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Medicaid Buy-In Workgroup Report
Final: 12/3/02
Workgroup Members
| Ms. Sue Babin |
Admin. Office of Quality Assurance & Special Projects, MHRH |
| Mr. Mike Braet |
Manager of Rehabilitation Service, Comm. Counseling Center |
| Mr. Leo Canuel |
Executive Director, PARI |
| Mr. Bob Cooper |
Sherlock Center |
| Mr. Jon Dupree |
Mental Health Consumer Advocate |
| Ms. Carol Ferraioli |
State Rehabilitation Council |
| Ms. Elaina Goldstein |
Interim Director, URI Center for Public Policy |
| Ms. Dianne Kayala |
Chief of Family Health Systems |
| Mr. John Martinelli |
Consumer |
| Ms. June McLain |
Research Associate III, URI Center for Public Policy |
| Mr. Thomas J. Rossi |
President T.J. Rossi Associates |
| Ms. Nancy M. Slater |
People's Advocacy Council Chair
|
Goals
To develop and get enacted into law, a Medicaid Buy-In for people with disabilities that will de-link Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) payments from health benefits in order that individuals will be able to return to competitive employment and at the same time be covered with affordable health insurance. A second goal is to develop a program that will prevent and /or delay both employed individuals who become disabled and disabled youth in transition from having to go onto the public programs in the first place.
Furthermore, we will need to measure whether the enactment of a Medicaid Buy-In is successful. This will be accomplished by developing overall program outcome indicators that measure long-term individual success. In addition, quality and system performance indicators and performance measures will be developed. They will monitor success at both a systems level and services provided at an individual level.
Background
The main purpose for developing a Medicaid Buy-In is to enable people with disabilities to live a productive life of dignity. The key element for any person to live a productive independent life is being able to work in good paying jobs that provide health benefits.
In our current system, the means by which someone becomes eligible for SSI and SSDI is to prove that they are permanently disabled and not working. This process can take up to two years to complete and by that time the individual, his/her family, and some health care and social service providers believe that working again may not be an option. Experience from the workers compensation system has proven that the longer a person remains out of work the more difficult it becomes to re-enter the workforce. Unfortunately, the current disability system has a permanent disability mentality. Rather than promote independence, the current system creates economic disincentives that make going to work an irrational choice for people who have become part of the Social Security disability program. Dependence is made possible because eligibility for necessary support services is based on a person having very low or no income.
For many people, returning to work could mean a substantial loss of health insurance, personal care assistants, housing, transportation services, food stamps, mental health and other critical life support services. The greatest fear for many individuals in Rhode Island is the loss of health and support services they receive from the Medicaid program. For many individuals, being on Medicaid has become a life necessity with recovery and return to full employment being thwarted by the fear of losing benefits, specifically, prescription drugs and personal care assistants.
Real System Change - The Paradigm Shift
In order for real system change to take place, a paradigm shift is necessary regarding how society views disability. Within the new paradigm, the emphasis in policy initiatives is placed on the following qualities:
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Maximized independence where economic self-sufficiency and gainful employment are key attributes.
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Maximized health and wellness per the World Health Organization's definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
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Equal opportunity, not separate opportunity
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Elimination of disability stereotypes.
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A secure safety net (not a hammock or a spider web).
Changing attitudes about disability and work must take place at every level in the service delivery system, but must begin with key decision makers. Government should adopt the role of "facilitator" rather than "caretaker". This means that adults with disabilities must be viewed as workers rather than beneficiaries, and an untapped resource rather than an unsolved problem. New programs should recognize that the old culture is one of dependency and paternalism and the new culture must facilitate and support returning to work. Individuals who are newly disabled and capable of re-entering the labor market should be fully supported in return to work efforts. The Social Security disability system needs to move away from a disability determination process and look more like the Workers Compensation return to work system. Today's disability system must move from a permanent disability mentality to a temporary disability mentality. This will entail revising the definition of disability so that the disability determination process is de-linked from assessing the ability to work. Additionally, new programs need to support employers so that they will have ways to support their valued workers who become disabled.
