Changes underway for determining in-home Medicaid services

New assessment system expected to start in January along with KanCare

2 | Agencies, Health Care Delivery, Medicaid-CHIP

Mary Barker, a case manager with the Jayhawk Area Agency on Aging, reassesses the needs of Vivian Glessner, a 91-year-old resident at Briarcliff Care Center in Topeka. Barker meets with Glessner every 11 months to make sure she’s receiving the appropriate level of Medicaid-funded services. An association representing the state’s area agencies on aging has bid on a contract that would have case managers for the frail elderly also assess the needs of people who are physically disabled or have traumatic brain injuries.

Mary Barker, a case manager with the Jayhawk Area Agency on Aging, reassesses the needs of Vivian Glessner, a 91-year-old resident at Briarcliff Care Center in Topeka. Barker meets with Glessner every 11 months to make sure she’s receiving the appropriate level of Medicaid-funded services. An association representing the state’s area agencies on aging has bid on a contract that would have case managers for the frail elderly also assess the needs of people who are physically disabled or have traumatic brain injuries.

— State officials are changing the way they determine which in-home Medicaid services are provided to the frail elderly and people who are physically disabled.

The new system will rely on a single agency or organization with a presence in each of the state’s 105 counties to assess what services a person will receive. Currently, there are more than 30 organizations involved with the process. Some assess only the elderly. Others focus solely on the physically disabled.

State officials said their aim is to create a “one-stop shop,” so that services will be determined in the same place regardless of a person’s condition.

'Mishmash'

“The system we have now is a real mishmash,” said Shawn Sullivan, secretary of the Kansas Department for Aging and Disability Services. “We’ll be going to one that takes more of a no-wrong-door, single-entry approach and implements a conflict-free provision of services.”

About 12,000 Kansans currently rely on the services provided by the system, at an annual cost to taxpayers of about $200 million.

A solicitation to potential contractors interested in managing the new system was put out in February. Bids were due April 3.

Sullivan said he hoped to have the contract awarded sometime next month so that a single, statewide Aging and Disability Resource Center (ADRC) will be up and running by Jan. 1, which also is the scheduled start of KanCare, Gov. Sam Brownback’s plan for letting managed care companies administer the state’s $2.9 billion Medicaid program. KanCare remains contingent upon federal approvals.

The resource center, according to Sullivan, would be in charge of measuring the needs of an elderly, physically disabled or brain-injured person. It also would do preliminary screening for Medicaid eligibility and help the person choose the managed care company best suited to meet the person’s needs.

Today, the assessments are handled by 11 area agencies on aging, 10 centers for independent living and about a dozen home health agencies that specialize in caring for the brain-injured.

“When you have this many systems in place, it can be confusing as to who to turn to for assistance,” Sullivan said. “With the ADRC, we’ll be going to one database, one information source and one hotline for people to call.”

Federal initiative

The change, he said, was driven by a federal initiative aimed at increasing efforts to help Medicaid beneficiaries live in community settings rather than nursing homes and a concern among state officials that not enough was being done to prevent the centers for independent living from inflating their assessments in ways that generated more work — and therefore more revenue — for their case management and home-health programs.

Currently, the centers are allowed to assess a physically disabled person’s needs, serve as the case manager and provide the services.

“When we did our KanCare public forums last year, we had a lot of (Medicaid) providers say we should look at separating the services — that it might be OK for someone to do the assessment and the case management, but it wasn’t OK to have someone doing case management and direct care,” Sullivan said. “Part of the ADRC is in response to that.”

The concern about potential conficts of interest has centered on the centers for independent living.

The area aging agencies assess the needs of the frail elderly and often serve as case managers, but unlike the centers for independent living, none of them provide in-home care. Instead, the frail elderly receive services from individuals hired by the seniors or employed by home health agencies.

“Objectivity has always been one of our core values,” said Julie Govert Walter, who runs the 18-county North Central-Flint Hills Area Agency on Aging in Manhattan. “We’re not getting paid to provide a service in somebody’s home, so there’s no incentive to say they need a whole bunch of services they may not really need.”

In Kansas, Medicaid provides home and community-based services for about 5,400 frail elders, 6,100 people with physical disabilities and 400 people with brain injuries. The new system will not apply to people with developmental disabilities who receive in-home Medicaid services. Their needs will continue to be assessed by one of the state’s 28 Community Developmental Disability Organizations.

Case management

Sullivan said that after Jan. 1, the ADRC assessments would be forwarded to the managed care companies, which then would take on the case management responsibilities.

The companies, he said, would have the option of subcontracting with other case management organizations. For example, the companies could subcontract with a center for independent living for case management or direct-care services.

Some details still are being worked out.

“We’re in the process — over the next couple weeks — of finalizing the details for the managed care plans,” Sullivan said. “That’s not been decided yet.”

But it’s clear, he said, that a subcontractor won’t be allowed to provide case management and in-home services for the same individual.

