M C I L Journal
				MCIL Journal 2007
				MCIL Journal 2006
				MCIL Journal Index

The Memphis Center for
Independent Living Journal

Index
of previous MCIL Journals

6/28/99, 7:44 amcdt

MiCASSA means REAL CHOICE

MiCASSA redirects the focus of the Medicaid long term services program from institutions to home and community services and supports. It enables people to make real choices. Given "REAL CHOICE" people overwhelmingly choose "HOME SWEET HOME."

MiCASSA means more older and younger Americans and children with disabilities will finally get the real choice of home and community attendant services and supports.

Studies show that people currently living in America's institutions and nursing homes do not have more severe disabilities than people who are living in their own homes with attendant services and supports. So why do they go into institutions when they'd rather stay at home? Because:

• Family members and other informal caregivers "burn out" or "age out"

• Government does not provide a real choice for home and community based services;

• Home care pays caregivers low wages and offers no benefits, which results in a shortage of qualified providers;

• People don't know that there are alternatives to nursing homes and other institutions.

Nursing home care costs taxpayers more than it costs to support people in their own homes, even when these folks are receiving other public benefits.

MiCASSA means CONSUMER CONTROL

No one understands the needs of people who use community attendant services and supports better than people with disabilities. MiCASSA would give them a policy-making role in designing America's community attendant services and supports program and deciding what services will be available, how they are paid for, and who is eligible.

Many people with disabilities can and want to select, train and supervise their own attendants. For them, MiCASSA provides options such as vouchers with which to pay attendants (including family members) and training in directing and managing their care. For those who prefer not to manage their own services, it also provides for a consumer-directed agency model.

MiCASSA's goal is to provide flexible, consumer-responsive services, which means that the person receiving the services decides how, when and where they are provided. That's what consumer control is all about.

GIVE US A REAL CHOICE!
OK MiCASSA in 1999!

• The demographics of our nation are changing - population is aging, more people with disabilities are living and needing assistance with daily living tasks.

• Although people with disabilities overwhelmingly prefer home and community services and supports over institutional services, the current long term care system favors costly institutional programs and profit seeking corporations.

• Currently, in America, non-institutional long-term care services are fragmented among many different funding sources and administering agencies and eligibility tends to be based on age or medical diagnosis rather than functional need.

• The system we have now is over 30 years old and does not work.

MiCASSA gives people a real choice of how to live their lives.

MiCASSA WILL:

1. Give people a real choice so that Medicaid dollars that are currently spent on institutions and nursing homes can be used for home and community services and supports.

2. Provide a variety of community services and supports including:

   • bathing and personal hygiene, dressing, grooming, lifting and transferring, feeding, bowel and bladder care and similar services;

   • meal preparation, shopping, cleaning and laundry;

   • assistance with money management, use of medications, and other daily living services;

   • services to assist consumers with mobility and transportation;

   • transition costs from the institution to the community (like utility and rent deposits, household supplies); and

   • assistance with health-related tasks as delegated or assigned by a nurse.

3. Ensure consumer control and direction. Gives people with disabilities and their families real control over how, when, and where they receive community attendant services and supports. Requires consumer and/or representative agree with needs assessment and plan of service.

4. Allow, if state chooses, eligibility of people whose income exceeds current limits, to promote employment.

5. Enable people with disabilities to live independently in their own homes and other community settings of their choice instead of being forced to reside in nursing homes or other institutions.

6. Mandate high quality assurance standards must include meaningful consumer input.

7. Give people a choice of delivery systems: an agency provider, vouchers, or fiscal sponsor.

8. Establishes grants and planning entities to help states move away from the current institutional bias in long term care.

Talking Points

1. Our long term service system must change. Created over thirty years ago it is funded mainly by Medicare and Medicaid dollars. These are medical dollars which were not originally conceived to meet the long term care needs of people. We must think out f the box to new system that empowers people and allows REAL choices.
   • The money should follow the individual not the facility or provider.

   • A national long term service policy should not favor any one setting over the other. It should be neutral and let the users choose where services should be delivered. Current system is not neutral.

   • Over 80% of our Medicaid dollars ($41 billion) spent on long term care is spent on institutional services, leaving only 20% ($10.5 billion) for all community services.

   • Current system is expensive and ways to meet the needs of people in the most cost-effective way must be explored.

   • Community services on average have been shown to be less expensive then institutional services and better liked by individuals.

2. Demographics of our country are changing
   1. aging process
   2. children being born with disabilities
   3. young adults - Medical technology keeping people alive who would have died previously.

3. People with disabilities both old and young, even those with severe mental or physical disabilities want services in the most integrated setting possible. Families must have REAL choice.

4. People with disabilities and their families want REAL choice which means:

   1. equitable funding opportunities.
   2. no programmatic or rule disincentives to community services.
   3. options for services delivery to include agency, vouchers and fiscal intermediaries. Empower people with disabilities and families.

5. Family values, keep families together.
   1. communities taking care of their own.
   2. children belong in families.
   3. Mom and Dad together with their grandkids.

6. Money following the individual can eliminate overburdening rules and regulations by government regulators.

7. A functional system based on need instead of medical diagnosis could end FRAGMENTATION of service delivery system.

8. Keeping people in the community allows the possibility for individuals with disabilities to train for work so they can become TAXPAYERS instead of TAX USERS.

