Like many other human services providers, the Illinois Network of Centers for Independent Living
(INCIL) is being hit hard by the Illinois budget crisis. Access Living is one of the 22 Centers for Independent Living (CILs) in Illinois. The CILs serve 95 of the 102 counties in Illinois. INCIL’s Executive Director, Ann Ford, shared the following, based on reports from 19 of the 22 CILs, which employ between 450-500 people:
•39 CIL staff have been laid off state wide since July 1, 2015
•93 CIL staff are working reduced hours because of furlough days, experiencing pay cuts ranging from 20% to 40%
•21 vacant CIL positions remain unfilled throughout the state (delaying hires is one way to save money)
•Two CILs are in the process of closing satellite offices
•All CILs are restricting travel, including in some areas travel to consumers’ homes
•At least four CILs are developing contingency plans to close in the event funding doesn’t come within the next six months
•It is difficult to determine how many consumers have gone without services. A reasonable estimate would be 800 to 1,000 people statewide
•The impact includes the enormous emotional toll this issue is taking on staff at all CILs, as they take on increased workloads while losing a portion of their income.
The CILs are doing the very best they can to continue to provide services to empower people with disabilities to live as independently as possible in the community. Quite often they are a real lifeline for many people with disabilities. During this difficult state budget crisis, know that your local CILs have been doing everything they can to show why their programs matter to the local community. The CILs are still waiting for just over $4 million in FY 16 budget money for CILs from the state of Illinois, as well as other funds specific to certain disability programs they run.
While Access Living has been holding on, we are very concerned about our fellow CILs at risk of closing. Please contact Ann Ford at annford@incil.org if you have questions about the network; you can also check www.incil.org to see what CILs serve your area. We also urge you to contact your Governor, state senators and representatives to urge them to work on a budget solution ASAP so that disability services are not further impacted.
Ann Ford
Executive Director
Illinois Network of Centers for Independent Living
This was originally shared as an Advocacy Alert from Access Living.
What Really Happens After Enrolling in Medicaid Managed Care?
Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS) HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.
The finished product outlines important points for case managers and their clients to consider.
One Day Changes Everything
Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan’s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.
Stratification Sets Up Future Contact Standards
Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee’s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare’s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.
Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.
The Care Coordinators’ Role
Care Coordinators focus on enrollees’ healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees’ medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.
It’s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.
Understanding what a care coordinator can—and cannot—be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.
Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.
Bryce Marable MSW
Health Policy Analyst
Health & Disability Advocates
People With Disabilities Who Opt Out of ‘Voluntary’ Wellness Programs Will Pay the Price, and the EEOC’s Okay With That.
The following originally appeared on the American Civil Liberties Union's Speak Freely Blog.
Voluntary wellness programs at work can provide benefits to employees, but employers are increasingly adopting “voluntary” wellness programs that unfairly burden workers with disabilities the most of all. Worse, the Equal Employment Opportunity Commission seems to think that’s okay, undermining core antidiscrimination protections it used to defend.
Here’s why.
ACA, Medicaid and Unintended Consequences for People with Disabilities
People with disabilities who are eligible for healthcare through Medicaid may experience painful gaps in coverage during transitions. There are groups of people with disabilities that are particularly vulnerable: those who need long-term care services, those who apply but are not yet found eligible for SSI in 209b states with expanded Medicaid and youth transitioning to the adult system.
Long-term care services and supports, such as personal assistance services or durable medical equipment, are critically important to some people with disabilities. Medicaid packages for people with blindness and disabilities, or AABD or SSI Related Medicaid, offer comprehensive coverage, including long-term care supports and services. For those who need them, these services are a lifeline to independence, living in the community and employment. Either not affordable or available through the private insurance market, Medicaid has been the sole access point for people with disabilities who need long-term care services. The Adult ACA Medicaid group, or expansion group, is a Medicaid program that may or may not provide an individual with long-term care services in any given state.
209(b) Expansion States Facing Challenges with Transitions
One key difference across states is the option to automatically provide SSI Related Medicaid to recipients of the federally-administered state supplementary payments though the Supplemental Security Income (SSI) program. Ten states use at least one eligibility criterion that is more restrictive than the SSI program for Medicaid eligibility and are referred to as 209(b) states. This means that an individual in these states who applies and is found eligible for SSI must make a separate application for Medicaid coverage.
The following states are currently 209(b) states: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma and Virginia. All but Missouri, Oklahoma and Virginia have expanded Medicaid eligibility through the ACA.
