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What is The “Money Follows the Person” Initiative,
Anyway?
Jason Rachel, Money Follows the Person Project Director, DMAS
Julie Stanley, Director, Community Integration for People with Disabilities
Governor’s Housing Conference
November 13, 2008
Overview: Money Follows the
Person Demonstration Project
• Four-year Medicaid Demonstration Project to assist
seniors and people with disabilities who currently live in
institutions to move to the community if they choose to
– Person-centered: Over 1,000 individuals in Virginia to move to
the community, each with an individual plan, supports they need,
and someone to work with them before and after they move
– Community-based: Partnerships among human services and
housing agencies (local government and private) are key
– State-planned and administered: Department of Medical
Assistance Services (DMAS) (Virginia’s Medicaid agency) working
with many other agencies, including state housing agencies
– Federally-sponsored: Centers for Medicare and Medicaid
Services (CMS) (federal Medicaid agency)
– State- and federally-funded: 25% state/75% federal for 1st year
living in community; 50%/50% thereafter
2
Community Supports for
Individuals Who Transition
• Each individual will enroll in a Medicaid home
and community-based “waiver” or a Medicaid
program called “PACE”
• All Medicaid waivers and PACE pay for a variety
of services available to people enrolled, based
on their individual needs for each service
• Non-Medicaid services will also be available
3
Housing for Individuals
Who Transition
• Each individual must move to a “qualified
residence” in the community
– Home owned or leased by the individual/family member
– Apartment leased by the individual/family member
– Setting in which no more than four unrelated individuals
reside
• Group homes (4 or fewer beds)
• Sponsored residential settings
• 4-bed Assisted Living Facilities
• Adult Foster Care
4
Medicaid and Housing*
• HUD-subsidized housing programs are largely
Federally-driven by Congress and HUD. Medicaid is a
Federal/State partnership. Some aspects are determined
by the Federal government, others by the State.
• HUD Housing Choices Vouchers (Section 8), 202,
811 and Hope VI programs are standardized programs
that operate consistently across States. Medicaid
programs can (and do) vary from state to state.
• Medicaid and HUD housing programs use very different
methods to determine financial eligibility. A person can
be eligible for a HUD housing program, but may not be
eligible for the Medicaid program.
• Medicaid funds cannot be used to pay for room or
board.
* The information on this and several subsequent slides is excerpted largely from A M edicaid Primer
for Housing Officials, Rutgers Center for State Policy/National Academy for State Health Policy,
September 2007. A copy has been included in your conference bag. 5
To Understand How Money
Follows the Person Relates to
Housing, It Helps to Understand
the Basics of the Medicaid
Program
6
The Medicaid Basics
• Provides primary, acute, and long-term support
services to individuals who meet income,
resource and other categorical requirements
(e.g., residency, citizenship)
• States have considerable flexibility to determine
who is eligible and what services will be covered
• Medicaid costs are shared between the Federal
government and States
• Medicaid pays for a significant amount of the
long-term support services provided to low-
income individuals
7
Medicaid Eligibility
• Medicaid eligibility is very complicated
• Eligible individuals are “entitled” to all
“mandatory” and “optional” services the State
covers under the regular Medicaid program
(called the “State plan”) if they meet the “medical
necessity” criteria to receive the service
• Some people are “dually eligible” for both
Medicaid and Medicare
8
Medicaid’s “Institutional Bias”
• Institutional placement is an entitlement.
• Home and community-based “waiver” services
are not an entitlement. States may create
waiting lists when they reach the maximum
amount that has been approved for the waiver
program.
• The Money Follows the Person Demonstration
Project is designed to reverse the institutional
bias.
9
Who is Eligible for Medicaid?
Primary eligibility categories:
• Mandatory eligibility groups, e.g., people who receive
benefits under the Supplemental Security Income (SSI)
program
• Optional categorically needy group, e.g., people who
receive payments under a State Supplement to SSI
– In Virginia, the state supplement is called an “auxiliary grant.”
Auxiliary grants are available in assisted living facilities and adult
foster care programs in Virginia.
• Medically needy group. States may extend Medicaid
eligibility to additional qualified persons who may have too
much income to qualify under mandatory or optional
categorically needy groups
– Virginia has a Medically Needy program that covers seniors and
people with disabilities.
10
How Do People Get Long-Term Medicaid
Services in the Community?
• Services that support people to live independently in
their home or apartment are primarily covered by States
under home and community-based waiver service
programs.
– The major exception is services for persons with mental illness,
who rely heavily on mandatory and optional State Plan services.
