify that “about eight million” people²  have signed up for coverage through the ACA’s new marketplaces as of April. Still, the majority of the public does not seem to register this as a success. Nearly six in ten believe that the number of people signing up for coverage fell short of the government’s expectations. Even among those who correctly identified the fact that 8 million people have signed up so far, roughly half believe enrollment fell short of expectations.

While almost four in ten believe the early problems with the law have been fixed, almost six in ten say “there have been so many problems since the law’s rollout that it’s clear the law is not working as planned.” There are expected partisan divisions on this question, but even among Democrats, who generally view the law favorably, about a third believe the law is still not working.

More want Congress to improve the law than repeal and replace

Despite this, the public is inclined to give the law a chance to work rather than throwing it out and starting over. Nearly six in ten (58 percent) say they want their representative in Congress to work to improve the law, while just over a third (35 percent) want them to work on repealing it and replacing it with something else. Like opinion on the law overall, this question is deeply divided by political party. Still, about three in ten Republicans and the same share of those with an unfavorable view of the law say they would prefer Congress work on improving it rather than repealing and replacing it.

Most common reason for remaining uninsured is not being able to afford coverage

When asked to say in their own words why they don’t currently have health insurance, the most common reason mentioned by the uninsured is that it is too expensive (39 percent), followed by employment-related reasons such as being unemployed or working for an employer that doesn’t offer coverage (22 percent). Roughly one in ten say they just haven’t gotten around to getting coverage or missed the deadline to apply (11 percent), and a similar share feel they don’t want or need coverage (9 percent).

 When reminded of the law’s requirement for individuals to get coverage or pay a fine and asked to choose the main reason they haven’t gotten coverage this year, cost again turns up as the biggest barrier for the uninsured; over a third (36 percent) say they tried to get coverage but it was too expensive. Fourteen percent of the uninsured say they don’t think the law’s requirement to have insurance applies to them personally, and another 13 percent say they didn’t know about the requirement. Twelve percent say they tried to get coverage but were unable. Just 7 percent say they would rather pay the fine than pay for health insurance.

Almost half the uninsured (45 percent) think they will have to pay a fine for not having health insurance this year, though a sizeable share of the uninsured (15 percent) say they don’t know what the amount will be.

Among the public overall, almost half (46 percent) say they don’t know what the fine is for people who don’t get health insurance this year, while 23 percent give responses close to the actual fine, including 14 percent who named dollar amounts between $90 and $100, 5 percent who said it is one percent of a person’s household income, and 4 percent who gave the precise answer that the fine is either $95 or one percent of income, whichever is greater.

Majority support contraceptive coverage requirement, including for-profit companies whose owners have religious objections

In light of the recent Supreme Court hearings in two cases challenging the ACA’s requirement that private health plans cover prescription birth control without cost-sharing, the latest Kaiser Health Tracking Poll finds that, in general, the public supports the requirement by a nearly 2-to-1 margin (61 percent support, 32 percent oppose). Women, younger adults, Democrats and independents are the groups most likely to support the requirement, while seniors are split on the question and a majority of Republicans are opposed.

Asked more specifically about whether for-profit companies whose owners have religious objections to birth control should be subject to the requirement, a majority (55 percent) of the public feel these companies should be required to cover birth control even if it violates their owners’ personal religious beliefs, while four in ten feel such companies should not be subject to the requirement even if it means their workers will have to pay out-of-pocket for birth control.

Over four in ten Americans (44 percent) reported following news coverage of the Supreme Court hearings regarding contraceptive coverage “very” or “fairly” closely, somewhat higher than the share that reported paying close attention to the recent Supreme Court decision overturning certain limits on campaign donations (37 percent). The Supreme Court contraception case was closely followed by similar shares of men and women, and similar shares of Democrats, Republicans, and independents.

More details on the public’s attention to health policy news in April can be found in the Kaiser Health Policy News Index.

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF) led by Mollyann Brodie, Ph.D., including Liz Hamel, Bianca DiJulio, and Jamie Firth. The survey was conducted April 15-21, 2014, among a nationally representative random digit dial telephone sample of 1,504 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Computer-assisted telephone interviews conducted by landline (750) and cell phone (754, including 440 who had no landline telephone) were carried out in English and Spanish by Princeton Data Source under the direction of Princeton Survey Research Associates International (PSRAI). Both the random digit dial landline and cell phone samples were provided by Survey Sampling International, LLC. For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the person who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2012 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January-June 2013 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margin of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margin of sampling errors for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

1. The survey was in the field April 15-21. The Obama Administration announced on April 1 that at least 7 million people had signed up for coverage through the ACA’s marketplace, and announced on April 17 that the figure was at least 8 million. For interviews conducted April 15-16, the question about enrollment numbers included “about 7 million” as a possible response option; that option was changed to “about 8 million” for interviews conducted April 17-21. Our analysis indicates there were no substantive differences in opinion for interviews conducted before and after the April 17 announcement. ↩︎
2. See previous footnote. ↩︎

In 2011, Tennessee was awarded a federal Money Follows the Person (MFP) grant, joining the now 45 states with MFP demonstrations.  MFP provides one-time and ongoing home and community-based and transition services that help Medicaid beneficiaries move from institutions to the community, with enhanced federal funding during each beneficiary’s first year home.  Funding for Tennessee’s MFP program totals $119 million and runs through September 2016.

Prior to receiving an MFP grant, Tennessee was reforming its Medicaid long-term services and supports (LTSS) system to rebalance enrollment and expenditures away from institutional care in favor of home and community-based services (HCBS).  For seniors and adults with physical disabilities, these efforts have been implemented within the context of Tennessee’s pre-existing capitated Medicaid managed care delivery system, TennCare.  TennCare was established in 1994 under Section 1115 demonstration authority and provides Medicaid medical and behavioral health services through two managed care organizations (MCOs) in each of the state’s three regions.  Enrollment in TennCare is mandatory and includes the state’s entire Medicaid-eligible population (1.2 million people).

In March 2010, the TennCare demonstration was amended to include CHOICES, a mandatory managed long-term services and supports (MLTSS) program for seniors and adults with physical disabilities administered through the MCOs.  Before the implementation of CHOICES, Tennessee’s LTSS system was fragmented with limited options for beneficiaries and heavily geared toward institutional services for both enrollment and expenditures.  The state’s primary objectives in establishing the CHOICES program included:

• Decreasing fragmentation and improving care quality and coordination;
• Expanding access to HCBS so that more beneficiaries can receive care in their preferred setting; and
• Rebalancing LTSS spending by providing cost-effective HCBS and serving more beneficiaries using existing Medicaid LTSS funds.

As part of its rebalancing efforts, Tennessee focused primarily on delaying or preventing the need for institutional placements, while also facilitating beneficiaries’ transitions from nursing facilities (NFs) to community-based settings.  In its first year of operation, CHOICES transitioned over 500 beneficiaries from institutions to the community.

In 2011, one year after the implementation of CHOICES, Tennessee received its federal MFP grant to support the transition of Medicaid beneficiaries living in institutions to the community.  Tennessee’s MFP program was integrated into the state’s existing LTSS programs, including CHOICES.  Working in conjunction with CHOICES, over 600 of the seniors and adults with physical disabilities who transitioned enrolled in Tennessee’s MFP program.  Those 600 individuals represent a subset of a much larger number of people who transitioned through the CHOICES program.  The MFP program utilizes a financial incentive structure that allows MCOs to earn additional payments when a beneficiary first enrolls in MFP and when she completes the MFP participation year, as well as supplemental payments when other MFP program benchmarks are met.

This case study of Tennessee’s MFP program describes key features and highlights recent experiences focused on the state’s rebalancing efforts for seniors and adults with physical disabilities in a capitated Medicaid MLTSS delivery system.  (Although Tennessee also serves people with intellectual disabilities (ID) through its MFP program, that population does not participate in the MLTSS program and instead receives HCBS on a fee-for-service basis through a Section 1915(c) waiver.)  The case study is based on interviews of Tennessee Division of LTSS, Bureau of TennCare staff, supplemented with background information obtained from the state website and Kaiser Family Foundation’s Commission on Medicaid and the Uninsured MFP surveys conducted between 2011 and 2013.¹   Data presented in this case study report are reflective of the program through June 2013; more recent data are available through the Bureau of TennCare.

MFP in Tennessee’s Capitated MLTSS Program

Through CHOICES, Tennessee provides its Medicaid MCOs with a fully blended capitation payment to cover all of the physical, behavioral health, and LTSS (including both NFs and HCBS for NF level of care (LOC) eligible individuals) needed by beneficiaries.  CHOICES beneficiaries are assigned to one of three groups:

• CHOICES Group 1 includes individuals who meet a NF LOC and receive institutional care;
• CHOICES Group 2 includes seniors (age 65 and older) and adults (age 21 and older) with physical disabilities who meet a NF LOC and receive HCBS; and
• CHOICES Group 3 includes seniors and adults with physical disabilities who qualify for TennCare as Supplemental Security Income recipients, who do not meet a NF LOC, but who, in the absence of HCBS, are at risk of NF placement.² 

While there is an enrollment target (which functions as a cap) for CHOICES beneficiaries who receive Medicaid HCBS, Tennessee has been able (except for a brief period while awaiting approval from the Centers for Medicare and Medicaid Services to increase the target) to keep pace with the need, eliminate a waiting list for HCBS, and significantly expand the number of beneficiaries receiving HCBS as well as the percentage of beneficiaries receiving LTSS in home and community-based settings versus institutional settings.  Further, pursuant to the terms and conditions of the state’s Section 1115 demonstration waiver implementing CHOICES, beneficiaries transitioning from a NF receive HCBS even if the CHOICES HCBS enrollment target has been reached, as do certain CHOICES beneficiaries who would be at risk of NF placement absent the provision of HCBS.

To enroll in MFP, beneficiaries must reside in a NF for at least 90 days prior to transitioning to a community-based setting.  Upon transition, Tennessee seniors and adults with physical disabilities who continue to require a NF LOC are simultaneously enrolled in MFP and CHOICES Group 2 to receive HCBS.  (Beneficiaries who transition from a NF into the CHOICES at-risk Group 3 receive HCBS but are ineligible for MFP as they no longer require a NF LOC.)

MCO Financial Incentives for Nursing Facility to Community Transitions

Capitated Payments

Tennessee’s CHOICES MCOs receive the same blended monthly capitated payment for all beneficiaries who meet a NF LOC (CHOICES Groups 1 and 2), regardless of whether those beneficiaries reside in NFs or receive HCBS.  This rate is based on the historical mix of NF and HCBS used by the population enrolled and also takes into account some projected change in the service mix over time (as MCOs focus on serving more beneficiaries in the community when appropriate).  Since, in most situations, the cost of institutional care is significantly higher than that of supporting a beneficiary in a community setting, MCOs have a strong financial incentive to minimize the time that Medicaid beneficiaries spend in NFs and to help those who can do so return to the community and remain there for as long as possible, even if they continue to meet an institutional LOC. Capitation payments for beneficiaries considered at risk of NF placement without the provision of HCBS (CHOICES Group 3) reflect the relatively lower cost associated with serving individuals who do not need an institutional LOC.

MFP Bonus Payments

To further prioritize institution-to-community transitions for MFP-eligible beneficiaries, Tennessee also provides specific financial incentives to MCOs for meeting certain MFP benchmarks (Text Box 2), which are detailed in the MCO contracts and listed below in Text Box 3.³   As a result, state officials believe that MCOs are more focused on reaching transition goals and note that MCOs have developed “transition teams” that concentrate on increasing MFP enrollment.  These teams work along with state MFP staff to ensure that NF residents who desire to transition to the community can do so and in as timely a manner as possible.

MFP Outreach and Enrollment

CHOICES MCO care coordinators are responsible for regularly assessing NF residents’ interest in and potential for transitioning to the community.  The MCO care coordinators are nurses and social workers, many of whom have experience working in hospitals, managed care systems and Section 1915(c) HCBS waivers.  Once a CHOICES NF resident is identified as a potential candidate for community transition (based on his/her desire to receive HCBS and ability to transition), the MCO care coordinator assesses whether the member is a candidate for transition to the community, and if so, whether the member is also an MFP-eligible individual. The MFP eligibility criteria include: (1) residing in an institutional setting for at least 90 days, (2) transitioning into an MFP qualified residence, and (3) signing an attestation stating a willingness to participate in MFP.  If the transitioning member does not meet all three of the above criteria, they would not qualify to enroll in MFP but would still transition into Group 2 with CHOICES services without simultaneous enrollment in MFP.  Outreach efforts are focused on helping beneficiaries understand Tennessee’s MFP demonstration and why the program is valuable for LTSS system change within the state.  Referrals to Tennessee’s MFP program come from a variety of sources, including beneficiaries themselves, family members, the Minimum Data Set 3.0 Section Q process,⁴  and NF staff.

MFP Care Coordination and Services

Transition and Care Planning

Once a beneficiary is identified for MFP, she works with a CHOICES MCO care coordinator to develop a transition plan that includes needs and risk assessments, a care plan, and a home safety check.  MCOs must develop a risk agreement as part of the person-centered care planning process for all CHOICES HCBS beneficiaries, including MFP participants.  This includes identifying the potential risks of receiving LTSS in a home and community-based (rather than institutional) setting; determining the potential consequences of the risks; developing and implementing strategies to mitigate the risks; and documenting and supporting the beneficiary’s informed decision to accept a reasonable degree of risk in living more independently in the community. Beneficiaries can receive HCBS so long as their needs can be safely met in a community setting at a cost that does not exceed institutional care.

The care plan takes into account a beneficiary’s physical and behavioral health needs, unpaid natural supports (e.g., a family caregiver), and other personal health care-related circumstances and details the type and amount of HCBS to be provided to ensure that the beneficiary’s needs are met in the community.  During the transition planning period, CHOICES/MFP beneficiaries who need assistance in securing housing work with MCO care coordinators and the MFP housing specialist to complete housing searches or make connections with community-based housing providers.  Prior to a beneficiary’s transition to the community, the MCO care coordinator assists the member as needed to ensure that essential household items (such as kitchen appliances, linens, etc.) are in place or purchased, necessary home modifications are completed, and utilities are set up.  MCOs are permitted to offer a transition allowance of up to $2,000 in order to help a member who needs assistance in securing these items.

Prior to the member’s transition, the CHOICES MCO care coordinator will conduct an on-site evaluation of the physical residence and meet with the member’s family or other caregiver (as applicable).  After the member transitions, CHOICES MCO care coordinators must visit the member face-to-face within 24 hours after transition if the member will live alone or call within 24 hours and visit face-to-face within seven days if the member will be living with family or in a Community-Based Residential Alternative (CBRA).  After the initial 90 days of community living, the MCO care coordinator is required to have at least monthly contacts and quarterly face-to-face visits with each beneficiary.  During these contacts, the MCO care coordinator assesses the beneficiary’s care quality, quality of life, and living environment.  These regular assessments continue after the 365-day MFP participation period ends, through the CHOICES program.