9. Overwhelmingly people prefer community services to stay in their own home. Federal government needs to work in partnership with the states to create flexible delivery systems that gives people with disabilities REAL choice.

10. Change can cause fear of the unknown. There are some long time providers of services and families who believe REAL choice would threaten what they have. We cannot continue the system as it is today. It is expensive, fragmented, over medicalized and not liked by almost everyone.

There's No Place Like Home!

Specifically what does this bill do?

1. Provides community attendant services and supports which range from assisting with activities of daily living (eating, toileting, grooming, dressing, bathing, transferring) instrumental activities of daily living (meal planning and preparation, managing finances, shopping, household chores, phoning, participating in the community), and health-related functions.

2. Includes hands-on assistance, supervision and/or cueing, as well as help to learn, keep and enhance skills to accomplish such activities.

3. Requires services be provided in THE MOST INTEGRATED SETTING appropriate to the needs of the individual.

4. Provides Community Attendant Services and Supports that are:
   • based on an assessment of functional need;
   • provided in home or community settings like -- school, work, recreation or religious facility;
   • selected, managed and controlled by the consumer of the services;
   • supplemented`with backup and emergency attendant services;
   • furnished according to a service plan agreed to by the consumer;
   • and include voluntary training on selecting, managing and dismissing attendants.

5. Allows consumers to choose among various service delivery models including vouchers, direct cash payments, fiscal agents and agency providers, all of which are required to be consumer controlled.

6. For consumers who are not able to direct their own care independently, MiCASSA allows for "individual's representative" to be authorized by the consumer to assist. A representative might be a friend, family member, guardian, or advocate.

7. Allows health-related functions or tasks to be assigned to, delegated to, or performed by unlicensed personal attendants, according to state laws.

8. Covers individuals' transition costs from a nursing facility or ICF-MR to a home setting, for example: rent and utility deposits, bedding, basic kitchen supplies and other necessities required for the transition.

9. Serves individuals with incomes above the current institutional income limitation -- if a state chooses to waive this limitation to enhance the potential for employment.

10. Provides for quality assurance programs which promote consumer control and satisfaction.

11. Allows states to limit the aggregate amount spent on long term care in a year to that amount the state would have spent on institutional services for such eligible individuals in the year.

12. Provides a maintenance of effort requirement so that states can not diminish more enriched programs already being provided.

REAL CHOICE SYSTEMS CHANGE INITIATIVES

1. MiCASSA also provides grants for Real Choice Systems Change Initiatives to help the states transition from current institutionally dominated service systems to ones more focused on community services and supports.

2. Each state will create a Consumer Task Force to develop a plan for transitioning services into a more community oriented system. A majority of the members must be people with disabilities or their representatives.

3. The Secretary of Health and Human Services, along with the National Council on Disability, will review regulations and report to Congress on how to reduce excessive use of medical services. The Secretary will also establish a task force to examine financing of long term care services.

Some Questions About the Medicaid Community Attendant Services And Supports Act MiCASSA

1. How are community attendant services and supports defined in MiCASSA?

   In MiCASSA, the term community attendant services and supports means help with accomplishing activities of daily living (eating, toileting, grooming, dressing, bathing, and transferring) instrumental activities of 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 attendants 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 most integrated setting appropriate to the needs of the individual" in a home or community setting, which may include a school, workplace, or recreation or 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 to a cognitive disability for example, can have assistance from a representative, like a parent, a family member, a guardian, an advocate, or 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 you would be eligible for MiCASSA. Financial eligibility for nursing homes is up to 300% of the SSI level (roughly $1,500 for a single person). In addition, states can choose to have a sliding fee scale for people of higher incomes; MiCASSA specifically references this as an incentive for employment. This sliding fee scale can go 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 maximum amount of control preferred by the individual with the disability. Options include: vouchers, direct cash payments or a fiscal agent, in addition to agency delivered services. In all these delivery models the individual has the ability to select, manage and control his/her attendant services and supports, as well as help develop his/her service plan. Choice and control 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 nursing 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 to the needs and desires of the consumers of these services. MiCASSA says the people who are already eligible for these services will simply have a choice of where they receive services. MiCASSA would adjust the current system to focus on the recipients of service, instead of mandating funding for certain 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 institutional 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 government or industry, the real choice.

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

   MiCASSA assures that a state need spend no more money in total for a fiscal 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 jump 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" caregivers is beginning.

9. . What are the transitional services?

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

10. How is Quality Assurance addressed in MiCASSA?

    States are required to develop quality assurance programs that set down guidelines for operating Community 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 public results of the quality assurance program public as well as an on-going process of review. Last but not least sanctions must be developed and the Secretary of Health and Human Services must conduct quality reviews.

11. 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 in 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 the 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 ending 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 options, 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.

The Memphis Center for Independent Living
1633 Madison Avenue, Memphis, TN 38104
(901) 726-6404 v/tty (901) 726-6521 fax
mcil@mcil.org 

MCIL is a United Way of the Mid-South member Agency

Return to the top of this page

MCIL would like feedback on the accessibility of this website.  Please send your comments and concerns to webmaster@mcil.org

© 2006 Tim Wheat