Limited Access to Long-Term Care and Providers in the ACA Adult Group
Because many SSI applications take longer to process than Medicaid applications, people with disabilities can frequently be found eligible for ACA Adult Medicaid while waiting for SSI eligibility to be approved. While this group of individuals who have been approved as ACA Adult Medicaid eligible has access to healthcare, they may not have access to long-term care services.
Once SSI eligibility is approved, however, the beneficiary is no longer eligible for the category of Medicaid (ACA Adult) they are currently receiving. When they are put into the correct category for coverage (SSI Related Medicaid), they are sometimes dropped from one health plan and put into another without their knowledge. The end result is a current Medicaid beneficiary who is denied or faces delayed access to long-term care services he or she should be receiving under SSI Related Medicaid, as well as potentially losing access to providers and being forced to reapply altogether.
In addition to the lack of access to needed long-term care services, people may also experience challenges related to accessing medical service providers. In some states, the integration of the ACA and managed care has vastly changed provider infrastructure, with managed care plans for SSI Related Medicaid offering different provider networks and services than ACA Adult Medicaid managed care plans.
Many individuals, especially those new to SSI Related Medicaid, will not be aware that they are in a different category until another action is taken, such applying for a Medicaid waiver service, attempting to contact their managed care plan or going to see their providers. Both of these issues can result from the timing of an individual’s Medicaid application and approval.
Youth with Disabilities Facing Challenges with Transitions
Youth with disabilities can also potentially face significant unintended consequences around access to appropriate healthcare coverage. Children with disabilities are found eligible for SSI due to a reduction in both Activities of Daily Living and Instrumental Activities of Daily Living. This means a youth can be eligible for SSI under a broader context of criteria, like an inability to socialize or play with others.
Adult disability determinations, by contrast, are made based on a disabling condition that impacts employment—not only current employment, any employment in the country that may be available to someone with such impairments. These are vastly different criteria.
As a result, many children are found eligible and begin receiving childhood SSI and SSI Related Medicaid. However, when they turn 18, they are required to meet the adult disability guidelines in order to remain eligible. Many children fail to meet those adult requirements and their benefits are terminated. Of those that are found ineligible when they turn 18, a number are later found to be eligible in further review or appeal processes. Because Medicaid waiver programs are available only to individuals who are current Medicaid recipients, a child may have waited years to be eligible for Medicaid waivers, be found eligible, only later to be denied eligibility for adult disability—which results in losing benefits under SSI Related Medicaid and SSI eligibility. If, upon later application, the individual is once again found eligible for both adult SSI and SSI Related Medicaid, he or she must now go to the back of the waiting list for the same waiver services previously lost under a youth determination. This can result in years without necessary, critical services and care.
Experiences in the States
Health & Disability Advocates conducted a short, informal survey of seven 209(b) states that have expanded Medicaid to learn more about how states identify people who are in the “wrong” eligibility category and the processes states have in place to prevent this from happening. With six of the seven states responding to the survey, HDA found that:
• Three of six respondents offer Medicaid provider packages that are different depending on whether you are in SSI Related Medicaid or ACA Related Medicaid.
• Three of the six responding states offer some variety of waivers to individuals even if they are placed in ACA Related Medicaid.
• None of the responding states have a formal process for coordinating information about individuals who transition eligibility from one service package to another.
• Four of six states are unaware of whether individuals have been improperly placed in the wrong Medicaid eligibility package; the remaining 33% have implemented trainings, but know that individuals continue to get placed into the wrong eligibility group.
• Five states (all but North Dakota) were not aware of specific alerts that notify the Medicaid beneficiary that their eligibility for one program has ended and another started.
Upon further contact, roughly half of the states were in the early stages of identifying the issue of individuals being inappropriately placed and noted a need to develop a process for re-engaging the beneficiary to get them connected to appropriate providers for maximized health.
Recommendations Going Forward
While states are currently uncertain about the scope and breadth of these issues, it is important to identify individuals who have fallen through the cracks and may experience a significant disruption in services and eligibility. At a minimum, requiring states to create an automated notification system for changes to eligibility would provide beneficiaries greater clarity and time to plan. In North Dakota, for example, individuals receive a notice as they leave eligibility under one Medicaid group and become eligible for another. Notice of and clear information about the ramifications of the change is critical.
Another recommendation for states is to look at integration of its systems and data tracking of disability populations. Data exchanges between the state and federal systems, along with the differing eligibility criteria among various programs, should make tracking persons with disabilities a high priority for states. Minnesota, for example, is developing a new integrated system with the capacity to match data sets to a broader context of information, such as employment status. This will greatly enhance the ability of the state to make sure that people with serious health needs receive the proper services and have access to the supports they need for the greatest possible independence.