The education system plays a key role in changing the attitudes and expectations of young adults with disabilities. Gainful employment and career planning becomes the goal, as opposed to make-work jobs. This entails setting career goals early in the education process so that appropriate training is available and accessed.
Full Engagement of Employers and Service Providers
From an employer's perspective, there is a need for workers who are qualified to perform jobs they have to fill. Business concerns that need to be addressed are funding for training, the cost of reasonable accommodations, and assurance that the cost of employee health benefits will not become prohibitive if they add workers with disabilities to their plans. Educated employers will appreciate the productivity of workers with disabilities, understand the real cost of accommodations, and know the resources to provide clear and consistent responses to disability specific issues. A Medicaid Buy-In that integrates with employer health benefits will address the health benefit expense concern.
The new system must ensure that resources needed for service providers to support consumers are available. These include sufficient staff levels and a mechanism for accurate information dissemination. The support system needs to include public and private champions, especially among the business community. Employer leadership networks should be supported, encouraged and developed.
Summary of Meetings
The Workgroup held seven monthly meetings between March of 2002 through September of 2002. Elaina Goldstein, Executive Director for the Medicaid Infrastructure Grant, provided staffing for the Workgroup. Enclosed is a summary of each Medicaid Buy-In meeting. (See attachment A).
Methodology Taken in Developing Recommendations
Through the series of meetings held over the past six months, which entailed reviewing the current system and an in-depth analysis of the various design features of Medicaid Buy-In programs across the country, the Workgroup acknowledges the overall dysfunction of the current system of employment of people with disabilities in Rhode Island and realizes that changing this system is an ongoing process that is expected to take many years. At the same time the Workgroup realizes that changing attitudes of all stake-holders, which includes various people who help individuals prepare for competitive employment, people who want to work, and employers who hire people with disabilities is expected to take time.
The development of a well thought out long-term plan involving commitment from the highest levels of government, at both the State and Federal level, and commitment from the business community is needed in order to change attitudes of individuals with disabilities, their families, providers of services and citizens across the State.
The current fiscal crisis in the State was also a major factor that the Workgroup considered in developing short and long-term priorities for implementing a Medicaid Buy-In. By consensus, the Workgroup determined that an incremental approach that would both target individuals most likely to benefit from a Buy-In and, at the same time, either reduce State expenditures and/or not raise them significantly, was the most prudent place to start a Buy-In program.
Strategies were developed for working with the General Assembly, consumers with various disabilities and the new Administration, to pass enabling legislation in this upcoming session. Longer-term strategies to work with various stakeholders and collaboration with multiple State and Federal agencies were also developed.
Recommendations
The rating scheme that was used for prioritization was an incremental approach to implementing a Medicaid Buy-In. The Workgroup wanted to set realistic achievable goals over a five-year implementation period and have developed the recommendations accordingly. The Workgroup has organized its recommendations into major system changes with recommended indicators of success. The Workgroup begins with the immediate short-term goals and progresses into the longer-range recommendations.
I. Shift From A Welfare-Entitlement System To A Safety Net Support System:
A. Medicaid Buy-In Legislation Passage In The 2003 General Assembly
Criteria For The Buy-In
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Foster Economic Independence
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Reform Income And Asset Limits Associated With Most Employment-Related Supports, E.G. Subsidized Housing, Food Stamps, Subsidized Transportation, Access To Health Care Coverage And Support Services.
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Allow Consumers To Save And Invest Earned Income In The Same Ways That The General Population Does.
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Allow For Consumers To Save For Periods In Which They Are Unable To Work And Not Have To Spend Down Their Savings Into Poverty To Be Eligible For Health Care And Other Supportive Services Necessary To Return To Work.
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Change The Perception That Medicaid Is Only For The Poor But Rather That It Is A Health Insurance Program For Individuals Who Do Not Get Coverage In The Work Place Because Of Pre-Existing Health Conditions Or Employer Limitations For Coverage.
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Competitive Employment Should Become The Primary Goal Of All Supportive Services For Working Age Adults With Disabilities (E.G. Community Mental Health Programs, Sheltered Workshops, Etc.).
