Presenter: Joshua M. Wiener Ph.D., RTI International, Washington, DC. June 30th, 2010.

What Does The Health Reform Legislation Mean For Long Term Services And Supports?

Lewis: We are pleased today to have a presentation entitled, "What Does the Health Reform Legislation Mean for Long Term Services and Supports?"

It's a continuing webinar in a series of webinars hosted by the center that will focus on issues around all aspects of personal assistance services.

First a little information on how this webinar and software works. The webinar will have audio with slides. For those of you who want or need captions to support the audio, you can select the cc button at the top of your screen. If you prefer to listen by phone, use the telephone handset button in the audio window, and you'll be connected to the teleconference. Dial the number, passcode given. I'm going to make that available to you for just one moment, so people can do that if they would like.

The presentation will take about 30 minutes or so, and then we will open the floor to questions at about 15 minutes before the hour. If you are using the computer audio, please uncheck your audio, that is the microphone button on the bottom left of your screen. It should be gray, not yellow.

Because of the size of this group, we are only going to take written questions. You can write to us in the chat window in the left-hand side of your screen. It will probably be best to send the message to moderators.

If you have an issue during the talk, send the message to me or to the moderators through the chat window. When it is question time, send those to the chat window as well.

The Center for Personal Assistant Services is funded by the National Institute on Disability and Rehabilitation Research in the US. Department of Education. It is a five-year research and training center at the University of California, San Francisco. The first center was established in 2003. Our current funding cycle began in the fall of 2008. The goal of the PAS center is to improve the access, qualities and costs of PAS for people with disabilities to live independently, comfortably and safely in the community, and to participate in society, including employment.

The center is conducting research in the following five areas. The need for PAS Home and Community Based Services, Workers and Care givers, that's the PAS workforce, Economics and Workplace PAS AND emergency preparedness. The major collaborators on the Center for PAS include the University of California, San Francisco, with Charlene Harrington as the principal investigator, the Center on Disability at the Public Health Institute in Oakland, California. The Topeka Independent Living resource center, in Topeka, Kansas, PHI, formerly known as the Paraprofessional Health Care Institute in New York. Research Triangle Institute in Washington, DC. and the Burton Blatt Institute, Syracuse, New York, and Washington, DC.

Today's talk is being given by Joshua Wiener. He's a senior fellow and program director for aging disability and long term care at RTI International. He's the author or editor of eight books and over 100 articles on health care for older people, people with disabilities, long term services and supports, Medicaid, health reform, health care rationing in maternal and child health. Dr. Wiener has written extensively on participant directed home care in the United States and other countries.

Without further adieu, I want to give you Joshua Wiener. Josh, you are ready to go whenever.

Josh: thank you very much, Lewis. Thank you for the introduction. It is a pleasure to be here today and to participate with the center in their research.

So, I'm going to be talking about what does health reform mean for long-term services and supports.

The announcement of the patient protection and affordable care act and the health care and education affordability act marked an historic moment in the reform of the American health care system. Although the two pieces of legislation focus on providing medical insurance to the uninsured and controlling acute care costs, the affordable care act addresses many major issues and long-term services and supports and post acute care. Including the lack of health insurance among direct care workers and people with disabilities, inadequacies of the financing system, the lack of home care, the absence of care coordination and poor quality care in nursing homes and some other providers.

The inclusion of the community living assistance and services and supports act, otherwise known as the CLASS act, is especially notable given the seeming intractability of financing reform for long term services and supports.

So, probably the most overlooked impact of health reform on long term services and supports are provisions that will provide health insurance to direct care workers such as certified nursing assistants, home health aids, and personal care attendants and uninsured people with disabilities.

In 2008, approximately 800,000 direct care workers did not have health coverage, including approximately one fifth of certified nursing assistants and one third of personal and home care aids. But half of direct care workers have career based coverage, the others do not. But, 12 percent of people with disabilities are currently uninsured. Although the new reform law does not include an employer mandate per se, employers with more than 50 workers will have to pay a penalty or a fee if any employee receives a premium tax credit to help people buy health insurance. The penalty is higher if the employer does not offer health insurance.

