[Hpn] Fw: Q&A on MiCASSA

Thomas Cagle nh-adapt@juno.com
Wed, 09 Apr 2003 05:11:07 -0400

From: "Stephanie Thomas" <adapt@adapt.org>

If you want this is groovier format feel free to lay it out, or you can
on the website www.adapt.org in the MiCASSA section, just change the year
and take off the bill number till we have the new one (after 4/28)!

Some Questions About the
Medicaid Community-Based Attendant Services And Supports Act

1. What are the community-based attendant services and supports in

In MiCASSA, the term community-based attendant services and supports
help with accomplishing activities of daily living (eating, toileting,
grooming,  dressing, bathing, and transferring) instrumental activities
daily living (meal preparation, managing finances, shopping, household
chores, phoning, and participating in the community), and health-related
functions (which can be delegated or assigned as allowed by state law).
These can be done through hands-on assistance, supervision and/or cueing.
They also include help with learning, keeping and enhancing skills to
accomplish such activities.

These services and supports, which include back-up, are designed and
delivered under a plan that is based on a functional needs assessment and
agreed to by the individual.  In addition they are furnished by
who are selected, managed, and dismissed by the individual, and include
voluntary training for the individual on supervising attendants.

MiCASSA specifically states that services should be delivered, "in the
integrated setting appropriate to the needs of the individual" in a home
community setting, which may include a school, workplace, or recreation
religious facility.

2.  If someone can't manage their attendant services completely
independently are they still eligible for MiCASSA services?

Yes!  People who have difficulty managing their services themselves, due
a cognitive disability for example, can have assistance from a
representative, like a parent, a family member, a guardian, an advocate,
other authorized person.

3. Do you have to be impoverished to be eligible for MiCASSA?

No.  If you are eligible to go into a nursing home or an ICF-MR facility
would be eligible for MiCASSA.  Financial eligibility for nursing homes
up to 300% of the SSI level (roughly $1,500 per month for a single
In addition, with the Ticket to Work and Work Incentives Improvement Act
1999, TWWIIA, states can choose to have a sliding fee scale for people of
higher incomes beyond the current Medicaid eligibility guidelines.

4. Is MiCASSA biased towards an agency delivery model?

No.  MiCASSA assumes that one size does not fit all.  It allows the
amount of control preferred by the individual with the disability. 
include: vouchers, direct cash payments or a fiscal agent, in addition to
agency delivered services.  In all these delivery models the individual
the ability to select, manage and control his/her attendant services and
supports, as well as help develop his/her service plan.  Choice and
are key concepts, regardless of who serves as the employer of record.

5. Will MiCASSA replace existing community-based programs?

MiCASSA does not effect existing optional programs or waivers and
includes a
maintenance of effort clause to ensure these programs are not diminished.
Waivers include a more enriched package of services for those individuals
who need more services.  With MiCASSA, people who are eligible for
homes and ICF-MR facilities can choose community attendant services and
supports as a unique service that is a cost-effective option.  The money
follows the individuals not the facility.

6.  Is MiCASSA a new unfunded mandate?

No.  MiCASSA is a way to make an existing mandate for nursing homes and
virtual mandate for institutions for mentally retarded persons responsive
the needs and desires of the consumers of these services.  MiCASSA says
people who are already eligible for these services will simply have a
of where they receive services.  MiCASSA would adjust the current system
focus on the recipients of service, instead of mandating funding for
industries and facilities.

7.  Why is MiCASSA needed?

Our current long term services system has a strong institutional bias.
Seventy five percent of Medicaid long term care dollars go to
services, leaving 25% to cover all the community based services.  Every
state that takes Medicaid funds must provide nursing home services while
community based services are completely optional for the states.  MiCASSA
says, let's level the playing field, give the person, instead of
or industry, the real choice.

8.  How does MiCASSA help states?

MiCASSA provides a five year transformation period for the states by
providing both an enhanced match and grants for the transition to Real
Choice before the benefit becomes permanent.  MiCASSA offers states
financial assistance to reform their long term service and support system
provide services in the most integrated setting, and thereby helps with
compliance with the Supreme Court's Olmstead decision as well.

9.  Will MiCASSA bust the bank?  What about the "woodwork" effect?

MiCASSA assures that a state need spend no more money in total for a
year than would have been spent for people with disabilities who are
eligible for institutional services and supports.

There is a lot of discussion about the people who are eligible for
institutional services, would never go into the institution, but would
at the chance to use MiCASSA.  (This is called the woodwork effect.)  The
states of Oregon and Kansas have data to show that fear of the woodwork
effect is blown way out of proportion.  There may be some increase in the
number of people who use the services and supports at first, but savings
will be made on the less costly community based services and supports, as
well as the decrease in the number of people going into institutions.

Belief in the woodwork effect assumes a lot of "free care" is now being
delivered by caregivers.  There is a real question whether this care is
truly "free".  Research on the loss to the economy of the "free"
is beginning.

10.  What are the transitional services?

Currently Medicaid does not cover some essential costs for people coming
of nursing homes and ICF-MR facilities.  These include deposits for rent
utilities, bedding, kitchen supplies and other things necessary to make
transition into the community.  Covering these costs would be one of the
services and supports covered by MiCASSA.

11.  What about people who need more supports?

For people whose costs are higher than 150% of the average nursing home
cost, MiCASSA will provide additional federal support to the states, so
people are not stuck in institutions because they need more services and

12.  What about people who are dually eligible for both Medicaid and

MiCASSA includes a national 5 to 10 year demonstration project in 5
to enhance coordination of services for non-elderly individuals dually
eligible for Medicaid AND Medicare.  These individuals often fall through
the cracks now.

13. How is Quality Assurance addressed in MiCASSA?

States are required to develop quality assurance programs that set down
guidelines for operating Community-based Attendant Services and Supports,
and provide grievance and appeals procedures for consumers, as well as
procedures for reporting abuse and neglect.  These programs must maximize
consumer independence and direction of services, measure consumer
satisfaction through surveys and consumer monitoring.  States must make
results of the quality assurance program public as well as providing  an
on-going process of review.  Last but not least sanctions must be
and the Secretary of Health and Human Services must conduct quality

14.  What is the purpose of the Real Choice Systems Change Initiatives
section of the bill?

MiCASSA brings together on a consumer task force, the major stakeholders
the fight for community-based attendant services and supports.
Representatives from DD Councils, IL Councils and Councils on Aging along
with consumers and service providers would develop a plan to transition
current institutionally biased system into one that focuses on
community-based attendant services.  Closing institutions, or at least
closing bed spaces must be thought through by the people that have an
investment in the final outcome, the consumers.  The plan envisions
the fragmentation that currently exists in our long term service system.

In addition, the bill sets up a framework and funding to help the states
transition from their current institutionally dominated service model to
more community-based services and supports.  States will be able to apply
for systems change grants for things like: assessing needs and gathering
data, identifying ways to modify the institutional bias and over
medicalization of services and supports, coordinating between agencies,
training and technical assistance, increasing public awareness of
downsizing of large institutions, paying for transitional costs, covering
consumer task force costs, demonstrating new approaches, and other
activities which address related long term care issues.

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