Services

The HCBS benefit package is the same regardless of whether CHOICES beneficiaries also participate in MFP.  In designing the MFP services package, Tennessee wanted to avoid any care disruptions for CHOICES/MFP beneficiaries at the end of their 365-day MFP participation period; after MFP, beneficiaries remain enrolled in CHOICES and continue to have access to the same array of HCBS as they did while they were MFP participants.  The following is a selected list of HCBS available in the CHOICES program:

• Adult day care services
• Assistive technology
• Attendant care services
• Community-Based Residential Alternatives
• Home-delivered meals
• In-home respite care
• Inpatient respite care
• Minor home modifications
• Personal care services
• Personal emergency response systems

Beneficiary Self-Direction of Services

Nearly all MFP programs nationwide promote beneficiaries’ self-direction of services.  Tennessee offers self- direction (called “consumer direction” in Tennessee) for CHOICES beneficiaries, including those enrolled in MFP.  The self-direct program follows an employer authority model, allowing CHOICES beneficiaries to direct and manage certain aspects of the provision of services, including, primarily, the opportunity to recruit, hire, and supervise direct service workers.  Prior to CHOICES, there were no options for seniors and adults with physical disabilities to self-direct their services in Tennessee.  Now, about 8.5 percent of the CHOICES HCBS population is enrolled in the self-direction model.  Self-direction program participation is lower among CHOICES members enrolled in MFP (3.2%) than in the CHOICES program as a whole, but Tennessee has seen an increase in MFP beneficiaries choosing to self-direct services since 2012.  The state hopes to continue to increase the utilization of self-direction among CHOICES/MFP participants as well as traditional CHOICES HCBS participants; there is an MFP benchmark in place in to track progress in this area.

Service Delivery and Back-Up Plans

Under CHOICES, delivery of HCBS is monitored at the beneficiary-level on an ongoing basis through the use of an electronic visit verification system, which MCOs are required to maintain.  This system requires direct care workers to log in at the beginning of each visit, and if a worker does not arrive as scheduled, an alert is generated to the provider agency as well as the MCO, with both entities obligated to take immediate action to resolve the potential gap in care.

Another key feature of Tennessee’s CHOICES program includes access to a 24-hour back-up assistance to prevent a lapse in the provision of essential medical and supportive services or other circumstances that could negatively affect a beneficiary’s health or welfare.  There is an oversight process in place to ensure that the back-up strategy is working as intended.  In addition to specifying the services and supports that he/she will receive, the beneficiary’s care plan includes a daily care schedule.  The care coordinator develops the care plan in conjunction with each member, and then the MCOs create authorizations based on the approved schedule in the care plan.  Each CHOICES beneficiary’s care plan also includes a back-up plan that describes specifically how the beneficiary’s service and support needs will be met if a direct care worker does not arrive as scheduled to ensure the beneficiary’s continued health and safety.  The back-up plan includes the names and telephone numbers of persons and/or agencies to contact as well as the services and supports provided by each.  The MCO care coordinator is responsible for ensuring that all individuals included in the back-up plan are willing and able to fulfill their assigned roles and responsibilities.  For beneficiaries who self-direct their services, the Fiscal Employer Agency (FEA) is responsible for helping the member develop the initial back-up plan.  The MCO care coordinator is responsible for assessing the adequacy of the beneficiary’s back-up plan, and for helping the member update the plan as needed on an ongoing basis.  If the back-up plan is deemed inadequate, the MCO care coordinator is responsible for following up with the beneficiary and the FEA until all concerns have been addressed.

MCOs are also required to provide access to a call center, 24 hours a day, 7 days a week, to assist beneficiaries in accessing needed medical, behavioral health, and LTSS.  The MCO call center is staffed with nurses who triage urgent care and emergency calls and facilitate the transfer of calls to the care coordinators.  In addition, MCOs are required to designate a staff member to work with the state Medicaid program’s managed care call center staff for immediate resolution of service issues.  The state Medicaid managed care call center also operates 24 hours a day, 7 days a week to help beneficiaries navigate service delivery issues and/or the appeals process.

MFP Staffing and Key Partnerships

Three full-time MFP staff members – a project manager, a data specialist, and a housing specialist – manage Tennessee’s MFP program in conjunction with other state LTSS Division leadership.  Each staff member provides technical assistance to the CHOICES MCOs, and the state communicates with MCO care coordination team leaders on a weekly basis at minimum.  Tennessee’s MFP project director oversees strategic development and regulatory compliance efforts.  The data specialist manages the MFP database that is used primarily to track a potential MFP candidate’s movement through the enrollment process.  Data collection is accomplished via an online LTSS eligibility/enrollment workflow management system, and MFP enrollment and expenditure data is fully integrated into the State’s Medicaid Management Information System.  The housing specialist is charged with improving communication and coordination between MCOs and affordable housing resources across the state.  For example, the housing specialist holds monthly phone calls with MCO staff to discuss complex transition cases and provide guidance on available options that best meet MFP participants’ needs.  Key partnerships with Tennessee’s MFP program include:

Area Agencies on Aging and Disability (AAADs):  Tennessee’s Medicaid program contracts with the state’s nine AAADs, which function as regional Single Points of Entry (SPOE) into the state Medicaid LTSS system and facilitate eligibility and enrollment.  In addition to providing information about the CHOICES program, AAADs explain enrollment processes, including financial and categorical eligibility criteria, conduct individual functional assessments, and facilitate submission of Medicaid applications to both the state Medicaid LTSS Division for LOC determinations and the state Department of Human Services for financial eligibility determinations.⁵   In addition to their role as regional SPOEs, AAADs conduct the MFP Quality of Life (QoL) surveys (described below).  AAADs were chosen to administer the QoL surveys because of their long-standing experience in working with Medicaid beneficiaries who receive HCBS.

Memphis Center for Independent Living (MCIL):  In an effort to enhance MFP beneficiaries’ transition experience, Tennessee contracts with MCIL for statewide peer-to-peer training of individuals who will transition from NFs to HCBS.  These peer volunteers, who are people with disabilities who have either transitioned from an institutional setting or live independently in the community, provide information about the Medicaid program, the Americans with Disabilities Act, and subsidized housing.  In addition, peers help MFP candidates develop skills such as self-advocacy, personal budgeting, and, for individuals participating in self-direction, direct support staff management.

Tennessee Housing Development Agency (THDA):  TennCare collaborated with Tennessee’s housing finance agency, the Tennessee Housing Development Agency (THDA), to create a pilot project that will provide a “bridge” rental subsidy from the time that the beneficiary leaves an institution until a permanent rental subsidy can be secured.  Pilot program participants will have access to CHOICES care coordinators as they explore more permanent subsidized housing options, and the pilot will be funded through both the THDA Housing Trust Fund and the state’s MFP rebalancing funds.

MFP Housing Steering Committee:  The MFP Housing Steering Committee works to expand access to community-based housing for individuals with LTSS needs.  This housing committee is comprised of representatives from TennCare CHOICES MCOs, AAADs, low-income housing finance groups, low-income housing builders, public housing authorities, and beneficiary advocates.  Committee members meet in-person on a quarterly basis, and the MFP housing specialist contacts committee members individually or as a group by phone or e-mail for guidance and resources as needed.  For example, the MFP housing specialist has utilized the expertise of individual members when issues arose with individual CHOICES beneficiaries, such as assistance with identification of housing resources in specific geographic areas.  Additionally, MFP staff have worked with the steering committee to address barriers and program details related to starting the THDA supportive housing pilot discussed above and sought input in structuring the first TennCare Housing Conference in October 2013.  This conference brought together low-income housing providers and TennCare CHOICES MCOs, with the goals of joint education and troubleshooting barriers associated with obtaining affordable accessible housing for beneficiaries transitioning from institutional settings.

LTC Ombudsman Program:  Tennessee’s LTC Ombudsman Program is operated by the state Commission on Aging and Disability. District LTC Ombudsmen and a statewide network of volunteer Ombudsmen assist residents of NFs or CBRAs with questions and concerns about services and play a critical role in facilitating large scale transitions, including transitions to community-based settings following the closure of an institution.  Ombudsmen, in addition to assisting LTSS beneficiaries in understanding and exercising their rights and responsibilities, also advocate on behalf of LTSS beneficiaries residing in institutions or CBRAs.

Quality and Evaluation

Surveys and Performance Measures

As required by the MFP grant, Tennessee administers the QoL surveyto consenting beneficiaries at three specific timeframes: approximately 10 days prior to discharge from the institution, 11 months post-discharge and 24 months post-discharge.  The QoL survey measures MFP participant’s perceptions and feelings across several domains, including life satisfaction, quality of care, and community life.  Current contact information for each beneficiary is tracked through the state Medicaid program’s IT system, which has been customized to capture beneficiary-specific demographic information.  MCOs have access to this system and must update beneficiary demographic information within two business days of notification of change.

The quality strategy for CHOICES is part of the integrated quality management strategyfor the entire TennCare program, and includes:

• Uniform measures of system performance;
• Detailed reporting requirements;
• Ongoing audit and monitoring processes;
• Measures to immediately detect and resolve problems, including gaps in care (e.g., Electronic Visit Verification);
• Independent review by an External Quality Review Organization and the Tennessee Department of Commerce and Insurance;
• A key focus on member perceptions of quality, including a modified QoL survey for LTSS members beyond MFP participants; and
• Advocacy for members across MLTSS system.

Certain LTSS performance measures were carried forward from Section 1915(c) HCBS waiver assurances and sub-assurances, including areas such as LOC (e.g., initial and annual LOC evaluations), care plan (e.g., freedom of choice, timely development and initiation of services, annual review, missed and late visits), qualified providers (e.g., credentialing and re-credentialing), health and welfare (e.g., timely reporting, investigation of critical incidents, member education regarding how to report abuse/neglect), and participant rights (e.g., notice of right to appeal any adverse action).  Now that Tennessee provides HCBS to seniors and adults with physical disabilities through a Section 1115 exclusively, the state continues to monitor these areas and strives to ensure prompt remediation of individual findings and to promote systemic improvements in the MLTSS delivery system.  All MCOs are required to maintain National Committee on Quality Assurance accreditation, and other performance measures will be added as new standardized MLTSS program measures are developed.

Critical Incident Reporting

CHOICES MCOs are responsible for developing and implementing a critical incident reporting and management system for incidents that occur in HCBS settings, including:

• Unexpected death of a CHOICES beneficiary;
• Suspected physical or mental abuse of a CHOICES beneficiary;
• Theft or financial exploitation of a CHOICES beneficiary; and
• Severe injury sustained by a CHOICES beneficiary.

MCOs must review, track, and analyze critical incident reports to identify and address potential and actual care quality and/or health and safety issues.  Specifically, MCOs must review the number and types of incidents and findings from investigations; identify trends, patterns, and opportunities for improvement; and develop and implement strategies to reduce the occurrence of incidents and improve the quality of HCBS.

MCO-contracted HCBS providers are required to report critical beneficiary incidents, and, along with MCO care coordinators, are contractually obligated to take necessary steps to prevent further harm to beneficiaries and to respond to any emergency needs.  For beneficiaries who elect to self-direct services, the MCO care coordinator is responsible for conducting investigations and working with the beneficiary and the FEA to take necessary steps to respond to critical incidents.

MCOs submit a quarterly CHOICES HCBS Critical Incidents Report to the Tennessee state Medicaid agency, which provides information, by month, about specified measures pertaining to MCOs’ management of critical incidents.  State staff review incident management data and also conduct critical incident audits to ensure timely and appropriate remediation of individual issues.  Additionally, they identify potential opportunities for systemic improvements and work with MCOs to address individual beneficiary or broader systemic concerns.

Institutional to Community Transition Progress in Tennessee

From the implementation of Tennessee’s MFP program on October 1, 2011 through June 30, 2013, 628 beneficiaries transitioned to the community through MFP.  Of those, 598 were seniors and adults with physical disabilities simultaneously enrolled in the CHOICES MLTSS program (the remaining 30 beneficiaries simultaneously enrolled in MFP and a fee-for-service HCBS waiver for people with ID.  As of June 30, 2013, another 77 NF residents were in the process of transitioning to the community via MFP as CHOICES participants (Figure 1).  In comparison, during that same time period, 1,069 beneficiaries transitioned home through CHOICES, without enrolling in MFP.

Table 1 shows the total number of transitions by population group in Tennessee’s MFP program.  Seniors and adults with physical disabilities are the target groups most likely to transition as MFP participants as the number of persons with ID residing in institutions is significantly less.  While the average age of a Tennessee MFP participant is 65 years old, beneficiaries of all ages – from age 21 to 101 – have transitioned to community-based care under Tennessee’s MFP program.  One MFP participant, a person with ID, had been institutionalized for 60+ years.⁶ 

The entire transition process for Tennessee MFP participants – from initiation in the NF to the date of relocation to the community– took 31 days on average to complete (the national average is 3.5 months⁷ ) with significant variation by target population.  On average, persons with ID (who are not served through CHOICES MLTSS in Tennessee) were in the pre-transition stage for 83 days, while seniors transitioned in 26 days.  MFP participants with ID most frequently transitioned to CBRA settings, while CHOICES/MFP participants primarily transitioned to a house owned or leased a family member.

On average, it costs the state $1,969 per month to serve a CHOICES/MFP participant in the community (Figure 2).⁸  MFP participants who are seniors are less expensive to serve in the community than adults with physical disabilities ($1,399 and $2,930 per month, respectively).  Across all CHOICES/MFP target populations, the average monthly HCBS expenditures are higher than those for non-MFP HCBS beneficiary populations and lower than those for Medicaid LTSS beneficiaries served in institutional settings (e.g., $3,710 per month to serve individuals in NFs).

The average reinstitutionalization rate of MFP participants in Tennessee, including persons with ID, was about 10 percent.  Reinstitutionalization is defined as returning to a NF, hospital, or Intermediate Care Facility for Individuals with Intellectual Disabilities, regardless of length of stay, during the beneficiary’s MFP participation year.  Nationally, states reported an average reinstitutionalization rate of 11 percent across all MFP populations.⁹ 

In 2011 and 2012, Tennessee achieved its MFP transition benchmarks; as of August 2013, MCOs reported being behind on their state-set annual transition goals for 2013.  Some of this lag can be attributed to the fact that on July 1, 2012, Tennessee changed its Medicaid NF LOC criteria to target NF services to beneficiaries with higher acuity care needs, while continuing to make HCBS more broadly available to beneficiaries who do not meet the new more stringent LOC standards (i.e., Group 3 beneficiaries).  As a result, the state has diverted nearly 20 percent of all NF applicants to more cost-effective and integrated community-based care.