No penalty is imposed for employers who enroll in Medicaid, nor is a fee imposed for failure to offer health insurance to part time employees which has a major impact for the long term services and supports workers. But half personal home care aids in 2008 worked part time or full time for only part of the year.

With the exception of people for whom health insurance is too expensive relative to income, individuals not receiving health insurance through their employers are required to obtain health coverage through Medicaid or the newly formed health insurance exchange. Currently, although there is some variation by states, Medicaid generally excludes nondisabled adults without children, people with income above the federal poverty level, and those with more than $2,000 in financial assets. Under health reform, all people under the age of 65 with incomes below 133 percent of the federal poverty level will be eligible for Medicaid. Even under current rules, almost one quarter of certified nursing assistants are enrolled in Medicaid. Some people with disabilities who continue to work or who do not qualify for either supplemental security income or disability insurance will also become eligible for Medicaid through this new pathway. Older people are excluded from these new provisions because they are all, or almost all eligible for Medicare.

Workers not obtaining health insurance through their employer, through Medicaid or through the health insurance exchange will have to pay a penalty. To make policies more affordable, tax credits will be available to people with income between 133 and 400 percent of the federal poverty level. In addition, cost sharing subsidies will protect people below 400 percent of the federal poverty level from high out-of-pocket costs from deductibles and co insurance.

In terms of general health insurance reform, the medical underwriting that keeps many people with chronic illnesses and disabilities from getting insurance now will be prohibited.

Championed by Senator Ted Kennedy, the CLASS act was a voluntary public insurance program for long-term care that is part of the affordable care act. Medicare does not cover long-term care, and Medicaid requires people to be poor or become poor paying for health care or long-term services in supports before it provides assistance. Only about 10 percent of older people, less than one percent of the non eligibility adult population have private long term health care insurance. Although the CLASS act has the potential to change long term services and supports financing over time in quite radical ways, it received little attention during the health reform debates, and few people outside of the handful of experts and advocates know about it. The CLASS act draws heavily on existing long term care insurance programs in Germany and Japan.

So, unlike private long term care insurance, the CLASS act does not require or does not even permit medical underwriting. In addition, benefits are provided on a lifetime basis rather than for a fixed number of years or expenditure level. This feature is especially attractive to younger people with disabilities who potentially could receive benefits for very long periods of time. Only working people are eligible to enroll, however. After paying premiums for at least five years, enrollees who meet the disability benefit criteria will receive a regular cash payments to help them meet their long term services and supports. Benefit eligibility will rely heavily on documentation provided by the enrollee's medical provider in a process modeled more on disability insurance programs than relying on assessment to function by insurance or state staff as is typically done by private long term care insurance for Medicaid programs.

The exact level of disability needed to obtain benefits is left to the secretary of the department of health and human services in designing the benefit program. However, the statute does require the secretary must set a standard that is at least a limitation in two or 3 activities of daily living, substantial cognitive impairment or an impairment that is equivalent to those two other levels of disability.

The average benefit will be $50 a day. But the actual benefit that a person receives will vary by their level of disability. With people with more severe disability receiving higher payment and people with less severe disability receiving a lower payment. Although this benefit level has been criticized as inadequate, it is about twice what Medicaid spends per year on Medicaid beneficiaries in home and community based services waivers for elder people and younger persons with disabilities. Legislation does not specify how many levels there will be and what the cash benefits will be for each level. Germany established 3 basic benefit levels for its public long term care insurance program and Japan has 7 levels.

Unlike public insurance programs in countries like Japan, Germany and the Netherlands, the CLASS act does not require participation by its citizens in the insurance program. As a result, the program is subject to what insurance experts call adverse selection. That's to drive up the cost of premiums and potentially create an insurance debt spiral. Without medical underwriting to exclude them, people with disabilities who need long-term services and supports may disproportionally enroll in the program raising premiums. To the extent that people who are nondisabled do not enroll, the program's ability to spread the cost of people giving benefits across a broad population will be limited and premiums could rise causing nondisabled people to disenroll which would cause the premiums to further increase, which would then cause additional nondisabled people to disenroll.