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Incorporate Accrued Personal And Societal Benefits Into Budget Analysis Of Support Programs, Not Just The Cost Of The Program.
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Establish A True Safety Net Of Health Coverage, Cash Payments, And Employment-Related Supportive Services
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The Safety Net Of Support Must Be Flexible And Allowed To Grow And Contract In Relation To Consumer Needs.
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Structure Medicaid As An Insurance Product Rather Than A Welfare Program.
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Medicaid Insurance Should Provide Health-Related Benefits Needed To Support Work Transportation And Personal Assistance In The Workplace.
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Continue To Address Timely And Adequate Payments To Health Care Providers So That More Providers Will Accept Medicaid Patients.
Recommendations
The passage of the Medicaid Buy-In will take a targeted effort over the next six months. A consultant will be retained to educate key members of the House and Senate on the issues surrounding a Medicaid Buy-In here in Rhode Island. This consultant will work with grant staff in developing a short paper highlighting the barriers people with disabilities face in obtaining employment and becoming competitively employed. The issue is one of human dignity and independence. The national number of unemployed people with disabilities is approximately 70%, and this is unacceptable in Rhode Island.
Significant outreach to the business community and disability communities has already begun by the Co-chairmen of the Workgroup. The Governor's Commission on Disabilities has also agreed to become actively involved in getting legislative support for this initiative.
In addition, a budget article template will be developed with technical assistance by the Department of Human Services to address the cost of this program in the short run. Over a five-year period the expectation is to help .5% of the current number of people on SSDI get back to competitive employment. This estimate is approximately 120 people. The first round of outreach will be to individuals currently on the State-only Personal Care Assistance (PCA) program and for people currently on home and community based waivers who have limited their income for fear of losing Medicaid. This number is approximately 70 individuals. Further offsets to the cost for the state will be premiums paid by the individuals who participate in the Buy-In and tax revenue generated by the working individual.
The deliverables for the consultant will include education and advocacy, introduction of legislation in the Rhode Island General Assembly, hearings, and movement to the floor. In addition, any Federal changes that have been deemed necessary such as a definition of employment will be discussed with the Rhode Island Congressional delegation.
Target Populations
The Workgroup has identified four major groups that a Buy-In should target. The first two are people who have been determined disabled and are on public programs. The second two are what the Workgroup is calling "early intervention-prevention groups"- individuals who have not been determined disabled by the public programs. Each group might need a different benefits package and wrap- around program depending on a future benefits-need study conducted for each target group.
1. People Currently on SSDI/SSI
This group is easiest to target since we know who they are, and they are likely the most difficult to get back to work since they have been out of work, in most cases, over two years. Federal SSA and Congressional expectations are that 1% of the total people currently on SSDI will be able to return to work. In Rhode Island that total is approximately 240 individuals. Many of these individuals are dual eligible, they have both Medicare and Medicaid coverage.
It is recommended that the Medicaid Buy-In program targets people who are currently in the public disability system as well as people who are newly disabled and not yet on the disability roles. Taking budget considerations into account the Committee recommends an incremental phase- in over five years.
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First year legislation will target individuals currently in another Medicaid eligibility category who are also on Medicare. These individuals are dually eligible beneficiaries, and limit their income because of the fear of losing all benefits. Many of these people are in a category called Medically Needy. They must show that they have expended a certain amount of money for their health care before they are eligible for Medicaid. These people remain eligible for a maximum of six months and then must reapply for Medicaid.
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Second year legislation would target the people who are just applying for SSDI (and therefore not eligible for Medicare for at least two years) and are also in the MART Medicaid eligibility status. Significant savings in the current program could be obtained if these individuals are re-employed because their premiums would offset cost to the State and employment would limit their involvement in and dependence on the public programs.
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In year three, people who applied for the Medically Needy eligibility category but did not meet the required contribution would be targeted. These individuals have higher earning potential documented by the SSDI income they receive. An additional 200 participants are expected in this category. In year three we hope to be able to include a definition of employment for this eligibility category that is approved by Congress. Once the definition is approved we would require people to work at least ten hours per week. For those people who are eligible for employer-based coverage we would have a system designed for employer contributions to the program.