In order to improve transition rates and meet its 2013 MFP transition benchmark, Tennessee is pursuing additional strategies to better support the remaining higher acuity NF population during transition and in the community.  Examples of these strategies include the following:

• Developing a set of “best practices” that includes the most effective MCO staffing models such as transition teams, data-driven methods of MFP candidate identification, and use of natural and community-based supports, other outside resources, and community partners to improve MFP transition successes.  These best practices were disseminated to all MCOs for use in developing their internal processes and enrollment strategies;
• Statewide peer-to-peer trainingfor beneficiaries transitioning from NFs to community-based settings and who wish to support other candidates in transition (described above);
• Ongoing technical assistance provided by the state to the  MCOs to help identify the strategies and practices that are proving to be successful in identifying and facilitating MFP transitions; and
• Ongoing development of community-based services and supports and alternative residential settings.

LOOKING AHEAD

Given the state’s NF LOC eligibility criteria and an emphasis on NF diversion by providing HCBS to beneficiaries identified as at risk of NF placement, Tennessee expects a decline in the number of beneficiaries who transition from NFs to the community via MFP in 2014.  As a result of these initiatives, Medicaid beneficiaries being served in NFs have higher acuity of care needs and the challenges associated with supporting the higher acuity individuals in the community are greater.  To improve transitions, Tennessee is currently looking at a variety of options, including expanding community housing options that cost-effectively serve NF residents who desire to transition to the community.

Tennessee has integrated its MFP program into its existing Medicaid LTSS system, including CHOICES, the capitated MLTSS program for seniors and adults with physical disabilities.  Together, these two Medicaid LTSS rebalancing efforts, MFP and CHOICES, are succeeding in placing more beneficiaries in home and community-based settings.  In just under three years, the percentage of seniors and adults with physical disabilities receiving HCBS in Tennessee grew from 17 percent in 2010 to 40 percent as of August 31, 2013.  This shift in care setting reflects Tennessee’s progress in meeting its community integration obligations under the U.S. Supreme Court’s 1999 Olmstead decision and beneficiaries’ preference for needing and receiving community-based care.  Specifically, MFP has assisted in the paradigm shift within MCOs and the way they approach transitions.  As a result of MFP, MCOs have changed staffing models, hired housing specialists, and developed care coordinator performance goals related to transitioning individuals from an institutional setting into MFP.

The lack of affordable, accessible housing options remains a challenge for MFP participants and for NF residents who desire to transition to the community and so Tennessee’s MFP program has focused on developing community housing options through its partnership with the state housing finance agency.  Further, state officials maintain that the allowance of federal Medicaid matching funds for institutional room and board but not community housing assistance perpetuates the institutional bias in the Medicaid LTSS system and impedes MFP states’ efforts to transition individuals to the community.

The performance of Tennessee’s overall MFP program as well as that of CHOICES MCOs will continue to be monitored over time, with program adjustments as needed to ensure that the state continues to achieve its rebalancing goals.  Looking ahead, the CHOICES program and MFP will continue to work together to support the transitions of seniors and adults with physical disabilities from institutions to the most integrated community setting in which they can be served.

1. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs. ↩︎
2. CMS Waiver Documents, Fact Sheet: TennCare II-WAI, available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/tn/tn-tenncare-ii-fs.pdf. ↩︎
3. CMS, Technical Assistance Training Series, “State Approaches to Medicaid Long-Term Services and Supports: Advanced State Training,” July 11, 2013, available at: http://www.chcs.org/usr_doc/State_Approaches_to_Medicaid_MLTSS_Foundational_webinar_07_11_13.pdf. ↩︎
4. Section Q of the MDS 3.0 focuses on resident participation in assessment and goal setting, and is designed to identify the resident’s goals and expectations relating to where the individual lives and receives services.  If a resident indicates that he or she desires to transition out of the nursing facility (NF) to a community-based setting, the NF must initiate care planning and may make a referral to a local contact agency, which will respond by providing information to the resident about community–based services and supports.  The revised federal Minimum Data Set (MDS) assessment tool for NF residents, MDS 3.0, went into effect on October 1, 2010. ↩︎
5. As of January 1, 2014, eligibility determinations are made by the Medicaid Agency- in a new Member Services unit. ↩︎
6. CMS, Technical Assistance Training Series, “State Approaches to Medicaid Long-Term Services and Supports: Advanced State Training,” July 11, 2013, available at:  http://www.chcs.org/usr_doc/State_Approaches_to_Medicaid_MLTSS_Foundational_webinar_07_11_13.pdf. ↩︎
7. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs. ↩︎
8. This average includes just the CHOICES/MFP participants and therefore excludes the ID population whose average per capita costs are $10,298. ↩︎
9. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs.   ↩︎

Since March 2008, Maryland has transitioned over 1,900 Medicaid beneficiaries from institutions to community-based settings through its Money Follows the Person (MFP) demonstration.  MFP provides one-time and ongoing home and community-based and transition services to help Medicaid beneficiaries move from institutions to the community, with enhanced federal funding during each beneficiary’s first year home.  The total MFP grant funding awarded to Maryland from 2007 to date is $86.3 million and runs through September 2016.

Prior to participating in MFP, Maryland had policies in place that promoted serving Medicaid beneficiaries with long-term care needs in the most integrated setting.  For example, the state legislature passed the “Money Follows the Individual” (MFI) Act¹  in 2003, and Maryland offered several Section 1915(c) home and community-based services (HCBS) waivers targeted to seniors and people with disabilities by 2005.  Under Maryland’s MFI initiative, people who qualify for Medicaid institutional long-term services and supports (LTSS) can apply to receive those services in the community as waiver participants regardless of any budgetary caps on HCBS waiver enrollment.  Initially MFI was targeted to nursing facility (NF) residents, and now MFI also applies to people living in State Residential Centers (Maryland’s term for Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (ICFs/ID) and chronic care hospitals).

Today, Maryland’s MFP program continues to lead the state’s LTSS rebalancing efforts through outreach to institutional residents, pre- and post-transition peer support services, housing location assistance, additional HCBS waiver benefits, and a web-based system to track beneficiaries throughout the transition process.  The enhanced federal funding provided by MFP also helps support broader LTSS system change and sustainability initiatives in Maryland.  For example, many of the lessons learned from the first five years of MFP in Maryland are being applied as the state implements new options to rebalance Medicaid LTSS authorized under the Affordable Care Act (ACA), such as the Balancing Incentive Program (BIP), which requires structural reforms and is aimed at increasing the proportion of LTSS dollars spent on HCBS, and the Community First Choice (CFC) state plan option to provide attendant services and supports.  This case study describes key features of Maryland’s MFP demonstration and highlights recent program experiences.  The case study is based on interviews with staff in the Maryland Department of Health and Mental Hygiene (DHMH), Office of Health Services, Long Term Supports and Services Administration, which administers the MFP program.  The interviews were supplemented with background information from state websites and Kaiser Family Foundation’s Commission on Medicaid and the Uninsured MFP surveys conducted between 2008 and 2013.² 

MFP Program Features in Maryland

Outreach and Enrollment

Maryland utilizes several statewide outreach efforts for its MFP program, including peer outreach and support, peer mentoring, options counseling, and marketing materials, described below.  State officials noted that the number of HCBS waiver applicants has increased tremendously as a result of the outreach, options counseling, and application assistance services available through MFP.

Peer Outreach and Mentoring:  Maryland uses peers (individuals with a disability or with non-professional life experience with Medicaid LTSS) to provide outreach to NF residents and others, such as facility social workers, nursing staff, family, administrators, and resident councils.  Peers have an ongoing presence in NFs and are encouraged to share their personal experiences with community living and mentor residents throughout the decision-making and transition process.  Once a resident indicates he or she is interested in learning more about community-based options, peers make referrals for options counseling and follow up via the LTSS web-based tracking system (described below).  At the request of a resident, the peer will maintain the relationship throughout the HCBS waiver application process.  The state agency for people with disabilities and its peer support contractors are responsible for recruiting and training peers, monitoring peers’ activities, and collecting and reporting data.

Options Counseling:  In addition to the peer outreach and support program, Maryland offers options counseling services to NF residents through its MFP demonstration.  The Area Agencies on Aging (AAAs) and Centers for Independent Living (CILs) receive referrals from residents and their families, guardians, and advocates, peer outreach workers, facility staff, ombudsman, and the Minimum Data Set (MDS) 3.0 Section Q assessments³  and then provide in-depth education on the services and supports available in the community.  For Medicaid beneficiaries who desire additional help, options counseling can include HCBS waiver or CFC application assistance. Once a resident applies for HCBS waiver or CFC services, a supports planner⁴  (a case manager from an AAA or non-profit HCBS provider) coordinates the medical and financial eligibility determination process, starts the person-centered planning process, and if needed, connects with the housing specialist within their agency or the MFP housing specialist.

Marketing Materials:  In Maryland, MFP outreach methods have included marketing materials developed by the state, letters to facility administrators, educational articles in industry publications such as the Health Facilities Association of Maryland and LifeSpan Network newsletters, and trainings for HCBS providers. Marketing has been targeted to AAAs, CILs, local health departments, social service departments, advocacy groups, NF trade associations, county/senior expos, local/state/national conferences, senior provider networks, and housing organizations.  Outreach materials illustrate the experiences of individuals with physical disabilities with transitioning from an institutional setting and living successfully in the community.  Other state-generated materials provide information on services and supports available through HCBS waivers, basic financial and functional eligibility criteria, and guidance on how to request additional information and application assistance.⁵   MFP staff frequently provide presentations to local and statewide groups about MFP-specific initiatives, as well as broader rebalancing reform efforts.

Key MFP Services and Supports

Home and Community-Based State Plan and Waiver Services:  Once enrolled in MFP, beneficiaries can access HCBS through the Medicaid state plan benefits package and/or one of Maryland’s Section 1915(c) waivers for seniors and people with physical disabilities, people with brain injuries, and people with intellectual/developmental disabilities.  As noted above, although HCBS waiver enrollment slots are limited, Maryland’s MFI state law allows Medicaid beneficiaries residing in an institution to apply to receive HCBS through a waiver, regardless of waiver enrollment caps or waiting lists.  Once enrolled in a HCBS waiver, beneficiaries may access any of the services in the waiver’s benefits package as well as the services available through the state plan benefits package, as medically necessary.  Common HCBS that Maryland’s MFP participants may receive include personal assistance, supports planning, assistive technology, environmental accessibility modifications, medical day care, personal emergency response systems, and transition services.

MFP Demonstration and Supplemental Services:  In addition, MFP demonstration and supplemental services are available during beneficiaries’ 365-day participation period.  MFP demonstration services are HCBS that are not available to non-MFP participants; demonstration services receive enhanced federal matching funds.  Maryland’s MFP participants receive post-transition peer mentoring as a demonstration service.

Maryland’s MFP supplemental services are one-time services that are not otherwise allowable, may not be long-term in nature, and are designed to help support the participant’s initial transition; supplemental services are reimbursed at the state’s regular federal matching rate.  Maryland offers flexible funds (up to $700 per enrollee) as an MFP supplemental service, which can be used to cover an initial supply of groceries, security deposits, rental application fees, and/or other needed goods and services that could not otherwise be funded by Medicaid.

Stakeholders and state officials identified flexible funds and transitional case management as two critical services that contribute to the success of the Maryland’s demonstration.  Prior to funding transitional case management as a waiver service, MFP paid for the service as a demonstration service to applicants who did not otherwise have access to this service.

New Home and Community-Based Waiver Services That Originated in MFP:  Maryland’s MFP program was the catalyst for adding services to two of the state’s existing Section 1915(c) waivers.  For example, transitional case management services (which include housing assistance) previously was covered as a demonstration service only for MFP participants transitioning to the HCBS waiver for seniors, and in 2012, was added to the waiver benefits package.  In addition, as a result of recommendations made by the stakeholder advisory group, environmental assessments, nutritionist/dietitian services, and home delivered meals were added to the HCBS waiver benefits package for people with physical disabilities and transition services were added to the waiver for seniors in 2009.  The added services are now available to all participants in the HCBS waiver for seniors and people with physical disabilities, regardless of MFP enrollment status.

Beneficiary Self-Direction of HCBS:  Nearly all MFP demonstrations nationwide promote beneficiary self-direction of services and supports as an alternative to the provider management service delivery model.  Self-direction promotes personal choice and allows the beneficiary to control a service budget and/or the selection, training, and dismissal of providers.  Nationally, about 19 percent of MFP participants are enrolled in a self-directed model.⁶   Currently, there are limited options for beneficiary self-direction of HCBS in Maryland; only MFP participants who receive services through one of the state’s HCBS waivers have the ability to self-direct their services, but none currently exercise this option.  The state plans to expand access to self-direction for beneficiaries receiving attendant care services and supports through the CFC state plan option in 2014 and will offer voluntary self-direction training to these beneficiaries. More opportunities for self-direction now exist under the new Home and Community-based Options (CO) Waiver (which combined the Living at Home Waiver (LAH) and the Waiver for Older Adults (WOA)), e.g., setting rates for personal assistant services, taking a more active role in hiring and firing workers, acting as one’s own supports planner/case manager.

Housing Assistance

Because finding accessible affordable housing is often the biggest challenge to transitioning to the community, Maryland provides housing assistance to MFP participants through a number of strategies:

Housing Location Assistance as a Home and Community-Based Waiver Service:  One of the major components of transitional case management is the provision of housing assistance.  Supports planners/case managers provide information about types of housing options, the availability of housing, and the housing subsidy systems, and will also provide intensive support to complete applications, acquire needed documentation, and secure housing.  Housing assistance may also include opportunities for MFP participants to visit different housing options using their supplemental service funds.  Housing assistance will be available to residents of state residential centers who indicate a preference for independent community housing instead of an Alternative Living Unit and will be provided by their Service Coordinators.  Through MFP, DHMH maintains four housing specialists who accept referrals from transitional case managers and provide enhanced housing assistance when the case manager is unable to secure community housing.  These specialists are also tasked with establishing and maintaining relationships with local public housing authorities (PHAs) to advocate for additional resources and providing training to MFP partners.

Expansion of Subsidized Community Housing:  MFP’s housing specialists participate in statewide housing policy development.  For example, in February 2011, MFP staff worked with partners to help secure 112 federal category 2 Housing Choice vouchers from the U.S. Department of Housing and Urban Development (HUD) for non-elderly individuals with disabilities transitioning from institutions.  Since then, all of these vouchers have been awarded to beneficiaries.

Additionally, in February 2013, Maryland received $10.9 million in grant funding from HUD for a Section 811 Project-based Rental Assistance program (PRA).  The Maryland Partnership for Affordable Housing (MPAH), a grant project obtained through a Centers for Medicare and Medicaid Services (CMS)-sponsored Real Choice System Change grant, enabled MPAH to successfully create an inter-agency agreement between the state housing, Medicaid, and disability agencies and together apply for the Section 811 PRA grant.  Maryland’s Section 811 PRA demonstration will support 150 units for the non-elderly persons with disabilities.  To underscore their commitment to the goals of Maryland’s Section 811 demonstration, local PHAs committed an additional 102 vouchers or rental units for MFP participants with disabilities age 62 or younger.  Maryland’s MFP housing director works with state and local partners to develop and implement the PRA program, while MPAH develops the infrastructure required by the PRA demonstration, including coordination of services and supports between agencies and an efficient and timely unit referral system.