The CLASS act attempts to lessen adverse selections by including the following provisions. With the exception of full time students, enrollment is limited to people who are working. Although the number of required hours is fairly minimal. Retirees and people with disabilities who are not working cannot enroll. Using a definition of disability much broader than used to qualify for benefits under the CLASS act, only about 20% of people with disabilities are currently in the labor force.

Moreover, for employers who participate in terms of doing the payroll deduction, all workers will be automatically enrolled. People with disabilities and people without disabilities. Individuals who don't want to participate in the program may, if they want to, opt out of the program, but they must actively decide to do so. This approach draws on behavioral economics research participation and 401 k retirement programs. But I've found that participation rates are much higher when people are required to opt out rather than opt in.

To discourage people from waiting until they are disabled before they enroll, enrollees must pay premiums for at least five years before they are eligible for benefits. In addition, premiums must continue to be paid after the five year period. This requirement, which is very widely misunderstood, is more akin to a waiting period than a vesting period for a 401 k plan. Financing for the CLASS act is entirely out of premiums paid by enrollees which may vary by age as determined by the secretary. But there are no subsidies from general revenues as there is for acute care insurance. There are subsidies for full time students and working people with incomes below federal poverty level, but these subsidies are financed by other insured enrollees and not by general federal revenue.

So, there is a very difficult policy issue here. Setting the premium is a classic chicken and egg problem. If the actuaries assume that large numbers of people, including substantial numbers of people without disabilities will enroll or at least not disenroll, then premiums will be relatively low and large numbers of people, including those without disabilities are likely to enroll. Advocates of the CLASS act point to the mere universal enrollment in Medicare's part b and part d as evidence that enrollment levels will be high under the CLASS act.

Conversely, if actuaries assume that relatively few disabled people will enroll and most people with disabilities will enroll, then premiums will be high and few people, especially those without disabilities will join the program. Premium estimators who argue this position note voluntarily enrollment in private long term care insurance policy in employment settings is low with generally only about five to 7% of workers enrolling.

Premium estimates developed during the health reform debate assumed low levels of enrollment resulting in quite high average premiums ranging from $123 to $180 a month. Using a premium estimator developed by Avalere Health with SCAN Foundation, they estimate that a class like product would cost $116 a month under a voluntary program but would only cost about $40 a month under a mandatory program where everybody participated.

So, active marketing as a class insurance program will be absolutely critical to the program's success as will convincing actuaries that a high proportion of eligible workers will enroll. The initial premium could create a self-fulfilling prophecy that could determine the program's ultimate success or failure. The combination of the five year minimum enrollment and the limitation of enrollment to the working population means the program will start off collecting more in revenues than it pays out. This was critical to the politics of including the CLASS act in the final bill, because the congressional budget office as a result of this buildup of reserves at the beginning scored the CLASS act as reducing the deficit by over $70 billion during the period 2010, to 2019.

So, the affordable care act also includes a number of provisions aimed at promoting Medicaid home and community based services. The most common critique of the long term care delivery system is its institutional bias. Despite the strong preference for people to stay at home, spending for long term services and supports for older people and younger adults with physical disabilities is overwhelmingly for nursing home care. Only about 32 percent of Medicaid's long term care expenditures for this population were for non-institutional services in 2008.

States rely largely on Medicaid home and community based services waivers to finance their expansion of non-institutional services. These waivers allow states to cover a very broad range of services and to include people with slightly higher income levels than are normally allowed. The waivers also give states strong fiscal controls over expenditures by requiring that eligibility be limited to people who need nursing home care, mandating that average expenditures not exceed the cost of nursing home care, and allowing states to limit the number of beneficiaries who receive services, a practice not permitted in the regular Medicaid program. Federal government also exercises higher levels of administrative oversight on waivers than on regular Medicaid services, something which many states view as burdensome.

