Comments on Minnesota’s Reform 2020 Section 1115 Waiver Proposal

Anne L. Henry, Minnesota Disability Law Center

Thank you for the opportunity to comment on Minnesota’s Medicaid Section 1115 waiver proposals submitted November 21, 2012. Our office is Minnesota’s designated Protection and Advocacy System for persons with disabilities and represents children and adults with significant, often lifelong, conditions including intellectual and developmental disabilities, mental illnesses, physical disabilities and brain injuries.

1. Introductory Comments

We support many of the initiatives and requests contained in the Reform 2020 1115 waiver proposal and appreciate changes which have been made since the initial draft. The following comments describe some of our remaining concerns.

2. Community First Services and Supports (CFSS). pages 29- 45, waiver request pages 135 – 137

Many of our clients with disabilities rely on personal care assistant (PCA) services to remain in their homes.

a. Minnesota should seek a 1915k State Plan Amendment rather than an 1115 Demonstration Waiver. We are in strong support of reforming Minnesota’s personal care assistance (PCA) services program using the 1915k Community First Choice Option (CFCO). We question why our state is seeking an 1115 waiver to accomplish what can be much more efficiently and simply established through a state plan amendment under 1915k for the 90% of those eligible for PCA services who qualify for an institutional level of care.

i. A state plan amendment is less costly with less administrative burden.

ii. The definition of the forms of assistance allowed in PCA services (hands-on assistance or cuing and constant supervision) should be revised. We understand that the1115 demonstration waiver rather than a state plan amendment is sought for the reform of PCA services to “mitigate the initial risks of 1915k . . .” (see page 39, second paragraph) which we understand to mean that the state seeks to limit the costs associated with reforming PCA Services, including costs due assuring that the new program will meet the nondiscrimination requirements of 1915k such as the prohibition against discrimination based on the form of services and supports needed [42 C.F.R. § 441.515(b)]. We urge that our state, as part of the reform of PCA services, improve the definition of the type or form of assistance needed by the person in order to qualify for PCA units of service to cover those who need cuing and supervision to accomplish essential tasks such as eating, bathing and dressing in order to remain in own their homes.

The change should be part of Reform 2020 to assure requirements of 1915k prohibiting discrimination based on the form of services and supports the individual needs to lead an independent life. Whereas Minnesota used to allow persons who needed “prompting and cuing” to accomplish activities of daily living (ADLs) to qualify for PCA services, the current statute covers only those who need “hands-on assistance” or “cuing and constant supervision,”(emphasis added) Minn. Stat. § 256B.0659, subd. 4(b)(1). The impact of the more restrictive criteria has meant that persons who do not have physical limitations but require prompting, cuing or supervision have been denied eligibility for PCA services in ADLs unless the person needs constant supervision from the beginning to the end of the task. Those affected have been persons with mental illnesses, intellectual or developmental disabilities and persons with brain injury who require cuing and supervision, but are able to complete a task without “constant” supervision when they have been assisted and prompted. The first comment posted for Minnesota’s section 1115 waiver is a person with a mental illness adversely affected by this restrictive definition under current PCA provisions.

iii. Fiscal Analysis should be updated and changed. We understand our state has fiscal concerns about the costs associated with removing the term “constant”. There are factors which change the fiscal analysis and should alleviate these fiscal concerns which will be provided to state officials due to lack of space.

b. We support the request for a CFSS 1915i-like group for those who do not meet an institutional level of care. For the 10% of current PCA recipients who do not meet this requirement, we support our state’s request for a 1915i-like group but urge that Minnesota’s financial eligibility rules continue to apply. The state’s waiver request does not explain how many people will be affected by the financial eligibility change.

c. Institutions for Mental Disease should be added as an institutional level of care for CFSS.

d. Change the plan to eliminate extended PCA for those using HCBS waivers. We are concerned about excluding persons on home and community-based services waivers (HCBS), 1915c, from CFSS and instead creating a similar service for HCBS enrollees under a different name. It is likely that persons who access both state plan and extended PCA services will have their services cut as a result of this change.
e. We support the increase in minimum amount of service. We support the increase in the minimum amount of time for persons who have one dependency in an activity of daily living (ADL) or Level I behavior to at least 75 minutes per day with an average across this group of 90 minutes per day due to extra time allowed for complex health conditions or behavioral issues.

f. We support other 1915k reforms. We support the other aspects of reforming Minnesota’s PCA program under provisions of 1915k. We urge that all 1915k provisions be required if the 1115 waiver is approved for CFSS.

3. 4.2.3 Demonstration of Innovative Approaches to Service Coordination (Children with CFSS), page 45

We urge that this proposed new service coordination be included in the general care coordination efforts under health reform rather than as part of PCA reform.

Thank you

as a person suffering from 5 diagnosis of mental illness i was greatly affected by previous cuts to the PCA services. Having a pca helped me in getting out of bed and doing things helpful to my illness management, like getting motivated to brush my hair and teeth, getting dressed, going shopping, helping to prepare meals, and because i also suffer from physical ailments like arthritus and fibromyalgia, getting my apartment cleaned was a huge help.Now i struggle everyday to do the simplest things, often forgetting meds and not even getting dressed, because i no longer have a pca. please help save this program, and even restore it, so our quality of living can be maintained.

First of all I feel we have to increase the number of beds in corporate foster care from 4 to 5 or 6. This will allow us to take care of each client at a reduced rate as in most cases it will not lead to increased staffing and if it does it will not lead to a 25 to 50 percent increase in staff by increaseing the number of beds from 25 to 50 percent. I feel that by doing this one thing, we will be able to make more funds available to provide more and better services without actually increasing the budgets for these mentally ill persons. I also feel that in addition to gun control, we need to look at a national data base for those who are potentially dangerous, whether they live in an institution, foster care or at home. Many of these folks have little or no criminal background, which is great, but they do have the potential to become dangers to themselves and or others. Raising taxes on those earning over a set amount with the funds designated for domestic spending rather than the seemingly undending wars we get involved in would also have a positive impact on persons suffering from mental illness along with all other domestic issues. I have little or no faith in our elected representatives doing anything, let alone anything positive, but I am not going to give up trying.