Maryland’s MFP grant also funds the following activities to support the Section 811 PRA demonstration:

1. Person-Centered Planning Training – MFP funded this training, with an emphasis on housing, for case managers, service providers, and other professionals.
2. Housing Subsidies – One million dollars in MFP funds are being held in trust by the state housing agency to fund housing subsidies for demonstration participants for a period of up to six months if the PRA demonstration is not renewed and housing funding is no longer available from HUD.
3. Support to Help Beneficiaries Maintain Community Housing – The MFP housing director and housing specialists will be responsible for training and supporting case managers who will help PRA beneficiaries navigate landlord/tenant issues and maintain stable community housing.
4. Streamlining Eligibility Determinations – The state Medicaid agency is contracting with a non-profit to administer the PRA demonstration’s web-based eligibility and unit identification system.

Staff Dedicated to Housing for People with Disabilities:  Maryland’s MFP program currently funds two positions through an agreement with the state agency for people with disabilities, a housing specialist and an interagency housing liaison.  This housing specialist administers the MPAH program described above, provides technical assistance to waiver supports planners/case managers and landlords participating in the PRA Section 811 demonstration, maintains housing waiting lists, and manages waiting list preferences and the selection process.  The housing specialist also is the state disability agency’s liaison to other state agencies, advocacy groups, stakeholders, and the public for housing outreach initiatives related to MFP.

In addition, the state disability agency housing specialist administers the Weinberg Affordable Housing program.  Since 2011, the state housing, Medicaid and disability agencies have had a joint venture with the Weinberg Foundation to work together to finance affordable, quality, independent, and integrated housing opportunities for people with disabilities and very low incomes.  To qualify for these units, participants must be between the ages of 18-61 at the time of occupancy, receiving Supplemental Security Income or Social Security Disability Insurance with income between 15-30 percent of the area’s median income, and willing to live in the identified project location.

The interagency housing liaison coordinates special MFP projects related to housing between the state Medicaid and disability agencies, such as the MFP bridge subsidy⁷  and transit-oriented development and sustainable community planning initiatives to create affordable accessible housing for people with disabilities transitioning out of NFs.  The liaison also is responsible for developing and maintaining key relationships with affordable housing stakeholders including PHAs, developers, and local municipalities.

State Staffing and Key Partnerships

Maryland’s MFP program has 13 full-time staff members within the state’s Medicaid agency: a project director (who also currently oversees the state’s BIP implementation); an associate project director; a housing director; three housing specialists; a data specialist; a policy analyst/behavioral health specialist (who also works on implementing the state’s CFC state plan option and acts as the MFP liaison with state and local mental health agencies); three staff members who focus on transitioning individuals with developmental disabilities and work closely with the state’s agency for people with developmental disabilities; a finance specialist; and an Aging and Disability Resource Center (ADRC) specialist.  All of these positions are fully funded by federal MFP administrative dollars. Key partnerships with Maryland’s MFP program include:

ADRCs – Like other states nationally, Maryland has received ADRC funding from the federal Administration for Community Living and CMS to develop a program to streamline access to information about LTSS, especially HCBS options.  Maryland’s program, called Maryland Access Point (MAP), began in 2004,⁸  and is led by the state department of aging; twenty local MAP sites make up the statewide “no wrong door/single entry point” information and referral system.⁹   MAP staff assist individuals with navigating the state’s LTSS system and application processes and make referrals to service providers.Collaborations between the state Medicaid agency and the MAP program have expanded significantly as a result of MFP.  The MAP program receives MFP funding to assist with MFP functions and to support staffing, marketing, and training to expand the MAP program.  MFP and state Medicaid agency staff participate on steering committees for all MAP initiatives, such as the Person Centered Hospital Discharge Program and the Community Options Counseling Program.

AAAs – AAAs are the lead agency for the MAP sites (with the exception of the Worcester County Health Department) and have a key role in developing partnerships with other local agencies such as CILs, local social services departments, county health departments, and public housing authorities, and help with options counseling and application assistance for NF residents pursuing community LTSS options.  Outside of the MAP sites, AAAs also provide supports planning for the CO Waiver.

CILs – CILs are a state-mandated MAP partner and provide peer outreach and ongoing supports to NF residents.  CILs also provide peer mentoring to NF residents through, for example, community integration activities, during the final stages of the transition process and post-transition.  CILs also partner with the AAAs in providing options counseling.

State Housing Financing Agency and Local Public Housing Authorities – MFP staff are working to strengthen relationships with the state housing financing agency and the local PHAs, as described above.  State officials report that continued education and advocacy are the key steps towards an increased supply of safe, affordable, and accessible housing for people with LTSS needs in Maryland.

Long-Term Care Ombudsman– The state Long-Term Care Ombudsman programs are available as a resource for NF residents and their relatives and advocates.  Ombudsmen investigate complaints, provide mediation, and assist with residents’ issues concerning rights, payments, guardianship, and NF placement.  Ombudsmen are also knowledgeable about transition services and about Medicaid HCBS and they refer people to MFP that express a desire to return to the community.

MFP Stakeholder Workgroup – This workgroup meets bi-monthly with attendance ranging from 34 to 50 beneficiaries, agency staff, providers, and advocates from the aging and disability communities. This group provides input on demonstration activities and priorities for rebalancing investment.

State Departments of Aging and Disabilities – These state agencies administer the options counseling and peer support programs for MFP beneficiaries, respectively, and provide additional quality oversight and monitoring.

Maryland Disability Law Center – This is Maryland’s protection and advocacy agency for people with disabilities. They provide input on how MFP activities impact NF residents and make recommendations to improve the process.

State University Systems – The state Medicaid agency funds the University of Baltimore’s Schaefer Center to administer the Quality of Life (QoL) Survey to MFP participants and The Hilltop Institute at the University of Maryland, Baltimore County to provide ongoing IT support, data management, and analysis to assist with CMS reporting requirements and provide analysis to assist state staff in the policy making process.  Hilltop also developed Maryland’s initial web-based MFP tracking system (described below).

Quality and Evaluation

QoL Survey:  As noted above, Maryland administers the CMS QoL survey to MFP participants.  The survey is given to participants during three specific timeframes: prior to discharge from the institution, twelve months post discharge date, and twenty-four months post discharge date.

Web-Based Tracking System:  As noted above, Maryland uses a web-based system to track potential and enrolled MFP participants from initial contact through transition.  The tracking system is accessible by peer outreach contractors, options counselors at the AAAs and CILs, waiver case managers, and the various state agencies involved in MFP.  The system initially was built to track the QoL survey administration and assist state staff in monitoring contractor activities (such as peer outreach and options counseling), the number of application assistance referrals, and the administration of flexible funds (an MFP supplemental service).

The tracking system combines administrative data from the state’s Medicaid Management Information System, MDS 3.0 nursing home assessments, and other data sources to help the MFP program director and staff appropriately identify specific characteristics associated with successful or unsuccessful transitioning and promote person-center transition planning.  In 2013, the state’s multiple web-based Medicaid LTSS tracking systems were integrated into one system.  Maryland’s medical assessment tool and new time-keeping system for attendant care providers also were added.  A reportable events module went live in 2014, and there are future plans to add a client portal and include tracking capabilities for other community-based supports such as CFC.

In addition to tracking associated specifically with MFP, each of the Section 1915(c) waivers in which MFP participants may enroll has a comprehensive quality management system that includes emergency back-up systems and incident reporting and management strategies.

Transition Progress

As of March 2014, 1,931 people have transitioned to the community through Maryland’s MFP program (Figure 1).  Seniors and people with physical disabilities are the target groups most likely to transition as MFP participants.  The average age of an MFP participant is 61 years old.  State officials report that Maryland is on pace with its annual transition goals and expect the MFP enrollment rate to stay the same in the year ahead.  The oldest beneficiary to transition via MFP was 106 and the youngest was 19.

On average, it cost $4,618 per month to serve an MFP participant in the community in calendar year (CY) 2011 (Figure 2).  The per participant per month cost of serving seniors in Maryland’s HCBS waiver ($3,333) was lower than the cost of serving adults with physical disabilities in in Maryland’s HCBS waiver ($5,904).  Across all MFP populations, the average costs are comparable to other Medicaid HCBS beneficiary expenditures across the state and are lower than the average costs of serving Medicaid beneficiaries in institutional settings ($6,082).  For individuals who enrolled in MFP in CY 2011, average monthly Medicaid expenditures decreased after transition across all waiver programs, except for the Older Adults waiver program (expenditures remained the same) (Figure 3).  Per member per month Medicaid HCBS expenditures were highest among traumatic brain injury (TBI) waiver participants ($16,891).¹⁰ 

On average, Maryland’s MFP participants took 6 months to transition to the community.  This compares to a national average of 3.5 months.¹¹   Under MFP, there are three types of community-based residences in which MFP participants can choose to reside: a house owned or leased by the beneficiary (or a relative), an apartment leased by the beneficiary, or a group home in which no more than four unrelated individuals reside.¹²   In Maryland, senior MFP participants most often transition to a house whereas individuals with physical disabilities most often transition to an apartment. Most individuals with intellectual/developmental disabilities and individuals with TBI transitioned to a group home.

About five percent of Maryland’s MFP participants have been reinstitutionalized either in a hospital, NF, or ICF/ID. Nationally, states reported an average reinstitutionalization rate of 11 percent across all MFP populations.¹³ 

MFP and ACA LTSS Options

MFP contributes to ongoing LTSS rebalancing efforts in Maryland as well as supports the research, development, and implementation of the ACA’s new and expanded opportunities to increase access to Medicaid HCBS.  When the state needed to revise its MFP Operational Protocol in 2011, following the ACA’s extension of the MFP demonstration, Maryland engaged an active stakeholder group (comprised of consumers, advocates, consumer protection agencies, Legal Aid, AAAs, CILs, state agencies, case management providers, and NF associations) to solicit ideas about potential changes to MFP.  The group decided MFP should support rebalancing initiatives by reinvesting savings into CFC, BIP, implementation of a universal assessment tool, and MAP sites.  As of March 2014 Maryland had implemented the BIP program, a Section 1915(k) CFC state plan option for attendant care services and supports with enhanced federal funding, and the new state plan option to provide health home services.  Alongside the CFC implementation, the two Section 1915(c) waivers that serve most MFP participants (i.e., LAH and WOA) were combined to create the new CO Waiver as mentioned above.  All services allowable under CFC were removed from the CO Waiver and covered through the state plan option.  These state plan services are available to CO participants that live in a community-based setting, including MFP participants.

MFP and BIP:  The state utilized lessons learned from MFP when applying for BIP, a new ACA option that provides financial incentives to states that implement certain structural reforms to increase access to community-based LTSS.  BIP requires states to create a conflict-free case management system, develop a no wrong door/single entry point system, and utilize a statewide core standardized assessment.  States, such as Maryland, that spent 25 to 50 percent of their fiscal year 2009 Medicaid LTSS dollars on community-based LTSS are eligible to receive a two percent increase in their federal matching rate through September 2015 by participating in BIP.

Maryland’s MFP demonstration helped finance the structural changes required under BIP.  In order to do this, the MFP Operational Protocol was revised in January 2012 to explicitly define programs and activities that help Maryland develop a more balanced system of LTSS in home or community-based settings, such as research and implementation of a core standardized assessment (the interRAI) and staff funding for MAP sites that serve as Maryland’s Single Entry Point/No Wrong Door system.  Maryland was approved for its BIP grant in March 2012.

MFP and CFC:  The ACA established CFC, a new Medicaid state plan option that allows states to provide expanded statewide home and community-based attendant supports and other waiver-like services to individuals who require an institutional level of care.  States taking up this option receive a permanent six percent increase in their federal matching rate for CFC services.  CFC is designed to assist individuals with activities of daily living, instrumental activities of daily living, and health-related tasks and with acquiring, maintaining, and enhancing their own skills to accomplish these tasks.  CFC services include “self-direction” training; backup systems; and at state option, other services and supports linked to an assessed need or goal in the person-centered service plan.

Maryland implemented the CFC option in January 2014.¹⁴   The state has utilized CFC to consolidate, under one program, personal assistance services that were previously available as three separate programs: the state plan personal care services benefit, the Section 1915(c) waiver for persons with physical disabilities, and the Section 1915(c) waiver for seniors.  By consolidating personal assistance services under one program, the state is able to standardize rates, providers, and regulations and to provide participants with increased self-direction opportunities. The state reports that initial CFC start-up costs such as staffing, technology, training, and outreach will be financed using MFP and BIP funding, and CFC will be sustained through the six percent enhanced federal match on CFC services.¹⁵ 

Looking Ahead

The goal of Maryland’s MFP demonstration is to encourage LTSS rebalancing by improving the transition process, increasing outreach, and decreasing barriers.  To accomplish this, Maryland uses federal MFP funding to provide peer mentoring services, options counseling, and application assistance to NF residents, improve information technology, offer housing assistance, provide flexible transition funds, and add services to existing HCBS waivers.  In addition, the state leveraged MFP funding to accelerate LTSS rebalancing efforts through new and expanded ACA LTSS options.  MFP has helped finance the structural changes required in BIP and helped to fund the start-up costs associated with the CFC state plan option.  Additional funding has been approved in Maryland’s MFP Operational Protocol to support specific rebalancing efforts, including housing partnerships with the state agency for people with disabilities, training initiatives, a Bridge Subsidy Rental Assistance program, provider registry, and enhanced peer support for ICF/ID residents who wish to transition to the community.¹⁶ 

Maryland officials report housing as the number one challenge facing LTSS beneficiaries who want to transition from institutions to the community.  With Maryland’s housing costs among the highest in the nation, finding affordable housing can be difficult for potential MFP participants.  MFP staff continue to be concerned that participants entering a NF have given up their previous housing, making it harder to transition back into the community.  Therefore, assistance with locating housing, provided through the supports planners or MFP housing staff, and ongoing training to develop housing expertise among waiver case managers and MAP partners continue to be a focus of Maryland’s MFP program.  At a systems level, MFP will continue to support collaborations with developers, landlords, property managers, and the state and local housing authorities to advocate for safe, affordable, accessible, and integrated housing for persons with LTSS needs.  Other ongoing efforts include continuing to improve how BIP and MFP work together (through funding structural changes and the expansion of services); strengthening MAP sites through BIP funding; planning for program sustainability; standardizing services and supports, provider requirements, and rates across the various HCBS waiver programs; supporting NF diversion programs; and determining how the January 2014 definition of home and community-based setting affects Maryland’s CFC option and Section 1915(c) waivers.¹⁷ 