The health care reform law includes several initiatives that provide additional options to cover Medicaid, HCBS services and in some cases provide financial incentive to do so.

The state balancing incentive payments program basically would give states that say they want to increase their percentage of long term services and supports expenditures for home and community based services to apply for a time limited increase in their federal Medicaid match. So the result would be that the state would have to pay less than they would normally.

In addition to specifying how they will increase their proportion of spending for home and community based services, states must establish a single point of entry to long term services and supports, establish conflict free case management and a standardized assessment instrument to be used for determining eligibility for home and community based services. There is no penalty, however, if the state gets the higher match and does not meet the target.

The second option in statute is the community first choice option. This is a state plan provision for attendant services and supports an optional less expensive version of the long advocated Medicaid community attendant services act. Covers a broad range of services including those often needed to transition people from the nursing home to the community. Like Medicaid home and community based services, eligibility is limited to people who need an institutional level of care with incomes up to 300 percent of the supplemental security income payment level.

Unlike, however, the Medicaid home and community based services waivers, states are not required to limit average per person expenditures to less than or equal to what Medicaid spends on institutional care. Also unlike the waivers, states cannot set a ceiling on the number of persons who can receive services. There can't be a waiting list nor can they limit benefits to a certain sub area or target population in the state. Services provided through this option receive a six percentage point increase in the federal Medicaid match.

The adjustor reduction act of 2005 established a new Medicaid state option for home and community based services. Section 1915(i). As enacted the provision allows states to cover more than personal care but covers a less expansive range of services than permitted under home and community based service waivers. Unlike the waivers 1915(i) allows states to cover people needing less than institutional care. However, because the link to institutional care was broken, states are not allowed to cover people up to the 300 percent of SSI payment level.

The deficit reduction act provision also did not allow the waiver of comparability, thus requiring states to offer the same benefit package to all eligible's. Like Medicaid, home and community based waivers, states were able to limit the number of people served.

While this provision added additional options, only 4 states adopted this provision. So apparently most other states did not believe that offered enough advantages over the regular personal care benefits or the home and community based services waiver to implement it. So the accountable care act tries to modify section 1915(i) in some ways to make it more attractive to the states and consumers. By broadening the scope of covered services, allowing states to reach the same groups financially and functionally as home and community based service waivers do and waiving comparability. The accountable care act reduces the fiscal controls given to the states by eliminating the ability to establish enrollment caps and also requires statewide coverage.

So, I think these provisions illustrate several issues related to creating a more balanced delivery system. The most direct way to expand Medicaid home and community based services would have been simply to mandate the coverage, the affordable care act relies instead on providing voluntary options for the states, some with financial sweeteners. This policy calls for options rather than mandates reflect overall Medicaid policy by the federal government over the last 20 years.

Second, the state balancing incentive program and community first option program provides states with financial incentives but only if they comply with certain requirements. From the federal perspective the goal is to obtain behavioral change in exchange for additional services.

Third, the community first choice option and the modifications to the section 1915(i), I think showcased the tensions that exist between consumers and states on expanding these Medicaid services. Consumers want statewide coverage at the widest possible range of services provided to the highest possible income group without the constraint of limiting average expenditures to nursing home levels, and especially without the barrier of limitations on the numbers of beneficiaries and the resultant waiting list. In contrast, states, especially in this time of fiscal crisis while desireth of expanding home and community based services worry about runaway spending. In particular, given that less than a quarter of people with disabilities receive paid help, states are concerned about large increases in use if they broadly offer services. States believe they need fiscal controls that consumers oppose and may not adopt options that do not provide them.

So, the health reform legislation finances the expansion of health insurance for the uninsured through new taxes mainly on upper income people and through reductions in the Medicare payment rate. So it's acute care providers including inpatient rehabilitation facilities, skilled nursing facilities, home health agencies and hospices are among the providers affected. In part, post acute care providers are targets because of high Medicare profit margins. For example, the Medicare payment advisory commission estimated that the Medicare margin for skilled nursing facilities will be 10.3 percent in 2010. Skilled nursing facilities have argued they need higher Medicare payments to offset the losses they incurred on Medicaid residents.