“You can provide both services,” Sullivan said, “but not for the same person.”

The three managed care companies with KanCare contracts are Amerigroup, UnitedHealthcare and Sunflower State Health Plan, a subsidiary of Centene.

Whether the managed care companies will be willing to use third-party case managers remains to be seen.

“That’s one of the things we don’t know,” said Shari Coatney, executive director at Southeast Kansas Independent Living, which is based in Parsons and serves eight counties. “They could subcontract some of it out or they could do it all themselves.”

Sullivan declined to say which or how many organizations have bid on the ADRC contract, noting that negotiations were ongoing. He also would not say how much the department plans to spend on the ADRC services.

Typically, bidders and state officials decline public comment about proposals while they are in negotiation.

Janis DeBoer, executive director of the Kansas Area Agencies on Aging Association (K4A), confirmed that her organization had bid on the contract. But she declined further comment about it.

K4A represents the 11 area agencies on aging in Kansas, covering all 105 counties.

MCO role remains unclear

Coatney, who also is president of the Statewide Independent Living Council of Kansas board of directors, said the centers did not bid on the contract. Instead, she said, they signed letters of support for K4A.

“We don’t know how all this is going to play out,” Coatney said. “But we’ve always had good relations with the folks on the aging side, so we’re excited for them and we look forward to working with them.”

Coatney said most people involved in services for the state’s frail elderly and physically disabled think K4A was the sole bidder for the contract.

Ami Hyten, assistant director with the Topeka Independent Living Resource Center, said she doubted the managed care companies, also known as MCOs, would be interested in subcontracting their case management services.

“The purpose of managed care is to identify and contain costs, and to the extent that case managers set up plans of care and utilization — I wouldn’t expect the MCOs to abrogate that,” Hyten said. “They haven’t in other states.”

Spokespersons for the managed care companies declined comment, instead referring questions to officials at the Kansas Department of Health and Environment, the agency that oversees Medicaid finance.

“Case management is the responsibility of the (managed care) plans, either directly or indirectly. We are working with the plans on how that will be operationalized,” said Kari Bruffett, the agency’s director of health care finance.



The KHI News Service is an editorially independent initiative of the Kansas Health Institute. It is supported in part by a variety of underwriters. The News Service is committed to timely, objective and in-depth coverage of health issues and the policy-making environment. All News Service stories and photos may be republished at no cost with proper attribution, including a link back to KHI.org when a story is reposted online. An automatically updated feed of headlines and more from KHI can be included on your website using the KHI widget. More about the News Service at khi.org/newsservice or contact us at (785) 233-5443.



Comments

cespinoza (C Espinoza)August 14, 2012 at 1:30 p.m.

I would like to clarify a statement made by Sullivan. “The change, he said, was driven by a federal initiative aimed at increasing efforts to help Medicaid beneficiaries live in community settings rather than nursing homes and a concern among state officials that not enough was being done to prevent the centers for independent living from inflating their assessments in ways that generated more work — and therefore more revenue — for their case management and home-health programs.”

The Centers only get a flat rate fee for administering the “Home Health Programs”. No matter if an assessment generates 10 hours a month or 100 hours a month of personal care attendant time, the Center for Independent Living does not make more money. The Centers receive $115 per month per person as stated in your article from February 13th 2012 “Centers struggle to cope with new rules” http://www.khi.org/news/2012/feb/13/c...

Magnolia (Amy McFarren)August 15, 2012 at 8:15 a.m.

The problem with the upcoming changes is the effect it will have on the consumers, the beneficiaries. The state wants us to believe they are thinking of these frail elderly, physically disabled people - I'm not buying it. K4A is an organization with deep pockets, pockets lined by the state of Kansas. The Area Agencies on Aging currently provide assessment and case management services for the frail elderly population (as well as other mandated programs). Did you know they get other operational monies from the state? The AAAs and the state are bed mates at best - K4A is a lapdog of Sec. Sullivan and the state at worst. If you believe the Area Agencies on Aging have the best interest of Kansas Seniors at heart, I invite you to speak to a frail elderly beneficiary. These seniors report unreturned phone calls, quick 15 minute visits, no explanation of services, etc... Talk to a Frail Elderly case manager - last week I was told by a AAA case manager that he was encouraged to not be responsive to phone calls and requests for help. I will also add, contracted case managers and independent case managers are very responsive, taking customer needs to heart. This is the very group of case managers that is expected to be eliminated.
After the implementation of KanCare we will see a steep decline in the Medicaid providers willing to accept Medicaid payment. Providers outside of nursing homes will not receive reimbursement for services they are providing. This has already started after changes implemented in 2011 to the Frail Elderly waiver. A decrease in providers will force many people into the nursing home or to exist in the community without needed services. Lack of community care and an increase in nursing home admissions will result in higher rates of hospitalizations, or death.
Thanks for looking out for Kansas seniors!