Joe Entwisle, MS, CLCP
Sr. Policy Analyst
Health & Disability Advocates
Rauner's Budget is Bad Medicine for State's Health Services
The following post originally appeared on Crain's Chicago Business.
The much-anticipated “turnaround budget” from Illinois Gov. Bruce Rauner feels more like a “look back,” parading out failed ideas from past years. Rauner says this budget "preserves services to the state's most vulnerable residents”—but a quick review suggests this is far from true. Instead, we see a budget that:
• Further decimates a fragile community mental health system
• Reduces access to lifesaving drugs for people living with HIV and prevention services for those at risk of HIV
• De-funds critical substance-abuse treatments
• Drastically reduces cost-effective breast and cervical cancer screening services
• Makes it harder, and in some cases impossible, for people with disabilities and seniors to get support to live at home
• Reduces funding for evidence-based tobacco prevention and cessation services
• Eliminates Medicaid benefits for preventive health services, including adult dental care
• Eliminates health insurance for workers with disabilities, coverage unavailable in the private marketplace
• Slashes funding for hospitals serving Medicaid populations
• Eliminates funding for care coordination, originally designed to contain costs
• Secures Illinois' position near the bottom of states for per-enrollee Medicaid funding
It's ironic the governor calls these cuts “tough medicine,” when the proposed budget would deny any medicine and critical health care services to so many. We've been down this road before, and here's what we learned:
• Cuts of $113 million to mental health and addiction treatment services in fiscal years 2009-11 increased state costs by more than $18 million due to increased emergency room visits, hospitalizations and nursing home placements.
• Elimination of Medicaid coverage for adult dental services in 2012 caused spikes in emergency department visits for dental problems. In-patient ER treatment for dental problems averaged $6,498, nearly 10 times the cost of preventive care delivered in a dentist's office.
• Disinvesting in HIV prevention will lead to new infections, for which the Centers for Disease Control estimates lifetime treatment costs of $379,668 per case.
• For every dollar Illinois spends on providing tobacco cessation treatments, it has on average saved $1.29. Cutting funding for smoking cessation services will increase costs by up to $32.3 million annually in health care expenditures and workplace productivity losses.
As proposed, the Rauner budget is not only bad for our health, but it's bad for businesses, too, likely resulting in decreased productivity, loss of jobs and economic activity, and greater health care costs for employers. Some examples:
• The proposed child care “intake freeze” and increase in parent co-pays will lead to increased absenteeism as employees will take time off to care for children. Such absenteeism already is costing American businesses nearly $3 billion annually.
• Planned cuts to Illinois hospitals are expected to result not only in the loss of more than 12,500 jobs but $1.7 billion in economic activity.
• Cuts in funding for health care services, such as cancer screening, most certainly will increase the health care costs of Illinois businesses. One study of major employers found that patients with cancer cost five times as much to insure as patients without cancer ($16,000 versus $3,000 annually).
We urge the governor to listen to the critics of this budget and learn from Illinois' past experiences. We stand prepared to support him on this learning curve.
Barbara A. Otto
CEO
Health & Disability Advocates
Federal Recognition of Same-Sex Marriage Could Mean Big Changes for Taxes and Health Care Reform
The Supreme Court issued two key rulings today on same-sex marriage, United States v. Windsor (regarding the federal Defense of Marriage Act or "DOMA") and Hollingsworth v. Perry (regarding California's Proposition 8). The Court struck down DOMA as unconstitutional and dismissed the appeal in the Proposition 8 case for lack of standing.
"These momentous decisions certainly have implications for taxes and the Affordable Care Act (ACA)," said Brian Haile, Senior Vice President for Health Care Policy, Jackson Hewitt Tax Service Inc. "Same-sex partners should understand some of the implications of marriage to their health insurance options under the ACA before they tie the knot. Simply put, getting hitched affects their health care."
Haile outlined the following:
1. Same-sex partners may now be able to file as "spouses." Under the federal income tax rules as currently written, taxfilers may be able to claim a same-sex partner as a dependent if they live together for the year, if the partner resides legally in the U.S., if the taxfiler provides at least 50 percent of the total support for the partner and the household, and if the partner has very limited income. This is a murky area – and the Court's decisions only partially clarify the law.