For post acute care providers, the savings from the health reform legislation are achieved by reducing the annual update for inflation. Through 2010, the estimated Medicaid savings for post acute care totaled $61 billion. Accounting for about 13% of the Medicare reimbursement rate cuts.

In addition to the payment reduction specified in the legislation, the accountable care act establishes an independent Medicare advisory board to address the long range solvency of Medicare. If the increase in Medicare per capita growth rate exceeds certain targets, the new board is charged with making recommendations to reduce expenditures and those will be implemented unless congress enacts alternative proposals that achieve the same level of savings.

People with chronic conditions and disabilities receive care in a fragmented and uncoordinated financing system and an uncoordinated delivery system, both within and between the health and long term services and support systems. Financing for acute care is largely the responsibility of Medicare and the federal government. Whereas long term services and support is dominated by Medicaid and state governments. This division creates standards for cost shifting and disincentives for cooperation across programs. Relatively little is known about effectiveness of care coordination as a way to try to improve care and save costs. Most of the health reform provisions address this issue through administrative changes within the centers for Medicare and Medicaid services or through demonstration projects. Those include the following:

There is the establishment of the federal coordinated health care office and the center for Medicare and Medicaid innovation within the centers for Medicare and Medicaid services. The first one, the federal coordinated health care office, its goal focus attention on high need, high cost population, basically people who are dually eligible for Medicare and Medicaid programs. The center for Medicare Medicaid innovation although are charged with more than care coordination will test innovative payments and delivery arrangements. Importantly, if the secretary finds the models are successful in these demonstration projects, the secretary will be able to implement them nationally without additional legislation.

Special needs plans, a continuing frustration with standard managed care organizations is that they lack the expertise and people with chronic conditions or disabilities. The special needs plans or Medicare advantage plan that target enrollment to beneficiaries who are dual eligible or nursing home residents, or have chronically disabling conditions. Some special needs plans provide both acute and long term services and supports. The accountable care act reauthorizes these special categories, requires them to have contracts with both with both Medicare and Medicaid, authorizes new risk adjustment payment and requires accreditation by the national committee for quality assurance.

Medical homes and related demonstrations. Medical homes are initiatives to reinvent primary care as the main mechanism for care coordination, especially among Medicare and Medicaid beneficiaries with chronic conditions and disabilities. There are a number of provisions here. One creates a state grant program to establish community health teams charged with the developing patient centered medical homes. The law establishes medical home services as an option in the Medicaid program. Another provision, the Medicare independence at home demonstration program will test the use of medical practices consisting of primary care teams, physicians, nurse practitioners and others to deliver services to people with chronic illnesses and people with disabilities at home and to coordinate their care.

With medical homes, the community care transition program demonstration will provide them transition services to Medicare beneficiaries at high risk of re-hospitalization or poor transitions from the hospital to acute care.

The national pilot program on payment bundling and related provision establishes a pilot program to change the way care is reimbursed with people with ten specific chronic conditions. Instead of each provider being paid separately, payments for acute hospital care, physician services, hospital outpatient services and post acute care will be combined, that is bundled, into a unified payment, paid to a single provider who will then be responsible for managing all care for that episode. This all-inclusive payment will encourage development of formal and informal integrated health systems but it raises questions of whether hospitals who are the group most likely to received bundled payment will increase or decrease the years of nonhospital services. If successful, this pilot may be expanded nationwide without additional legislation.

Finally, the Medicare hospice concurrent care demonstration tries to get one of the long standing criticisms of the existing hospice benefit. Under existing law, Medicare or Medicaid beneficiaries who elect hospice care must forgo curative care for terminal illness. This is widely believed to deter people from enrolling in hospice care even when they need it. The accountable care act establishes a 3 year demonstration project that will allow patients who are eligible for hospice care to receive all Medicare covered services during their period of hospice enrollment.

Finally there are a number of provisions related to nursing home quality.