• The Program of All-Inclusive Care for the Elderly
(PACE) is a managed care program that features a
comprehensive service delivery system to address the
long-term needs of individuals who are eligible for
nursing home care. The service package permits
individuals over 55 to continue living at home while
receiving services rather than be institutionalized.
11
What is a Home and
Community-Based Waiver?
• Home and community-based waiver services
help individuals who are eligible for Medicaid, and
who otherwise qualify for admission to an
institution, to live independently in the community
• To be approved by CMS, the cost of waiver
services cannot exceed what the State would
have spent in the absence of the waiver
• Services can be targeted to certain groups or
regions of the state
– Virginia’s waivers are targeted to certain groups, but all
are available statewide.
12
Waiver Eligibility
• Individuals must meet the State’s medical
(functional level) criteria for admission to an
institution:
– Intermediate Care Facility for Persons with Mental
Retardation (now known as “Intellectual Disabilities”)
– Nursing Home
– Hospital
• Individuals must meet the financial requirements
for Medicaid
13
Virginia’s Home and
Community Based Waivers
• Elderly or Disabled with Consumer Direction
(largest, with over 12,000; no waiting list)
• Mental Retardation/Intellectual Disability (waiting
list for “slots”)
• Developmental Disabilities (waiting list for
“slots”)
• Day Support (no waiting list)
• Alzheimers and Dementia Assisted Living (no
waiting list)
• Technology-Assisted (no waiting list)
• HIV/AIDS (no waiting list)
14
Who Provides Waiver Services?
• Qualified public and private human services agencies
who enter into a ”provider agreement” with DMAS
provide the bulk of waiver services. These are called
“agency-directed” services.
• Some services can be “consumer-directed,” meaning
that the individual using the waiver is the “employer” and
therefore hires, supervises and fires his or her service
provider. Depending on the waiver, the following
services can be consumer-directed:
– Personal Assistance
– Respite
– Companion
– Individual Supported Employment
Individuals who consumer direct are assisted by
“Services Facilitators”
15
Can Waivers be “Project-Based”?
• No. Waiver services are available to eligible
individuals and cannot be assigned to providers.
• Medicaid waiver services stay with the individual
when the individual moves.
• CMS requires that people who use waiver
services have a choice of all qualified providers
of the services covered under a waiver.
• DMAS determines what providers are qualified.
16
New Medicaid Services Under
Money Follows the Person
• Transition Services
– Up-front household expenses when setting up a household
– Being added to five waivers
– $5,000 lifetime maximum per person
• Transition Coordination
– 2 months before and 12 months after the individual moves
– Being added to Elderly or Disabled with Consumer Direction
Waiver
• Consumer-Directed Individual Supported Employment
– Being added to three waivers
• 24-Hour Emergency Back-up Through 2-1-1 VIRGINIA for the first
12 months following transition to the community
17
Existing and New Services
To Be Added to Waivers
• Elderly and Disabled with Consumer Direction (EDCD)
- Environmental Modifications
- Assistive Technology
- Transition Coordination
- Transition Services
• Technology Assisted (TECH)
- Personal Emergency Response System (PERS)
- Transition Services
• HIV/AIDS (AIDS)
- Environmental Modifications
- Personal Emergency Response System (PERS)
- Assistive Technology
- Transition Services
18
Existing and New Services
To Be Added to Waivers, cont’d
• Individual and Family Developmental Disabilities
Services (DD)
- Consumer Directed Individual Supported Employment
- Transition Services
• Mental Retardation (MR)
- Consumer Directed Individual Supported Employment
- Transition Services
• Day Support (DS)
- Consumer Directed Individual Supported Employment
19
Non-Medicaid Services Under
Money Follows the Person
• Supplemental home modification funding if
amount needed exceeds Medicaid $5,000
maximum
• “Bridge rent” for up to 90 days after signing a
lease if needed for home modifications to be
completed before the individual moves
• Funding for each provided by the Virginia
Department of Housing and Community
Development
20
Waiver Services That Help
People Find Community Housing
• Depending on the waiver, one of the following
providers is available to assist individuals
moving to the community from institutions:
– Case Managers (MR, DD and AIDs Waivers)
– Transition Coordinators (EDCD Waiver)
– Health Care Coordinators (TECH Waiver)
• These are the people who will be contacting
housing agencies when rental assistance is
needed
21
The Housing Challenges
• Lack of accessible housing stock
• Housing and human services plan in different systems
• Inability to afford housing
– People living in institutions often have no, or extremely low, income.
• Sole income of many will be SSI, currently $638 per month.
• Some gave up homes to receive services in institutions because they
could not access the services and supports they needed to stay in the
community.
• While some may obtain employment, they will not have sufficient income
at the time of transition to afford rent.