1. Money Follows the Individual Act is codified in the Annotated Code of Maryland, Health General §15–137; the Maryland Department of Health and Mental Hygiene may not deny an individual access to a home- and community-based services waiver due to a lack of funding for waiver services if: (1) The individual is living in a nursing facility at the time of the application for waiver services;(2) At least 30 consecutive days of the individual’s nursing facility stay are eligible to be paid for by the Program;(3) The individual meets all of the eligibility criteria for participation in the home- and community-based services waiver; and(4) The home- and community-based services provided to the individual would qualify for federal matching funds. ↩︎
2. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs. ↩︎
3. The Minimum Data Set (MDS) 3.0 is an assessment tool that is used with residents in all Medicare-licensed nursing facilities.  Section Q of the MDS relates to the resident’s desire to return to receive services in the community. ↩︎
4. Effective January 6, 2014, applicants and participants have freedom of choice among available enrolled providers. ↩︎
5. Department of Health and Mental Hygiene, State of Maryland, Money Follows the Person Operational Protocol, 2011, available at: https://mmcp.dhmh.maryland.gov/docs/MFP-Operational-Protocol-v%201-1.pdf. ↩︎
6. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs. ↩︎
7. The Bridge Subsidy program links individuals in nursing homes and institutions to temporary housing subsidies until permanent support can be located. ↩︎
8. The Governor’s budget has provided annual funding of $250,000 since 2006. In 2013, Senate Bill 83 codified in state statute the Maryland Access Point (MAP) program and the agencies responsible for administering, supervising, and coordinating the program.  The MAP program has strengthened partnerships between state executive staff and legislators. Executive staff of the state’s Departments of Health and Mental Hygiene (Maryland’s Medicaid Agency), Disabilities, Human Resources, Housing and Community Development, Education, Veterans Affairs, and Aging are active on the State MAP Advisory Board and in the workgroups. ↩︎
9. To ensure that people can access the same information, the state Medicaid agency is working to create a toll-free hotline that connects directly to the caller’s local MAP; the hotline is expected to be available in 2014.  MAP site staff will complete a brief telephone screen that triages a person into LTSS, focusing on person-centered planning and providing direct referrals to functional and financial assessments when appropriate. ↩︎
10. The Hilltop Institute, presentation by Ian Stockwell and Rebekah Natanov to the Maryland Department of Health and Mental Hygiene, Medicaid Long-Term Services and Supports in Maryland: Money Follows the Person Metrics, June 4, 2013, available at: https://mmcp.dhmh.maryland.gov/longtermcare/SitePages/Maryland%20Money%20Follows%20the%20Person.aspx, See Hilltop presentation on MFP Metrics, Part 2. ↩︎
11. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs. ↩︎
12. Code of Maryland Regulations 10.07.14.02B(10). As defined in state law, assisted living facilities are qualified residential settings that may serve small groups of unrelated individuals.  Code of Maryland Regulations 10.07.14.02B(10) ↩︎
13. Molly O’Malley Watts, Money Follows the Person: A 2013 Survey of Transitions, Services, and Costs, Kaiser Family Foundation’s Kaiser Commission on Medicaid and the Uninsured, April 2014, available at: https://modern.kff.org/other/report/money-follows-the-person-a-2013-survey-of-transitions-services-and-costs. ↩︎
14. Maryland Department of Health and Mental Hygiene, https://mmcp.dhmh.maryland.gov/longtermcare/SiteAssets/SitePages/Community%20First%20Choice/General%20CFC%20Provider%20Memo.pdf ↩︎
15. Maryland Department of Health and Mental Hygiene, Balancing Incentive Program Application, February 2012, available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Balancing/Downloads/Maryland-Submission.pdf. ↩︎
16. A summary of these initiatives is available at: https://mmcp.dhmh.maryland.gov/docs/MFP-Operational-Protocol-v%201-1.pdf ↩︎
17. “Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice and Home and Community-Based Services (HCBS) Waivers,” 79 Federal Register 2947 (16 January 2014), pp. 2947-3039, available at: https://www.federalregister.gov/articles/2014/01/16/2014-00487/medicaid-program-state-plan-home-and-community-based-services-5-year-period-for-waivers-provider. ↩︎

To date, 45 states (including DC) have received Money Follows the Person (MFP) demonstration grants to transition Medicaid beneficiaries from institutions to the community.  Authorized by Congress in 2005 and extended through 2016 by the Affordable Care Act (ACA), MFP provides enhanced federal funding for 12 months for each participating Medicaid beneficiary.  Of the 45 states, 42 are currently operational, two states are not yet operational and one state’s demonstration is inactive.  In August 2013, the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured surveyed all MFP states about enrollment trends, services, and per capita spending in their demonstrations.  States also were asked to describe the interactions between MFP and the ACA’s new and expanded long-term services and supports (LTSS) options and any state managed LTSS (MLTSS) programs. New companion papers profile MFP demonstrations in two states – Maryland and Tennessee – as well as the experiences of four MFP participants.¹ 

Key Findings:

As of August 2013, over 35,400 Medicaid beneficiaries had enrolled in MFP and another 5,780 transitions were in progress.  Forty percent of all MFP transitions occurred in three states (OH, TX, and WA), with the most cumulative transitions in Texas (7,307 or 21%).  The majority of MFP participants nationally are persons with physical disabilities (38%) and seniors (37.5%). One in five MFP participants (19%) has an intellectual/developmental disability (I/DD); 5 percent have a mental illness.  Over 10,300 Medicaid beneficiaries moved to the community through MFP between 2012 and 2013 (Figure 1).  On average, MFP participants were 58 years old, took 3.5 months to transition and most often moved to an apartment.  States also reported an 11 percent reinstitutionalization rate across all target populations.

Access to comprehensive pre- and post-transition services enables MFP participants with a range of chronic and disabling conditions to successfully return to the community.  MFP participants receive benefits provided under existing home and community-based services (HCBS) waivers and state plan benefits packages, as well as MFP demonstration services (37 states) and supplemental services (18 states).  Sixteen states offer both demonstration and supplemental services.  Examples include transition coordination, one-time housing expenses (e.g., security or utility deposits and household set-up costs), assistive technology, employment skills training, 24-hour back-up nursing, peer community support, and ombudsman services.  Demonstration services are additional HCBS beyond the existing state plan or waiver benefits package and are funded at the enhanced MFP federal matching rate during the individual’s participation year. Supplemental services are not necessarily long-term care in nature (e.g., coverage of one-time transition costs or services only offered during the transition year) and are reimbursed at the state’s regular federal matching rate.

The average monthly cost of serving an MFP participant in the community was $3,934 per person in 2013, lower than the amount reported in 2012 ($4,432).  Average MFP monthly costs were highest for individuals with I/DD ($7,496) followed by individuals with physical disabilities ($2,870), individuals with mental illness ($2,603),²  and seniors ($2,204).  All states reported that per capita costs of serving MFP beneficiaries were lower than those for institutionalized Medicaid beneficiaries (26 states responded).  Thirteen states said per capita service costs for MFP participants were comparable to those for other Medicaid beneficiaries receiving HCBS, seven states reported lower costs for MFP participants, and six states reported higher costs for MFP participants.

Lack of safe, affordable, and accessible housing and difficulty coordinating multiple LTSS initiatives alongside MFP were cited as the biggest challenges facing MFP grantees in the year ahead.  States have repeatedly cited the lack of housing options as the biggest barrier to MFP transitions since the demonstration began in 2008, with 20 states identifying this issue in 2013.  States reported the need for additional community housing resources to accommodate increasingly complex populations with medical and behavioral health needs.  States also were focused on coordinating MFP with the ACA’s new and expanded LTSS rebalancing options, such as the Balancing Incentive Program, and on the expansion of MLTSS.  Twenty-four MFP states reported operating or planning an MLTSS program that will include MFP participants.  States also reported working with the Centers for Medicare and Medicaid Services to navigate enrolling MFP participants in the new financial and administrative alignment demonstrations for dually eligible beneficiaries.

Conclusion

Looking ahead, 2014 will be a transformative year for the Medicaid program, as millions of individuals become newly eligible and states adjust to the ACA’s eligibility and enrollment changes.  Managing multiple competing demands will be a challenge for MFP program staff, especially those simultaneously involved in the Balancing Incentive Program and other new ACA LTSS options.  Lessons learned from MFP will help states prioritize resources and build on existing rebalancing efforts.  MFP participants repeatedly cite increased independence, regained freedom, and greater access to the community as key benefits of moving home.³   Increased outreach about HCBS (often provided by Aging and Disability Resource Centers), support and training of HCBS providers, flexible benefit design such as access to a one-time allowance to cover moving expenses and home modifications, and enhanced federal funding all have contributed to helping thousands of Medicaid MFP beneficiaries return to the community.

The Money Follows the Person (MFP) demonstration, authorized by Congress as part of the 2005 Deficit Reduction Act, provides states with enhanced federal matching funds for 12 months for each Medicaid beneficiary who transitions from an institutional setting to a community-based setting.  Qualified community settings include a house, apartment, or group home with less than four non-related residents.  The enhanced federal funding is designed to encourage state efforts to reduce reliance on institutional care for individuals needing long-term services and supports (LTSS) and expand options for individuals with disabilities and seniors who wish to receive services in the community.  The Centers for Medicare and Medicaid Services (CMS) initially awarded MFP grants to 30 states.  Thirteen additional states were awarded funding in February 2011, and another three states received planning grants in March 2012.⁴   With Florida recently withdrawing, there are currently 45 states, including the District of Columbia, participating in the demonstration.

Under the Affordable Care Act (ACA), MFP was extended by five years through September 2016, and an additional $2.25 billion in federal funds ($450 million for each federal fiscal year from 2012-2016) was allocated for the demonstration.  Funding is available to states for the fiscal year they receive the award and four subsequent fiscal years.  Any unused grant funds awarded in 2016 can be used until 2020.  The ACA also modified the MFP length of stay eligibility criterion.  Under the ACA, individuals who reside in an institution for more than 90 consecutive days are now eligible to participate.  The previous criterion for the institutional residency period was six months to two years.⁵   This policy change acknowledges that earlier intervention is often critical to prevent long-term nursing facility (NF) stays that make transitioning to the community more difficult.  Most states anticipated that this policy change would increase the number of future MFP participants.

The Kaiser Family Foundation’s Commission on Medicaid and the Uninsured (KCMU) surveyed state MFP project directors in 2008 and 2010-2012 to gauge states’ progress with transitions.  The 2012 KCMU survey found that 36 states had transitioned over 25,000 beneficiaries back to the community.⁶   While some state MFP demonstrations became operational in 2007, the majority of initial transitions occurred between 2010 and 2011 because states needed several months or years to get their programs up and running and begin transitioning beneficiaries.  States with pre-existing transition programs, such as Texas and Washington, were almost immediately able to transition individuals once their programs were funded and implemented, but other states needed significantly more time and resources to launch their MFP demonstrations.  Overall, the reach of the MFP demonstration is growing; participants include seniors, children, adults with intellectual/developmental and physical disabilities, persons with mental illness, and persons with disabling chronic conditions.  The number of participants has increased annually with the expansion of outreach efforts and the availability of technical assistance to help grantee states meet annual transition goals.⁷   States reported ongoing efforts to improve access to housing, a critical component of successful community placements.

This report is based on a KCMU survey of state MFP demonstrations conducted in August 2013.  The survey was designed to obtain state-level information on MFP enrollment, services, and per capita costs.  States also were asked to respond to questions about the role of beneficiary self-direction of services, access to community-based providers, the current economic environment, and the take-up of the new and expanded ACA LTSS options.  At the time of the survey, a total of 42 states had operational MFP demonstrations, two states (MT and SD) were not yet operational, and one state (OR) was inactive (Figure 1).⁸   The data for this report were provided directly from MFP project directors in response to a written survey.  The full survey instrument can be found in Appendix A of this report.  Survey responses were received from all 45 MFP grantee states.  Grantee states that had yet to reach operational status responded to as many of the survey questions as possible based upon their operational protocols as submitted to CMS.  Several more recent grantee states were still in the process of hiring an MFP project director and were not able to provide significant detail on their demonstrations. Two states, Florida and New Mexico, withdrew from the MFP demonstration prior to implementation and are not included in the total number of states participating in MFP.

Key Findings

Transitions

As of August 2013, over 35,400 Medicaid beneficiaries had enrolled in MFP and another 5,781 transitions were in progress (Figure 2). Three states (OH, TX, and WA) made up 40 percent of all MFP transitions, with Texas accounting for the most cumulative transitions (7,307 or 21%). Variation in program size reflects, among other things, the length of program operation, the size of the eligible population in each state, and state capacity and experience in operating transition programs.

Among the 42 MFP demonstrations that are currently operational, nine states became operational in 2012 (ME, MS, NV, and VT) or 2013 (AL, CO, MN, SC, and WV) and transitioned a combined total of 227 individuals, as of August 2013. Similar to when the first MFP grantee states became operational, new grantees are finding that it takes time to receive CMS approval of their operational protocol and to begin transitions once the demonstration is operational. Therefore, these states have set relatively modest transition goals for their first few years of the demonstration.

The majority of MFP participants to date are individuals with physical disabilities (38%) and seniors (38%). One in five MFP participants (19%) is an individual with an intellectual/developmental disability (I/DD). Individuals with mental illness (5% of total transitions) and those with I/DD are less likely to be candidates for transition due to their typically more extensive medical and LTSS needs. Seniors and people with physical disabilities also lead the number of transitions in progress.

Over the past three years, states reported taking steps to increase the number of transitions among individuals with mental illness. Twenty-six states reported efforts underway to increase transitions among this population, slightly down from the 29 states that reported targeting those with mental illness in 2012. Ohio’s state Medicaid agency has transitioned the largest number of MFP participants with mental illness (1,100) by working closely with the state’s Department of Mental Health and Addiction Services. Recently, Ohio began a program called “Recovery Requires a Community” that provides supplemental resources for individuals with serious and persistent mental illness who are living in an institutional setting and desire to live in the community; most individuals will enter the program after participating in HOME Choice (Ohio’s MFP demonstration) and the program provides additional independent living resources for individuals beyond the one-year MFP period.

State Medicaid agencies reported actively coordinating with their state Behavioral Health/Mental Health Departments and collaborating with community mental health providers to provide interdisciplinary services and community supports for people with mental health needs to successfully transition to the community. Other current state efforts to target this population include the following: education for mental health providers about MFP and available community-based supports, inclusion of MFP staff on states’ Institutions for Mental Disease discharge planning teams, identification of children living in psychiatric residential treatment facilities who could transition to the community, collaboration with CMS to amend the state MFP operational protocol to include individuals with mental illness as a target group, launch of a pilot program with the Balancing Incentive Program (BIP)⁹  to target individuals with mental illness specifically, and development of a Section 1915(i) state plan amendment¹⁰  to cover individuals with mental illness who need HCBS and who had not previously been eligible for Medicaid. Fifteen states reported no specific plans to target this population.Over 10,300 Medicaid beneficiaries returned to community residences from institutions through the MFP demonstration between 2012-2013. Despite a slow start for several states, MFP grantees averaged over 9,000 transitions per year over the past two years. In 2012, states were behind their original enrollment projection of 38,000 individuals; 2013 enrollment numbers show they are nearing that original transition projection.¹¹  In 2012, states reported transitioning nearly 25,000 individuals back to the community cumulatively, up from almost 17,000 individuals in 2011 (Figure 3). With the addition of 15 new MFP demonstrations since 2011 (all except two of those states are currently operational), more Medicaid beneficiaries are getting the opportunity to transition from an institutional setting to community-based living with person-centered, pre- and post-transition supports and services in place. Four states (AK, AZ, UT, and WY) have chosen not to apply for an MFP demonstration, one state (FL) was awarded an MFP grant and is no longer active, and one state (NM) began the application process but decided not to move forward.