Nursing home quality continues to be problematic with about a quarter of facilities having one or more deficiencies that caused harm or immediate jeopardy to residents. There are a number of provisions here in the bill to try to improve quality. Many of them geared at additional disclosure by nursing homes, regarding staffing, financial arrangements, expenditures, things of that nature, much of which would appear on nursing home compared web site. Workforce problems are also addressed in the legislation through a national demonstration on culture change, the use of information technology in nursing homes, and the ability by the secretary to require nursing homes to conduct dementia management and abuse prevention training, although the bill does not increase the minimum number of required hours of training. The bill also establishes a national program of criminal and background checks for direct care workers in long term services and supports.

In conclusion, not as far-reaching in long term care as it is in medical care, the health reform legislation includes major provisions that will affect financing and delivery of services for people with disabilities of all ages. First, the law aims to provide basic health insurance for all Americans including direct care workers and people with disabilities who are currently uninsured. For these populations, Medicaid expansions will play a critical role.

Second, although few observers initially thought it would survive to enactment, the CLASS act has, over the long term, the potential to change the long term services and support financing from a welfare based to an insurance based system. In order to do that, it will have to overcome the very substantial risk of adverse selection, either by finding some way to market to people who do not have disabilities or perhaps ultimately moving to a mandatory system. However the actuaries price the initial premiums may create a self-fulfilling prophecy for the program that will have to be addressed if the program is to succeed.

Third, the legislation provides several new Medicaid options for the states to expand home and community based services but it does not provide a mandate to do so. Given the financial troubles of the states on the availability of other Medicaid options, it is uncertain whether states will choose to adopt these new provisions. For some of them there are financial sweeteners, but not all of them are permanent.

Fourth, the legislation includes a plethora of initiatives to improve care coordination for people with disabilities. While the focus is mostly on medical rather than long term services and supports, attention to people with chronic conditions inevitably leads to consideration of people with disabilities of all ages and their needs. In particular, the national pilot program on payment bundling and the Medicare hospice concurrent care demonstration have the potential to fundamentally alter how the Medicare home health skilled nursing facility and hospice benefits operate. Fifth, those acute care providers will have their reimbursement trimmed substantially which will provide savings to finance expansion of health care for the uninsured. The Medicare business will likely remain profitable, but margins are likely to be reduced substantially. Nursing home quality reforms will have additional information that will be useful to regulators and consumers in monitoring and assessing providers, but it will not substantially change the current system of quality assurance which has had a record.

Looking to the future, additional changes both big and small are inevitable in the new framework established by this year's legislation. A new world of health and long term services and supports policy is just beginning.

Thank you.

I'm now open for questions.

Lewis: thanks very much, josh. That was a great summary of health reform legislation. Let me tell people here. Let me make this screen available for everyone. I think you should be able to see on your left-hand side, if you go to your screen, there is an arrow in upper right-hand corner, click that, click the screen image. That will bring you to a page you can ask questions via the chat window, and that is how we will do this because of the number of participants. We won't be able to voice everything. Those of you who are on the teleconference, if you can mute your phone, that way we can have clarity of audio.

I have one question to start off with, josh. Glen asked, you may have answered this, let's get specifics on it. Can you comment on if services such as adult day care may be a covered service via the health care reform?

Josh: yes. Basically, adult day care ought to be a covered service through many of the options added as part of the accountable care act. They are already available to be covered as part of home and community based services waivers. Obviously the state has decided to cover it and include it, but at least for the population that meets the nursing home level of care, that is already covered, but it should be available through some of the other options.

Lewis: okay. I want to respond. We have several questions that came in about whether the PowerPoint and more information was available. I do want to tell people that at the PASCenter.org web site there is a button for a link to our web cast. You can go to that link. We will be posting all of our web casts are archived there which include the closed captioning and the transcript of the presentation based on the closed captioning. That is one way for you to find the information, further information if you want, and for you to find the power points. I don't know, josh, is there another written document you are going to be producing about this?