– Medicaid program cannot pay
– No state-funded programs exist
– Federal housing rental vouchers are scarce, and those available are
not dedicated to individuals transitioning
22
What are We Doing to Address
the Housing Challenges?
• Operational Protocol (Project Manual) contains
extensive section and Appendices on housing:
– Transition services, environmental and supplemental
home modifications, and bridge rent
– Qualified residences
• Owning your own home
• Renting a home or apartment (including HUD subsidies)
• Living in adult foster care, assisted living facilities, sponsored
residential programs, and group homes
– Transportation information also included
23
What Else Are We Doing to
Address the Housing Challenges?
• Housing Task Force created by
Secretaries of Health and Human
Resources and Commerce and Trade
• Centers for Independent Living (CILS)
working in each locality with housing
agencies
• Combined strategies comprise Annual
Housing and Transportation Action Plan,
delivered to Secretaries October 15.
24
Housing and Transportation
Task Force
• Federal, state, local and private housing and
human services partners
• Developed detailed recommendations designed
to:
– Increase affordability and availability of community
housing
– Increase availability of accessible transportation
– Recognize importance of housing and transportation
link
– Education, awareness, and partnership building
among housing and human service agencies and the
individuals they serve
25
Increase affordability and
availability of housing
• Develop a community living supplement
• Increase availability of sponsored residential and adult
foster care providers through marketing and provider
fairs
• Make the auxiliary grant portable for all populations
• Produce new housing units through QAP LIHTC and
non-LIHTC initiatives, and low-interest loan programs
– VHDA to form Housing Solutions Work Group
• Assess local housing capacity and assure that needs are
included in local planning
• Direct federal housing trust fund monies, when they
become available, to these populations
26
Recognize importance of
housing and transportation link
• Develop interactive housing and
transportation website
• Use the existing Transportation and
Housing Alliance Toolkit as a resource
• Create incentives to develop housing on
public transportation routes
27
Educate housing community;
awareness, partnership building
• Offer assistance in follow up to HUD and Governor’s letters to
PHAs
• Provide technical assistance to local housing offices, planning
authorities and HUD offices on understanding the needs of
persons transitioning, on www.accessva.org, and on laws that
govern housing services, options and choice Encourage use
of Virginia Easy Access.
• Distribute Rutgers Medicaid Services Primer at Governor’s
Housing Conference
• Encourage PHAs to list accessible housing units on
www.accessva.org
• Through speaking engagements, e-distribution list, HUD Lines
and tele-tutorials, educate housing-related groups, including:
– VAHCDO, PHAS, Housing Counselors
– COSCDA
– Housing Commission
– Local planners and contract administrators
28
Educate disability/aging communities;
awareness, partnership building
• Orient individuals, advocates, local agencies to housing/transportation
planning
• Disseminate Annual Action Plan
• Ensure input of disability/aging communities is considered in housing
planning activities; create a mechanism to track local changes in policy and
relate ongoing needs/solutions to statewide and national housing funding
agents and authorities
• Develop HOME, CDBG, and HCV contact lists; disseminate to
organizations to encourage participation in needs statements and priorities
for resource allocation
• Document changes in housing policy; work with the SILC to interface with
multiple policy makers/funding agents to foster and sustain increased
housing options
• Assure that service agencies and advocates have information about
housing agencies and a description of the services they offer through:
– Virginia Easy Access
– A housing resource bank on www.olmsteadva.com/mfp/
– Dissemination of information on HUD-Assisted Apartments
– Training of Transition Coordinators
– Developing a Housing Primer for services agencies and advocates 29
Centers for Independent
Living (CILS)
• CILS are contacting PHAs to ask them to partner with
local agencies to support individuals transitioning under
the Demonstration. They are:
– offering assistance in understanding community living needs and
preferences of people with disabilities and seniors
– assessing local housing capacity needs and working with PHAs
to develop strategies to address the needs identified in future
plans and planning processes
– documenting local changes in public housing policy, and work
with PHAs to foster and sustain increased housing options
• A human services directory and the Medicaid primer will
be available to all housing agencies
30
How Will This Project
Benefit the Housing Community?
• Existing communication and policy gaps between some
service providers and some housing agencies can be
bridged
• Practical information on housing needs and preferences
of seniors and people with disabilities will be provided
• Medicaid services will be offered not only to individuals
in institutions, but also to individuals currently using
Medicaid “waiver” services in the community
• Individuals currently using Medicaid Waivers and public
housing can get more services they need
31
For Further Information
Visit the Money Follows the Person Website
http://www.olmsteadva.com/mfp/
E-mail MFP@dmas.virginia.gov
32
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