The 2013 survey asked states to report if they were on pace with their annual transition targets, and most (26 states) reported that they were on target to meet annual goals.¹²  Seventeen states reported that they were not on pace to meet their annual projections. States’ modest start with MFP transitions can be attributed to, for example, implementation delays and/or challenges related to transitioning populations with multiple chronic and disabling conditions. States reported a number of other contributing factors including the following: lack of affordable, accessible housing options particularly for individuals with complex medical and LTSS needs, a shortage of state MFP staff, and successful diversion programs that reduce institutional admissions.

Despite these challenges, 34 states expect their MFP enrollment to increase over the next year, while nine states anticipated no change in annual enrollment. No state anticipated a decrease in enrollment. State efforts to increase outreach and enrollment include hiring outreach coordinators, using the Minimum Data Set (MDS)¹³  to assist with targeted outreach, using peer-to-peer outreach to NF residents, collaborating with the state Long-Term Care (LTC) Ombudsman program, forming MFP stakeholder groups and/or advisory commissions, and educating formal and informal LTC providers and beneficiary advocates about MFP. Other selected outreach examples are highlighted below.

Illinois developed a web-based referral process for individuals, family members, and NF staff to directly refer individuals to its MFP program. The online referral form is located on the state’s MFP website and provides for greater accountability and tracking of referral follow-up activities through a centralized process. The Illinois Department of Healthcare and Family Services distributed a notice to all NFs outlining the online referral process in Spring 2013 and the number of referrals dramatically increased over six months that followed as awareness of the web-based system grew.

Nebraska’s MFP program implemented a media campaign in July 2013. The state has contracted with a television station that runs a commercial spot numerous times each month.

New Jersey recently re-branded its program as “I Choose Home-NJ.” The state is implementing a new marketing and outreach plan featuring strategies for facility-based marketing and education as well as focused messaging for the larger community that will include radio spots, letters to the editor, newspaper articles, an infographic for policy makers, and a press conference.

Outreach, Referrals, and Transition Support

Thirty-six states reported partnering with local Aging and Disability Resource Centers (ADRCs) to assist with MFP program referrals and to help coordinate transitions. Within a state, outreach and enrollment efforts are often accomplished through partnership efforts between the Medicaid program and other state agencies, community stakeholders, and MFP staff. The ACA appropriated $10 million a year for five years (2010-2014) to expand ADRCs to serve as community access points for individuals seeking information and referrals for LTSS. Coordinators at ADRCs that receive funding from state MFP demonstrations can assist with processing referrals from MDS 3.0, Section Q-Participation in Assessment and Goal Setting and MFP outreach and enrollment, including options counseling, MFP program eligibility verification, and HCBS waiver slot distribution to prospective MFP participants. Several states reported using MFP funds to expand ADRC activities in the year ahead. For example:

Illinois received funding to employ three Transition Engagement Specialists at three ADRCs in locations where individuals with serious mental illness can access MFP benefits. The specialists are charged with engaging potential MFP participants through cross-population outreach activities, building relationships with NF administrators and staff, assisting in the development of best practices related to MDS 3.0 Section Q referral processes, and improving the overall accuracy of referrals to the MFP program, including triaging referrals to determine which community agency is most appropriate to carry out follow-up processes with NF residents. Illinois’ MFP population is very complex, with almost half of MFP beneficiaries having five or more chronic health conditions in addition to a serious mental illness.

In Ohio, organizations in the ADRC network serve as local contact agencies and staff are called Community Living Specialists. These specialists use the Community Living Plan Addendum to assess the needs of individuals residing in NFs or other institutions when they are identified by the MDS 3.0 Section Q referral process as having a desire to reside in the community. Ohio is currently developing an electronic version of its assessment, which will allow for greater efficiency in follow-up interview assignment, outreach activity tracking, online data entry, and online interview approval. In addition, by integrating data validity checks, the state hopes to increase the quality of the data obtained.

Participant Characteristics

• This year’s survey included questions related to characteristics of MFP participants. Where possible, states were asked to report responses by target population. Across all MFP demonstrations, state officials reported the following results:
• The average age of MFP participants was 58 years old. MFP participants with I/DD were younger (on average
• 46 years old) than individuals with a mental illness or a physical disability, who averaged 49 and 51 years old, respectively. The average age of senior MFP participants was 76, up from an average age of 71 in 2011 and 75 in 2012.
• MFP participants averaged 3.5 months to transition back to the community – the same length of time that states reported in 2012. Individuals with mental illness or I/DD took longer to transition home compared to seniors and people with physical disabilities.
• MFP participants most often transitioned to an apartment. Seniors were more likely to transition back to a house (their own house or a family member’s house) or an apartment, whereas individuals with I/DD more often transitioned to a small group home.
• The average reinstitutionalization rate was 11 percent. In both 2011 and 2012, states reported an 8 percent reinstitutionalization rate. Reinstitutionalization is defined as returning to a NF, hospital, or Intermediate Care Facility for Individuals with Intellectual/Developmental Disabilities, regardless of length of stay, during the beneficiary’s MFP participation year. Across all target populations, seniors were most likely to be reinstitutionalized, and individuals with I/DD were the least likely to return to an institutional setting.

Benefits

Access to comprehensive pre- and post-transition MFP services enables Medicaid beneficiaries with a range of chronic and disabling conditions to successfully transition back to the community. States provide a comprehensive set of benefits to MFP participants, including those services provided under existing HCBS waivers and state plan benefits packages as well as MFP demonstration services and supplemental services, to ensure successful transition back to the community. Services that qualify for the MFP enhanced federal matching rate during a beneficiary’s MFP participation year are those waiver and state plan services that will continue once the individual’s MFP demonstration transition period has ended. Forty-three states currently offer home and community-based waiver services to MFP participants, and 34 states offer HCBS to MFP participants under their state plan benefits package. Common Medicaid HCBS are case management, homemaker services, home health aide services, personal care services, adult day health care, habilitation, and respite care.Thirty-seven states offered MFP demonstration services in 2013, which are additional Medicaid HCBS reimbursed at the enhanced MFP federal matching rate during a beneficiary’s 12-month MFP participation period. MFP demonstration services are provided in a manner or amount beyond what a typical Medicaid HCBS beneficiary receives and are not otherwise available to a non-MFP Medicaid beneficiary. For example, a state that does not normally offer caregiver training might make such services available to caregivers of MFP participants. After the beneficiary’s transition year ends, states are not obligated to continue MFP demonstration services but may choose to fund them through Medicaid at the state’s regular federal matching rate.

Eighteen states offered MFP supplemental services – which are not necessarily LTC in nature – in 2013. MFP supplemental services are only offered during the beneficiary’s demonstration transition year and are reimbursed at the state’s regular federal matching rate. Sixteen states reported offering both demonstration and supplemental services. States design MFP demonstration and supplemental services to ensure participants’ successful transition back to community living. These services include benefits such as transition coordination, coverage of one-time housing expenses (such as security deposits, utility deposits, and furniture and household set up costs), assistive technology, employment skills training, 24-hour back-up nursing, home-delivered meals, peer-to-peer community support, and LTC ombudsman services.

The 2013 survey asked states to report if MFP services were modified or added to the benefit package over the past year. Nineteen states reported no difference in the services offered to MFP participants, and 14 states reported making changes in 2013. Of the states reporting benefit alterations, 12 reported increasing services, with the remaining states reporting a decrease in services or a neutral change. Selected examples of state modifications to benefits are:

• The District of Columbia added two new demonstration services: peer counseling and enhanced primary care coordination.
• Georgia added three new demonstration services: life skills coaching, home inspection (pre and post-transition), and supported employment.
• Ohio added pre-transition case management services and increased transition coordination services through the beneficiary’s 90^th day of enrollment. These changes were intended to increase communication and collaboration among providers with the goal of better addressing the participant’s needs once she transfers to the community.
• North Dakota added transition adjustment support (“educational supervision”) to provide supervision and instruction to NF residents preparing to transition to the community and live independently.
• Vermont added adult family care homes as a new waiver service.

Many of the services offered under MFP are geared toward meeting the needs of Medicaid beneficiaries with complex health conditions and physical limitations. Notable services offered to ensure that such persons transition home safely include personal emergency response systems, trial overnight stays, and roommate matching services. Employment for people with disabilities, including MFP participants, also can help to ensure a successful transition from institutional to community living. States are offering supported employment services to MFP participants, although only a small share use them.¹⁴  Examples of these employment services include the following: non-medical transportation services, pre-vocational services, employment skills training, job coaching, vehicle modifications, and adaptive equipment which may include medical supplies or augmentative communication devices. New Jersey and Texas hired employment specialists, using MFP administrative funds, to assist participants with identifying goals and securing employment.

Beneficiary self-direction of services is an option in most MFP demonstrations, but participation rates are low and vary across states.Forty states offer or have plans to offer Medicaid beneficiaries the authority to make decisions about some or all of their services. Only four states responded that self-direction was not a component of their MFP demonstrations. Self-direction is an alternative to the provider management service delivery model. Self-direction promotes personal choice and control over the delivery of services, including who provides services and how they are delivered. For example, an MFP participant may be given the opportunity to recruit, hire, and supervise direct service workers. Participants may also have decision-making authority over how the Medicaid funds in a budget are spent.

An estimated 19 percent of MFP participants self-directed at least some of their services in 2013. Three states reported nearly 100 percent participation in self-direction (DE, OH, and SC) due to the fact that one-time home set-up funding was categorized as a self-directed service. Seventeen states reported the percentage of MFP participants who self-direct services to be 5 percent or less. Nine states reported an increase in the percentage of MFP participants who utilized self-directed options over the past year. Twenty-four states reported no change in the percentage of MFP participants who self-direct and one state reported a decrease.

Financing

The average monthly per capita cost of serving an MFP participant in the community was $3,934 in 2013 (Figure 4). States were asked to report average monthly per capita costs for MFP participants, which ranged from a high of $10,528 to a low of $1,299 per person per month, based on responses from 20 states. Differences in per capita costs may be attribu table to differences in MFP-covered services across states and/or a reflection of the diverse needs of the target populations. In comparison, the national average per user spending on Medicaid HCBS only, including Section 1915(c) waivers and the home health and the personal care services state plan benefits and excluding other Medicaid-covered services, was $16,673 in 2010; there was great variation among states and across programs.¹⁵  As with HCBS waiver expenditures, MFP states that transitioned a greater number of individuals with intellectual/developmental disabilities (I/DD) had higher per capita costs since these individuals have extensive medical and LTSS needs. Average MFP monthly costs were highest for people with I/DD ($7,496) followed by individuals with physical disabilities ($2,870), individuals with mental illness ($2,603)¹⁶  and seniors ($2,204). These per user per month costs are comparable with the costs reported by Mathematica Policy Research in their 2012 evaluation of the MFP demonstration.¹⁷ 

When asked to compare per capita costs for MFP participants with per capita costs for other Medicaid beneficiaries receiving HCBS, 13 states said costs were comparable, seven states reported that per capita costs were lower for MFP participants, and six states reported per capita costs were higher for MFP participants. The remaining states did not answer this survey question.When asked to compare the per capita LTC costs for Medicaid beneficiaries who reside in institutions to per capita LTC costs for MFP participants, 26 states reported that per capita costs were lower for MFP participants. No state reported that the two costs were comparable or that institutional care was lower.

Quality

States are using information obtained through the CMS MFP Quality of Life (QoL) Survey, quality management reviews, and critical incident reports to improve their MFP demonstrations. States identified the QoL survey as their main tool to measure quality and satisfaction among MFP participants. MFP grantees are responsible for the survey administration, data entry, tracking, quality assurance, and transmission of data to CMS. Nursing facility residents are asked to complete the QoL survey within 30 days prior to leaving the institution and again at one and two years post-transition. The QoL instrument captures the participant’s views on the following: (1) life satisfaction, (2) quality of care, and (3) community life. A national evaluation of QoL survey responses found that most participants fare well in the community and have enjoyed an improved quality of life in comparison to their quality of life in an institution. Gains in quality of life were largely maintained among beneficiary’s still residing in the community one year post-MFP participation, and, in some cases, previous MFP participants reported continued improvements such as greater access to personal care and community integration services¹⁸  Additionally, states reported that traditional quality standards – Medicaid LTC quality improvement and quality assurance processes that are in place through Section 1915(c) waivers and state plan assurances – are also applied to the MFP program.

In addition to the QoL survey, all MFP states must complete the following quality-related requirementsdevelop risk assessment and mitigation processes, which are reviewed by CMS and must be approved prior to MFP program implementation; (2) complete a review of 24-hour emergency back-up services; and (3) develop a critical incident report management system. States review incident reports to identify potential issues post-transition that may warrant changes to current systems. Several states, such as North Dakota, employ a quality assurance specialist to oversee MFP quality initiatives. Georgia convenes a quarterly evaluation team meeting to review results of the CMS QoL survey. Illinois uses the University of Illinois (UIC) at Chicago, College of Nursing to serve as the quality assurance vendor for its MFP program. In addition to advanced nurse consultation, case consultation, and data analysis, UIC also provides numerous quality reports to state MFP staff to inform policy decisions. In 2013, the state requested that UIC conduct an analysis of beneficiary sustainability in the community, specifically focused on identifying the characteristics associated with sustainability in the community during the participation period and the characteristics associated with reinstitutionalization.

Other quality measures reported by states include providing intensive case management during the entire MFP participation year and offering transition coordination services until 90 days post-transition. West Virginia is using transition navigators to follow MFP participants for the 365 days post-transition. The transition navigators contact beneficiaries on a monthly basis to review the individualized transition and risk mitigation plans to ensure that services and supports are being provided according to the participant’s plan of care and address any quality-related issues that may arise.

Issues Facing MFP in 2013 and Beyond

Linking MFP participants to safe, affordable, and accessible community-based housing options remains a critical focus for state and federal officials. Twenty states (down from 27 states in 2012) reported housing to be the most significant issue facing MFP in the year head. Since the first Medicaid beneficiary transitioned to the community as an MFP participant in 2008, states have been challenged to meet the housing need for Medicaid beneficiaries interested in transitioning back to the community. These beneficiaries often have ongoing and persistent cognitive and physical impairments and chronic conditions that result in the need for assistance with activities of daily living and also lack adequate income and resources to afford fair market rent on their own. To address housing shortages and to improve the communication between state Medicaid agencies and state housing agencies, 30 states have hired housing coordinators (or housing specialists) who assist individuals interested in transitioning with locating and securing housing. States such as Illinois, Michigan, Minnesota, and Washington employ multiple housing coordinators to improve outreach and coordination efforts, help link MFP participants to housing resources, and assist in LTSS rebalancing efforts. Often, housing coordinators will help individuals find housing and negotiate lease terms with landlords. States are also focused on lessening the amount of time it takes to transition individuals back to the community. In the year ahead, states will continue efforts to identify additional housing subsidies or vouchers while also building capacity for more community-based providers and services.