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Fourth year legislation would target individuals who are on SSDI and not working or who are only working a limited amount of hours per week but not eligible for Medicaid currently. The expectation of the program is to get 1% (approximately 240) of those on SSDI back to work by year five of the phase in.
2. Individuals Determined Disabled Through the Medical Assistance Review Team (MART) System
Disability determination is much quicker than SSA, but many of the individuals have little or no prior work history and have been on the system for longer than two years. Again this group is easy to target but may be difficult to place in employment. Nevertheless, if employment success is attained, the return on investment for the State, as well as the individual, may be significant. In addition, individuals who are concurrently applying for SSDI are also in this program.
The Workgroup strongly recommends emulating the New Mexico Buy-In program that targets this population. Savings to the State could be significant if these people become employed since they are on Medicaid only and any premium collected would be an offset of the cost of the program.
An evaluation of individuals who applied for Medicaid through the MART system but who were not found disabled is currently being conducted. The information may be useful in determining the needs of these individuals for services as well as employment.
3. People Who Have recently become Disabled or Are in the Beginning stages of Applying for SSDI
There is a need to work with SSA to identify these people. An evaluation of their needs will be performed to determine services required including, but not limited to, vocational rehabilitation, job training, and health and personal care assistance. In addition, forums and focus groups with employers and health care providers could also help identify these individuals. Staff of the Work on the Rhodes to Independence grant will jointly develop employer forums with Medicaid Infrastructure grant staff. An added benefit of such forums may be attitudinal change.
A new workgroup of employers and health insurance carriers is recommended. The charge of this workgroup would be to address the integration of private employer health benefits with the public programs and to develop a systematic means by which employers can help employees continue working if they become disabled. If successful, the cost to the Medicaid program would be offset by private funding and the cost of employers individual benefit programs would not increase. In addition, the cost to the Social Security program would also be reduced.
4. Young Adults with Disabilities Who Are Ready to Enter the Workforce
A collaboration with the School–to-Career efforts at the Departments of Education and Health is necessary to see what type of Buy-In would be most helpful for this target group.
A new workgroup of individuals from the Departments of Education, Health, and Human Services is recommended to determine the ways in which a Medicaid Buy-in can facilitate young adults transitioning to work.
B. Produce Twelve Monthly Able-Too Shows Highlighting Successful People with disabilities Who Are Working and Working and Their Employers
The Workgroup has determined that it will be critical that a public relations and/or marketing campaign be developed to change the attitudes of people with disabilities, their families and providers. The key issue is to assure people that by returning to work they will not lose important life support services.
To address this recommendation in the short term, grant money has been earmarked for the Commission's cable TV show ABLE –TOO to produce one show a month, for the next year, that highlights employed people with disabilities and their employers. A collaborative effort with MHRH and DHS is expected in this project. We see this as a positive first step in a long-term process of attitudinal changes.
C. Education Effort on Medicaid Buy-In Approaches to Broad Audience
The grant has appropriated money to be a co-sponsor of the Paul V. Sherlock Center on Disabilities Partnership to Employment Conference. In addition, grant staff has structured a Medicaid Buy-In session under the Systems Change Track of the conference. The session will bring people from the grant's Technical Assistance Center who will highlight how other states across the country have designed their Buy-Ins and how they are operating these new programs in difficult budget times. Workgroup members, Tom Rossi and Leo Canuel, will discuss what the Workgroup has accomplished and what still needs to be done. The Conference is scheduled for October 21, 2002.