To the extent that the Court's rulings expand the federal definition of marriage, then many of these individuals in jurisdictions that recognize same-sex marriages may now be able to file as "spouses" rather than "dependents." Other same-sex individuals who did not meet the restrictive dependent test may now become part of the taxfiler's household as a spouse in those states that recognize same-sex marriage. (For reference, 12 states and the District of Columbia marry same sex couples.) However, the marital status vis-a-vis federal law of same-sex couples who live in states that do not recognize their marriage remains unclear.
2. Same-sex partners with similar incomes may lose out. For example, same-sex partners who each have an income of $40,000 may be eligible for the premium assistance tax credits under the ACA – but only if they remain single. If they marry (in those states that allow same-sex marriage), then they would lose eligibility because their income would be over the threshold for a household of two.
3. Same-sex partners with different incomes may gain. For example, two persons in a same-sex relationship who had incomes of $30,000 and $80,000, respectively, would not qualify for the tax credits if they were married in states that recognize same-sex marriage (because their combined income is above the limit for a couple). However, the individual making $30,000 would qualify for the tax credits if he or she remains unmarried (as that individual's income is below the threshold for a household of one). Of course, the couple may end up paying a lower marginal tax rate if they marry and exercise a new right to file jointly – so part of the decision about whether and when to marry in states that recognize same-sex marriage may involve a complicated trade-off between minimizing taxes and accessing insurance.
4. Same-sex couples who currently access domestic partner benefits may gain. Under the current federal income tax rules, the value of the benefits that employers provide to opposite-sex spouses is largely excluded from income; however, the opposite is true from same-sex partners – and they have to pay taxes on the full value of the employer's contribution for same-sex partner health insurance, etc. These taxfilers may no longer have to treat the value of the health insurance as imputed income if they get married in states that allow them to do so – meaning that their taxes may go down. The same is true for employers: they may pay lower payroll taxes if the couple marries and no longer has to treat the value of the employer's contribution as imputed income.
5. Same-sex couples who do not have or do not access domestic partner benefits may lose out. If the couple marries (assuming that they live in a state that recognizes same sex marriage) and one employer offers spouse or dependent coverage, then the same-sex spouse may lose eligibility for the ACA tax credits. The ACA limits the tax credits to spouses and dependents who do not have access to coverage. Even if the employer does not subsidize spouse or dependent health coverage, the fact that a spouse has access may disqualify him or her from the tax credit program.
6. Married same-sex couples receiving ACA tax credit will have to file jointly. If a same sex couple were to get married in a state that allows them to do so and claim the new tax credits under the ACA, then the ACA rules require them to file a joint return for the respective tax year (as is the case with opposite-sex married couples).
Even with the Court's decisions, HHS still faces several related policy questions. The final rules about the new insurance marketplaces clarify that the marketplaces and insurers must "…[n]ot discriminate based on race, color, national origin, disability, age, sex, gender identity or sexual orientation."* Consequently, many observers had a number of questions about how HHS would interpret these requirements in the context of the small group marketplace even before the Court's rulings. For example, must the small group marketplace require insurance companies to provide same-sex domestic partner coverage to participating employers and employees?
"To my knowledge," Haile added, "the agency's only requirement in this regard is that insurers in the federal marketplace self-attest that they do not discriminate on this basis."**
Surprisingly, many same-sex couples (particularly lower-income same-sex couples) may be better off if HHS answers "no" to such questions. The reason is simple but not intuitive: the final rule on premium tax credit eligibility states that individuals who have access to "affordable" employer-sponsored coverage are ineligible for premium tax credits. However, "affordability" of employer-sponsored insurance is determined only with regard to the employer contribution to the employee-only coverage. Consequently, a same-sex partner (and for that matter, any dependent) may be ineligible for tax credits if the employer offers same-sex coverage – even if the employer makes no contribution to toward the associated premium. However, if partner or other dependent coverage is unavailable, then a same-sex partner or other dependent may have some hope of qualifying for a tax credit.
The Internal Revenue Service and other federal agencies may issue interpretive guidance later this year to clarify some of the outstanding questions, but the implications of the Court's rulings today certainly complicate both the tax code and health care reform.
* 45 CFR Section 155.120(c)(2); 45 CFR Section 156.200(e).
** Letter to Issuers, April 5, 2013, available at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf.
Brian Haile
Senior Vice President for Health Care Policy
Jackson Hewitt Tax Service Inc.
For more information about the Affordable Care Act and its impact on taxpayers, please visit Jackson Hewitt's public website or Brian Haile's Twitter channel.
(This post originally appeared on PRNewswire here)