Other key housing strategies employed include offering expanded environmental modifications, offering assistance with rent and security deposits as a demonstration service, and partnering with state housing authorities and the federal Department of Housing and Urban Development (HUD) to secure subsidized housing for seniors and people with disabilities. Several states noted that they recently applied for and/or received funding through the HUD Section 811 grant program to provide interest-free capital advances and operating subsidies to nonprofit developers of affordable housing for people with disabilities and project-based rental assistance. The following are additional examples of state initiatives to increase the supply of affordable housing options:

• Maryland cited continued education and advocacy as the key steps towards an increased supply of safe, affordable, accessible housing. The Real Choice System Change grant from CMS allowed MPAH (Maryland Partnership for Affordable Housing), a government agency, to successfully create an inter-agency agreement between the state Departments of Housing and Community Development, Health and Mental Hygiene, and Disabilities. MPAH and representatives from each agency worked together to submit an application for HUD’s Section 811 Project Rental Assistance (PRA) demonstration program and in February 2013, Maryland was awarded $10.9 million. MPAH is dedicated to developing infrastructure, including coordination of services and supports between agencies, as well as an efficient and timely unit referral system as required by the Section 811 PRA program. As part of the Section 811 application, several public housing authorities (PHAs) committed to set aside a total of 102 vouchers for people with disabilities age 62 or younger. (For more information about Maryland’s MFP Program, please see the companion case study.)
• Delaware has a web-based housing database that beneficiaries, case managers, and family members can use to search for community-based housing options.
• Wisconsin provides housing counseling as a relocation service under its HCBS waivers.
• Illinois hired three housing coordinators to improve outreach, coordination, and linkages to housing resources and assistance in LTC rebalancing efforts. They are responsible for assuring the Statewide Housing Referral Network operates smoothly and that referrals to housing providers are made promptly. Illinois also has a housing locator website with a special caseworker portal that provides detailed information on available housing options and accessibility information.
• The New Jersey Housing and Mortgage Finance Agency, Department of Community Affairs, and Department of Human Services, Division of Developmental Disabilities have launched the Special Needs Housing Partnership Loan Program (SNHPLP) aimed at creating affordable, supportive housing for people with I/DD. The SNHPLP will provide financing to create permanent supportive housing and community residences. As of September 2013, the SNHPLP had 60 beds committed, 30 projects in development, and 18 projects in the pipeline in nine counties and 19 municipalities in the state.

HCBS Providers

Two-thirds of MFP states reported an adequate supply of direct care workers in the community in 2013. States recognize that workforce initiatives are a critical component of successful community-based transition programs and are actively addressing challenges such as high turnover rates and shortages of direct service workers in rural settings. Most state efforts in this area are intended to strengthen the capacities of direct support professionals and elevate their standing as professionals (i.e., compensation, benefits, and authority). Examples of workforce development strategies adopted by states include: maintenance of a direct service worker registry website, promotion of Medicaid beneficiaries hiring family caregivers through the self-directed option, and use of MFP administrative funds for direct service workforce training. Several states have developed a standard training curriculum and certification process that can be used by HCBS providers and educators to enhance the pool of qualified and well-trained direct care staff. Texas reported accessing MFP funding for data collection (survey) of direct service workers as well as an employer/employee matching database. North Dakota has a workforce coordinator who partners with those in need of workforce development by marketing direct service work, coordinating training and options for career development, and supporting the current workforce with the goal of retention.

Tennessee is working on a workforce development project in conjunction with Lipscomb University’s School of TransformAging. The first goal of this initiative is to develop and implement a statewide, standardized competency-based training and certification program for HCBS non-medical direct care staff. In addition, the state is implementing a purchasing initiative that will restructure Medicaid payments made by contracted managed care organizations (MCOs) for NF services and core HCBS. A set of quality domains and performance measures will be developed for core HCBS – primarily those services that include hands-on assistance with activities of daily living. A modified reimbursement structure for these services will align payment rates with performance on the specified quality measures, incentivizing direct care providers to provide high quality, person-centered care.

Cost Containment

Although cost containment remains a priority for state Medicaid programs, MFP demonstrations were largely spared from cuts related to recent fiscal pressures. Thirty-six states reported that cuts to MFP did not occur over the previous year or were not likely to occur at the time of the survey. Only five states reported experiencing or anticipating cutbacks due to fiscal pressures that would affect their MFP demonstrations. One state reported a negative impact on potential MFP participants when, as a result of the federal budget sequestration, remaining federal funding for MFP Housing Choice Vouchers set aside for the I/DD population was cut with no guarantee that it would be restored. Another state noted that fiscal shortfalls and budget reductions impacting Medicaid for the past few years has resulted in no new investment in HCBS waivers, especially for the I/DD population; this has led to lower MFP transition targets.

Expansion of LTSS Under the ACA in MFP States

Forty MFP states have implemented or have plans to implement at least one new ACA LTSS option as of August 2013. The ACA included a number of new and expanded options that offer states the ability to take advantage of enhanced federal funding to re-orient their delivery of LTSS toward HCBS and away from institutional care. Many states are pursuing or have plans to pursue multiple ACA LTSS options, either separately or in combination. (For more information about state’s take-up of the options, please see the Kaiser Family Foundation’s State Health Facts website.) As of August 2013, 24 MFP states reported plans to take-up the Section 1915(i) option (12 states operational; 12 states planning), which allows states to provide HCBS as an optional benefit under their state Medicaid plan instead of through a waiver. Twenty-three MFP states reported plans to operate a health homes initiative, a new approach to manage care for people with chronic illnesses which provides states with an enhanced 90 percent federal matching rate for health home services during the first two years that a health home state plan amendment is in effect.¹⁹  At the time of the survey, 13 states’ health home initiatives were operational, and nine states were in the planning process. Twenty-two MFP states are pursuing BIP (16 states operational in August 2013; 6 states planning), which provides financial incentives (i.e., 2% or 5 % federal matching rate increase) to states that were devoting less than half of their LTC spending to HCBS and undertake structural reforms to increase access to community-based LTSS as an alternative to institutional care. Twenty MFP states reported pursuing new state demonstrations to align financing and integrate care for dually eligible beneficiaries (9 states operational; 11 states planning). Thirteen MFP states reported interest in taking up the Section 1915(k) Community First Choice state plan option (CFC) (3 states operational; 10 states planning), which provides a 6 percent federal matching rate increase for community-based attendant supports and services for individuals who require an institutional level of care.

The new LTSS options in the ACA interact with each other in ways that hold promise for improving the overall HCBS system. For example, states can “stack” enhanced federal matching rates for services that qualify under BIP, CFC, and/or MFP to increase the provision of HCBS. In addition, Maryland utilized lessons learned from its MFP demonstration to apply for BIP. BIP improves upon current rebalancing initiatives, including creating a conflict-free case management system, establishing a no wrong door/single entry point system, and utilizing a statewide core standardized assessment. Maryland’s MFP demonstration helped finance the structural changes required through BIP. In order to do this, its MFP operational protocol was revised in January 2012 to explicitly define programs and activities that help Maryland develop a more balanced system of LTSS in home and community-based settings. Three states reported challenges with coordinating the administration of the ACA LTSS options with MFP, but the majority of states (24 of 27 responding) reported no coordination problems at the time of the survey. In addition, the work that CMS and the states are undertaking to develop and implement these new options will help to improve and standardize access to HCBS across programs and funding sources. For example, CMS will share finalized elements from the BIP universal assessment instrument with states as an example for their use in CFC and other HCBS programs that require functional needs assessments. Together these options have the potential to improve care coordination for populations with chronic and complex health care needs.

Delivering LTSS in a Managed Care Model

Twenty-four MFP states reported operating or plans to implement a managed LTSS (MLTSS) program that will include MFP participants. These initiatives include enrollment of new eligibility groups into Medicaid managed care and new or expanded use of MLTSS. Tennessee has been operating its MLTSS programs (CHOICES) since 2010 and simultaneously enrolls beneficiaries into MFP and CHOICES. (For more information about Tennessee’s MFP Program, please see the companion case study.) An incentive structure allows MCOs to earn additional payments when an eligible person transitions into MFP, and again when the person has successfully resided in the community for a year. Additional payments are also tied to helping Tennessee achieve other MFP program benchmarks, including rebalancing LTSS expenditures, expanding participation in self-direction, and increasing the availability of contracted community-based residential alternative services for certain CHOICES participants. In the spring of 2014, Ohio will begin beneficiary enrollment in a three-year financial alignment demonstration for dually eligible beneficiaries. Under this initiative, managed care plans will be required to provide Medicare and Medicaid-covered services, as well as additional services under a capitated model of financing.²⁰  Along with the demonstration, a Section 1915(b)/(c) waiver will combine all services contained in the state’s current HCBS waivers requiring a NF level of care into a single waiver. Ohio projects that approximately 41 percent of persons enrolled in Ohio’s MFP program may be eligible for the new waiver.

Only two states reported challenges coordinating a MLTSS program with MFP. One state reported challenges related to on-going training to ensure that MCOs are knowledgeable about the additional quality requirements required under MFP. Additionally, modifying IT and claims systems to ensure the states receive the MFP enhanced matching rate for services for beneficiaries enrolled in managed care was a reported challenge. Another state reported challenges getting the MCOs to understand transition services. Of the 24 states with MLTSS programs or plans to pursue MLTSS, 14 states reported no problems coordinating MLTSS programs with MFP; two states reported coordination challenges; and the remaining states either did not answer the survey question or were still in the process of developing their MLTSS programs. Since some MCOs may lack experience serving populations with complex needs, important consideration should be given to ensure adequate access to services.

Continuing Rebalancing Efforts Post-MFP

States will continue their commitment to rebalancing LTSS when MFP expires. We asked states to report their plans to continue transitioning Medicaid beneficiaries from institutions to the community if MFP is not reauthorized after 2016 (with funding currently available until 2020). Some states reported that they would request an extension of the MFP demonstration. Other states noted they are beginning to strategize and looking at developing, and then further ahead implementing, sustainable policies and procedures that continue transition efforts. By reviewing what has been accomplished and learned through the MFP program, states can synergize effective program features with the newer LTSS initiatives, such as BIP. States reported plans to continue transitioning individuals through a number of options including: transition programs that existed before MFP began, transitions under existing HCBS waivers, and transitions through MLTSS that may include financial incentives for MCOs to provide community-based services. For veteran MFP states, MFP was and continues to be the catalyst for larger LTSS system reforms with many of the MFP demonstration services and processes now operational in other Medicaid LTSS programs (e.g., HCBS waivers). For states newer to MFP, the demonstration is needed to support transition efforts and future rebalancing initiatives. This, along with other system changes such as the strengthening of the ADRC network and progress toward a no wrong door/single entry point system, will enhance access to HCBS.

As of August 2013, over 35,400 institutionalized Medicaid beneficiaries had transitioned to the community through the federal MFP demonstration.  Currently, 45 states (including DC) participate in this demonstration, which has helped provide an alternative to institutional care for many seniors and people with disabilities and/or chronic conditions who need of LTSS to live independently.  Through a combination of pre- and post-transition services as well as access to housing supports, transition coordinators, durable medical equipment, and transportation services, MFP participants have been able to leave institutions and successfully return to their homes and communities.  Increased independence, regained freedom, and community integration were all important factors repeatedly cited by MFP participants.  These quality of life improvements cannot easily be measured in dollars; however, all states reported that the cost of serving Medicaid MFP participants who reside in the community is lower than serving Medicaid beneficiaries in institutions.

Despite progress moving Medicaid beneficiaries back home, MFP states are facing ongoing challenges related to lack of safe, affordable, and accessible housing and difficulty coordinating multiple LTSS initiatives alongside MFP.  Many states are experiencing a period of transformation in their LTSS delivery systems as they take on new LTSS options and MLTSS at relatively the same time.  The current challenge is continued collaboration among the various initiatives and determining how MFP fits into and can be a part of these new programs.  Specifically, states reported working with CMS to better understand the challenges and issues associated with enrolling MFP participants in the new dual eligible demonstrations.  Additional challenges reported included reaching the targeted number of MFP participants and obtaining adequate staffing and provider recruitment to ensure that those who want to transition can do so in a timely manner, especially in rural areas.

Looking ahead, 2014 will be a transformative year for the Medicaid program, as millions of individuals become newly eligible for Medicaid, and states adjust to the new scope and volume of eligibility and enrollment changes related to the implementation of the ACA.  Payment and delivery system reforms as well as ongoing Medicaid cost containment will create opportunities and increased pressures on state Medicaid programs. Managing multiple competing demands will be a challenge for MFP program staff, especially those simultaneously involved in implementing BIP and other new ACA LTSS options.   The lessons learned from MFP will help states prioritize resources and build upon the existing rebalancing efforts and innovations started under MFP.  For example, states are leveraging MFP funds to support start-up costs required for BIP and building on outreach strategies established under MFP.  States will draw from lessons learned under MFP to improve the delivery and financing of Medicaid LTSS.  States repeatedly cited the importance of appropriate housing options in ensuring successful transitions.  Meanwhile, increased outreach by ADRCs and other local entities, training and supports for HCBS providers, flexible transition support benefits, and enhanced federal funding all contribute to the success of the MFP demonstration and in turn, helping thousands of Medicaid beneficiaries return home.