In the longer term, the Workgroup recommends retaining a public relations and/or a marketing firm to develop a message and materials, on the Medicaid Buy-In program, and all supports, federal, state, or private that are available to help people become competitively employed
II. Support Systems Need to be Fully Integrated and Provide Accurate, Consistent and Timely Information Broadly Disseminated and Fully Accessible
Criteria for the Information System
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Comprehensive, Adaptable, Consistent, Integrated System
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Collaboration Among And Between Agencies, Employers, And Consumers And Their Families
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Cooperation Between Government Agencies, Employers And The Community
A. Develop an Information System that Accurately Tracks and Monitors People Looking and Working in Gainful Employment
The Data Workgroup, consisting of individuals from various Departments who facilitate employing people with disabilities has been meeting to ensure that a system is in place that will measure the impact and outcomes of the Medicaid Buy-In program and outreach efforts. The Federal grantor, the Center for Medicare and Medicaid Services (CMS), is requiring that certain core indicators be tracked and monitored. The Workgroup is in the process of costing out this effort. In addition, grant staff is surveying states around the country, which have had to submit this data this year, as to their incurred costs. Contractors and grant staff will conduct basic research on the costs of services used by enrollees, utilization, and trends over time.
The Data Workgroup has identified specific indicators to track that include, but are not limited to, the following:
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School-to-work transition programs in secondary school systems that track rates of post-secondary education admissions by school district, rates of competitive employment among young adults with disabilities after graduation, and other indicators of community participation and integration.
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Referral to vocational programs post-high school graduation is monitored by school districts.
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Reduction in the number of agencies that a typical individual with a disability must deal with in order to secure health care, housing, transportation, health, and employment-related services. This monitoring could be done on a yearly basis and should be targeted at individuals with physical (including sensory), cognitive (including acquired brain injury), and psychiatric disabilities. Query: Do the various "doors" to entry provide consistent and clear information about consumers' choices for employment supports?
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Consumer evaluation of the quality, clarity, and usefulness of the information they receive from governmental and private agencies.
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Analysis of health care utilization of Buy-In group (working people with disabilities) relative to SSI categorical group of non-working adults with disabilities.
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Indicators of earnings other than increased earnings during first year in program, e.g., shifts from SSI eligibility category with no earnings to some earnings in buy-in; changes in use of work incentives (1619 and PASS); demonstrate the connection between stable housing and work (individual case studies).
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Program Outcome Indicators:
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Securing jobs with competitive earnings.
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Changes in earnings over time (+/-).
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Length of time on a job.
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Changes in health care utilization and costs over time (by type of service).
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Systems Level Performance Monitoring:
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Analysis of the extent to which consumers earn under the Substantial Gainful Employment level of income.
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Monitoring physical accessibility of support services and employment opportunities.
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Monitoring changes in types of employment opportunities people with disabilities have (sector, job classifications, etc.).
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Documenting the extent of under-employment among individual with disabilities.
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Service Provision Performance Monitoring:
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Tracking the time it takes for an individual to become employed.
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Tracking the number of people accessing the Buy-In.
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Monitoring how quickly individuals can regain Social Security cash
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Monitoring the number of people in a given program that are interviewed, hired, retained and/or promoted.
B. Develop a State-wide Collaborative Long-Term Plan for Employing People with Disabilities
Currently there is a multitude of public and private agencies involved with helping people with disabilities become employed. The Human Resources Investment Council, (HRIC) which is charged with being the central repository for all employment policy within the State, could take the lead in establishing the collaborative.
It is recommended to model this collaborative after the Children's Cabinet, which has been successful at dealing with children's issues across multiple agencies jurisdiction.
C. Develop a Web-Based Information and Referral System
Ideally, this would be possible in the short run. Unfortunately, the cost could be prohibitive in the current fiscal environment.
It is recommended to work with the Long-term Care reform effort, which is tasked to recommend a new information system in the next session of the General Assembly.
Budget Implications/ROI to State
After December 1, 2002, staff of the grant will be working with the Budget Office at DHS to develop a budget article for the first phase of the Medicaid Buy-In and a schedule for a five-year full implementation plan.
By implementing a Buy-In, the program will have significant financial and humanistic savings in the long term. To make these significant changes costs will most likely increase in the short term. By phasing in the program, we intend to minimize costs as long as the budget crisis exists. It is important to keep in mind that costs and benefits accruing to the State for all public programs need to be included in any cost-benefit analysis that is prepared. For instance, reductions in food stamps, housing benefits, and cash payments, as well as, increases in tax revenue may offset increased Medicaid costs.
Attachment A - Meeting Summaries