1. For more information see Molly O’Malley Watts et al., “Maryland’s Money Follows the Person Demonstration: Support Transitions Through Enhanced Services and Technology,” available at: https://modern.kff.org/medicaid/issue-brief/marylands-money-follows-the-person-demonstration-support-transitions-through-enhanced-services-and-technology/; “Tennessee’s Money Follows the Person Demonstration: Supporting Rebalancing in a Managed Long-Term Services and Supports Model,” available at: https://modern.kff.org/medicaid/issue-brief/tennessees-money-follows-the-person-demonstration-supporting-rebalancing-in-a-managed-long-term-services-and-supports-model/ and “Money Follows the Person Demonstration Program: Helping Medicaid Beneficiaries Move Back Home,” April 2014, available at: https://modern.kff.org/medicaid/issue-brief/money-follows-the-person-demonstration-program-helping-medicaid-beneficiaries-move-back-home/. ↩︎
2. Only six states reported per capita costs for the population with mental illness and therefore, the per capita cost listed might not be reflective of the overall target population group. ↩︎
3. Carol V. Irvin et al., “Money Follows the Person 2012 Annual Evaluation Report,” Mathematica Policy Research, October 15, 2013, available at: http://www.mathematica-mpr.com/publications/pdfs/health/MFP_2012_Annual.pdf. ↩︎
4. Additionally, in the summer of 2013, CMS announced a time-limited, competitive funding opportunity for existing MFP grantees called the MFP Tribal Initiative.  States can use the Tribal Initiative funds to develop state-administered community transition programs for institutionalized American Indians and Alaska Natives or to delegate program administration to a Tribe and also for program planning and implementation costs.  For more information, see http://www.medicaid.gov/State-Resource-Center/Downloads/MFP-FOA.pdf. ↩︎
5. Days that an individual resides in an institution for the sole purpose of receiving short-term rehabilitation under Medicare cannot count toward the 90-day residency period required for MFP eligibility. ↩︎
6. Molly O’Malley Watts, “Money Follows the Person: A 2012 Survey of Transitions, Services and Costs,” Kaiser Commission on Medicaid and the Uninsured, February 2013, available at: http://modern.kff.org/medicaid/issue-brief/money-follows-the-person-a-2012-survey-of-transitions-services-and-costs/. ↩︎
7. Susan Reinhard, “Money Follows the Person: Un-burning Bridges and Facilitating a Return to the Community,” 36 J. of the Am. Soc’y on Aging 52, 54 (2012), available at: http://www.asaging.org/blog/money-follows-person-un-burning-bridges-and-facilitating-return-community. ↩︎
8. At the time of the survey, Montana and South Dakota reported plans to be operational by January 2014.  As of March 2014, Montana and South Dakota are not yet fully operational. ↩︎
9. BIP is a new ACA LTSS option that provides financial incentives to states that implement certain structural reforms to increase access to community-based LTSS as an alternative to institutional care. ↩︎
10. Section 1915(i) provides a new Medicaid eligibility pathway due to the ACA amendment of the Deficit Reduction Act of 2005 (DRA); for more information, see http://www.hhs.gov/od/topics/community/iathcbssmd8-6-102.pdf. ↩︎
11. This enrollment projection was based on the original 30 states that received an MFP demonstration grant in 2007. ↩︎
12. Starting in 2011, CMS revised its policy to begin holding states accountable for meeting their transition goals. CMS can withhold the disbursement of MFP grant funds for those states falling far short of their transition goals. As a result, many states reduced their annual transition goals for 2010 and subsequent years. “Money Follows the Person Demonstration: Overview of State Grantee Progress,” July-December 2010,” Mathematica Policy Research, Inc., January 2011, available at: http://www.mathematica-mpr.com/publications/PDFs/health/MFP_jan-july2010_progress.pdf. ↩︎
13. The revised federal MDS assessment tool for NF residents, MDS 3.0, went into effect on October 1, 2010. Section Q of MDS 3.0 focuses on resident participation in assessment and goal setting, and is designed to identify the resident’s goals and expectations relating to where the individual lives and receives services. If a resident indicates that he or she desires to transition out of the NF to a community-based setting, the NF must initiate care planning and may make a referral to a local contact agency, which will respond by providing information to the resident about community–based services and supports. ↩︎
14. Carol V. Irvin et al., “Money Follows the Person 2012 Annual Evaluation Report,” Mathematica Policy Research, October 15, 2013, available at: http://www.mathematica-mpr.com/publications/pdfs/health/MFP_2012_Annual.pdf. ↩︎
15. Terence Ng et al., “Medicaid Home and Community-Based Service Programs: 2010 Data Update,” Kaiser Commission on Medicaid and the Uninsured, March 2014, available at: https://modern.kff.org/medicaid/report/medicaid-home-and-community-based-service-programs/. ↩︎
16. Only six of 26 states serving persons with mental illness reported per capita costs for this population and therefore, the per capita cost reported might not be reflective of costs a for this target population group across the MFP demonstration programs. ↩︎
17. Carol Irvin et al., “Money Follows the Person 2012 Annual Evaluation Report,” Mathematica Policy Research, October 15, 2013, available at: http://www.mathematica-mpr.com/publications/pdfs/health/MFP_2012_Annual.pdf%20. The report calculated per person HCBS expenditures based on MFP services files and program participation data files submitted by 25 grantee states through December 2012. Costs for MFP participants were approximately $3,625 per person per month ($2,298 per elderly; $3,060 per person with a physical disability; $7,797 per person with an I/DD, and $4,158 per person with a mental illness). ↩︎
18. Carol Irvin et al., “Money Follows the Person 2012 Annual Evaluation Report,” Mathematica Policy Research, October 15, 2013, available at: http://www.mathematica-mpr.com/publications/pdfs/health/MFP_2012_Annual.pdf%20. ↩︎
19. Molly O’Malley Watts, MaryBeth Musumeci, and Erica L. Reaves, “How is the Affordable Care Act Leading to Changes in Medicaid Long-Term Services and Supports (LTSS) Today? State Adoption of Six LTSS Options,” Kaiser Commission on Medicaid and the Uninsured, April 2013, available at:http://modern.kff.org/medicaid/issue-brief/how-is-the-affordable-care-act-leading-to-changes-in-medicaid-long-term-services-and-supports-ltss-today-state-adoption-of-six-ltss-options/; updates available at: https://modern.kff.org/state-category/health-reform/. ↩︎
20. Ohio is one of nine states (CA, IL, MA, MI, NY, OH, SC, VA, and WA) testing a capitated model in which managed care plans will provide and coordinate Medicare and Medicaid acute, physical health, behavioral health, pharmacy, and long-term services and supports (LTSS). For many dual eligible beneficiaries, the financial alignment demonstrations will be the first time that LTSS will be coordinated with other health care services. For more information, see MaryBeth Musumeci, “Long-Term Services and Supports in the FinancialAlignment Demonstrations for Dual Eligible Beneficiaries,” Kaiser Commission on Medicaid and the Uninsured, November 2013, available at: http://modern.kff.org/medicaid/issue-brief/long-term-services-and-supports-in-the-financial-alignment-demonstrations-for-dual-eligible-beneficiaries/. ↩︎

Money Follows the Person (MFP) is a federal Medicaid demonstration designed to incentivize states to shift Medicaid long-term care spending from institutional to home and community-based services.  MFP was authorized in the Deficit Reduction Act of 2005 and then extended in the Affordable Care Act through 2016.  Under the demonstration, participating states receive 365 days of enhanced federal funding for qualified services for every Medicaid beneficiary who transitions from an institution to a community-based setting.  Currently, 45 states have received federal MFP demonstration funding.  A companion report, Money Follows the Person: A 2013 State Survey of Transitions, Services, and Costs, summarizes 2013 survey data on enrollment trends, services, and per capita spending and describes the interactions between MFP and new and expanded options under the Affordable Care Act as well as managed care. Two state case studies – Maryland’s Money Follows the Person Demonstration: Supporting Transitions Through Enhanced Services and Technology and Tennessee’s Money Follows the Person Demonstration: Supporting Rebalancing in a Managed Long-Term Services and Supports Model – provide insight into how MFP was incorporated into existing infrastructure and also how MFP supports larger rebalancing initiatives.

Based on personal interviews conducted in August 2013, the profiles of four MFP participants residing in Maryland or Tennessee are presented here to highlight the diverse experiences of persons with LTSS needs who transition from nursing homes to the community. Each of these individuals is dually eligible for Medicaid and Medicare services. Such personal stories add a human dimension to the ongoing conversations among federal and state policymakers about supported transition, community integration, and expanding access to Medicaid home and community-based services.

MFP Helps Dually Eligible Beneficiary With A Physical Disability Move Home And Return To Work

Chuck, Age 60, District Heights, Maryland

Chuck spent many years caring for his sick wife and neglecting his own health problems.  When he finally sought a doctor’s opinion for his chronic back pain, the diagnosis was a disc problem, likely a result of many years working as a motor vehicle driver.  After losing his wife to lung cancer, Chuck decided to trade in his wheels for a job as a group home manager, working and living with adults with intellectual and developmental disabilities.  One morning in February 2009, as Maryland was being hit by a heavy snowstorm, Chuck noticed food was low in the group home and went out to the grocery store to restock supplies.  On his way home, he slipped on ice and ruptured several discs in his back.  Several months later, Chuck had surgery to repair his back; during his recovery he developed a blood clot and lost movement from the waist down.  Following a second surgery to remove the blood clot, he was admitted to a nursing home where he lived for three years.

Describing life in the nursing home, Chuck shared, “[it was] no place for me, but I had no place to go.”  Chuck made the best of his time in the nursing home, becoming mobile again with the assistance of a walker and serving as the President of the Residents’ Council and unofficial Chaplain, but still his hope was to return to the community.  Chuck qualified for Medicaid shortly after his admittance to the nursing home and subsequently enrolled in Medicare.  Having met the nursing home length of stay eligibility criteria, Chuck had the option to move to a community-based setting through the Medicaid MFP demonstration.

Chuck described his transition to the community as easy because he had a relative willing to take him in.  Currently, he spends his days working from home as a telemarketer.  He wants to have his own place and has been on a housing waiting list for a few years.  Chuck stressed the need to increase affordable, accessible community-based housing options for people with physical disabilities and articulated that, “Without some place to go, the money won’t follow the person.”In April 2013, Chuck left the nursing home and moved in with his brother and family.  As an MFP participant, Chuck obtained a chair lift, a wheelchair, a hospital bed, shower chair, and a one-time allocation of $700 to purchase household goods.  He relies on the help of a personal care attendant eight hours a day, seven days a week and receives in-home therapy.  Chuck takes six prescription drugs daily for pain, muscle spasms, and high blood pressure.  He explained, “If I didn’t have Medicaid [and had to pay for care out-of-pocket], I would be in a lot of trouble … the cost of all these services would be through the roof!”

Chuck’s personal goals are to get out into his community more frequently without the assistance of his family or personal care aide.  He described himself as a prisoner in the house from the time his aide leaves at noon until he has help again in the evening.  He has authorization for a motorized wheelchair but is waiting for the home ramp to be installed.  Despite some frustration, Chuck shared, “I am 60 and still active … Medicaid’s been very instrumental to me.”

MFP Helps Dually Eligible Beneficiary Overcome Amputation Challenges And Return To Independent Living

Vera, Age 76, Nashville, Tennessee

Vera was able to locate and secure a first floor apartment that was both physically accessible and affordable on her limited Social Security income.  Vera receives six hours of personal care services every day, except on weekends when her family comes to help her.  She is very independent and chooses to bathe and cook for herself.  She relies on five prescription drugs a day, including insulin to manage her diabetes.  She takes the bus to doctor appointments and twice weekly physical therapy sessions.  Vera explained, “It’s easy to get around with my [wheel]chair now that I am in a lower level apartment” and said that there are no real challenges to living independently at home.  Vera shared that the best part about living on her own in the community is that “nobody is waking me up all through the night, and now I can go outside and talk to my neighbors again.”Vera suffers from peripheral vascular disease and diabetes.  Complications from both conditions resulted in a leg amputation when an infection spread throughout her lower limb.  Following the surgery and hospitalization, Vera needed 24-hour care and moved into a nursing home.  Given her physical limitations, staying in her third floor walk-up apartment was not an option. Life in the nursing home “wasn’t like being at home,” according to this mother of seven and former hotel housekeeper.  While her family visited her often in the nursing home, Vera passed the majority of her time in the nursing home “just waiting to go home.”  Vera qualified for Medicaid during her nursing home stay and within eight months moved back to the community as a participant in the Medicaid MFP demonstration.

MFP Helps Dually Eligible Beneficiary Return Home After An Accidental Fall And Subsequent Surgeries

Kathy, Age 61, Middle River, Maryland

Kathy worked all her life in retail where she enjoyed meeting new people each day.  One morning in 2008, while getting ready for work, Kathy fell down a set of stairs and fractured every bone in one of her ankles.  The accident required ankle fusion surgery and a six-week hospital stay followed by nursing home placement.  After her surgery and rehabilitation, returning home was not an option.  Kathy lost her rental apartment because she was unable to work and pay her bills.  Kathy described her one-year stay in the nursing home as “very unpleasant.” During that time, her health spiraled downhill.  She experienced several mild heart attacks, had five stents put in, and required two follow-up ankle surgeries.  In addition, Kathy was diagnosed with type II diabetes, diabetic retinopathy, and hypertension.

With no income and limited savings, Kathy qualified for Medicaid. Subsequently she qualified for Medicare and Social Security Disability Insurance based on her work history and disability status.  A nursing home social worker helped Kathy sign up for Medicaid and informed her about the Medicaid MFP program.  Wanting to transition out of the nursing home and return to the community, Kathy applied for MFP and federal Section 8 housing assistance.  Kathy commented, “I don’t think I would have survived in the nursing home; Section 8 and Medicaid are my lifelines.”

Kathy credited the MFP program with “taking care of everything” from setting up her needs assessment (she qualified for 40 hours of personal care services a week) to helping her pay outstanding gas and electric bills from the $700 allowance for one-time transition-related expenses.  She described her experience of returning to the community as an MFP participant as “a rebirth” and shared, “I regained my freedom after leaving the nursing home. I don’t feel like a nobody anymore.”

Kathy’s health remains “fair.”  She relies on 20 medications a day to manage multiple chronic health conditions.  She is usually able to get around with the assistance of a cane or walker and uses a wheelchair only as needed.  She uses transportation services to get to doctor visits as well as a Medicaid-paid medical alert service.  Her personal goals are to find part-time work or to volunteer. 

MFP Helps Dually Eligible Beneficiary With Multiple Chronic Conditions Return Home To His Family

Martin, Age 58, Shelbyville, Tennessee

Martin, 58, a former small machine repairman and welder, remembers waking up one night with the feeling that, as he described, “half of me was gone.” Martin had experienced a stroke that resulted in partial left side paralysis.  Hospitalized after his stroke, Martin later ended up in a nursing home, unable to walk or talk.  Martin has a multitude of chronic conditions including diabetes, hypertension, heart disease, and arthritic knees.  Although he received “good care” in the nursing home, Martin described his year there as “terrible.”  During that time, his son was killed in a car accident and his sister passed away.  He recalled, “Everything hit me just right there, just like that.”  Determined to return home and regain his strength, Martin worked hard at maintaining his physical therapy regime.  He noted, “I was right there [the physical therapy center in the nursing home] when it opened every day.”  All his hard work paid off when, in June 2013, Martin was able to return to the community with the help of the MFP program.  As a result of his disability, Martin is dually eligible for Medicare and Medicaid and receives Social Security Disability Insurance benefits based on his work history and disability status.

Martin was fortunate to be able to move into his 83-year old father’s home.  He still has some difficulty speaking, and the numbness on his left side prevents him from writing.  Martin receives therapy three times a week in his home and daily personal care services in the morning and the evening.  He takes seven prescription drugs a day, including insulin for his diabetes, and he relies on a wheelchair to get around.  Through the MFP program, Martin had rails installed in his shower.  Martin acknowledged that, if not for Medicaid, the costs of these services and supports would exceed what he can afford to contribute out-of-pocket to his care.  Martin said the best parts about being home are “being close to my father and my kinfolk and having my freedom.”  His daily challenges involve not being able to reach things around the house.  Martin hopes to walk again, but in the meantime, he would like to leave the house more often and return to his favorite hobbies of fishing, checkers, and tinkering in the garage.