Josh: yes. The talk I gave today will appear in the next issue of the public policy and aging report, which is published by the Gerontological Society of America. When that comes out I will work to get that on to the center for PAS web site. That will be on health reform. There will be a number of articles that will focus on the CLASS act.

Lewis: okay. Now, going forward here. Before I ask the next question. A couple of you are using software's way to raise your hand. I'm not going to be able to do all those. Write your question in the chat window if you have a question you want to ask.

The next question is from Kathleen Kelly, Josh. She says who is and what progress has been made to implement the CLASS act at this time?

Josh: I don't think things have gotten very far. The department of health and human services has not decided who is going to be responsible for the CLASS act in terms of administration. The office of the assistant secretary for planning and evaluation has begun some analysis and to commission some analysis on the CLASS act. We are not very far along yet. The secretary is supposed to put out a proposed benefit package and premium structure at the end of next year. It is actually not clear on the legislation when this is supposed to kick off in terms of people enrolling. That will probably be 2012, although things might possibly slide to 2013.

Lewis: the next question is from Donna at ABILITY. She says: will care coordination be covered by funders?

Josh: in the legislation, there's primarily demonstration projects on the Medicare side. If you are in an area where in those projects, the care coordination will be covered. But it was not made into a general Medicare benefit. During the debate there was some talk of doing that but it ended up being a demonstration project on the Medicare side. I mentioned during my talk that on the Medicaid side it is an option for states if they want to do it. But, this is obviously not a great environment for adding benefits to the Medicaid program because of the fiscal problem the states are having. It is available as an option.

Private insurers, the benefit package is still somewhat influx, but given that kind of judgment in the legislation that care coordination needs demonstration and evaluation, I would doubt it would be part of the mandatory benefit package.

Lewis: next question for Mike Meyer. When did the CLASS act go into effect? Josh responded to that one.

We will go to the next one. You could say when it goes into effect. Josh, do you want to answer that?

Josh: well, as I said, there is not a date in which it says that it has to be offered. But, there are a number of other provisions that do have dates such as when the secretary is supposed to layout the benefit package and what the premium structure will be. There are numerous advisory panels under the CLASS act. There are dates for those. But I think we are probably looking at 2012 or maybe 2013 for enrollment. I think part of the problem is as I said in the beginning, very, very, very few people even know that this program exists. And so there is a tremendous amount of education that needs to be done. The secretary also has a great deal of discretion in terms of designing the program.

People should remember there is a five year waiting period after enrollment before people become eligible for services.

Lewis: we have about five minutes left. We are getting quite a few questions. We have to do these quickly. Access center asked: how is community first choice act different or is it different from the community choice act adapt advocated for?

Josh: I don't think there were many changes. I can't answer that in detail. I don't believe there were many changes from what adapt had been promoting. I think the key question is that on the other home and community based service proposals here not proposals, legislation are options for states. If they want them they can take them. If they don't want them they don't have to do it. I think states are quite comfortable with home and community based services waivers. There has not been a lot of take up on the other options. We will see.

Lewis: okay. The next question, again, Darrell Nixon asked to restate the location of where slides and the presentation can be accessed. It is listed in the chat window. It is http://www.pascenter.org/webcast/index.php. You can go to PAScenter.org and that's all you need to go to. On the left-hand side you will see a link for web casts. That's where this will ultimately be.

Next question. Medicare advantage targeted to dual eligible this is from Sarah Blanton. Did I hear this correctly? If so, how does dual eligible get enrolled when they are unable to pay for their premium?

Josh: well, that is a difficult question. If they are imposing premiums people can't afford, people will not be able to enroll. The reimbursement through Medicare and through Medicaid ought to be enough to cover services. So, but obviously dual eligible population by definition is low income. Premiums either have to be zero or nominal.

Lewis: okay. Next question from Justin. How can the state keep its long-term care expenditures for HCBS from skyrocketing if they were to change their Medicaid plan to the 1915(i) option?

Josh: first of all whether it would skyrocket is a matter of great debate. They would have to be very careful about the amount of services that people receive to make sure they were not excessive, they would have to control the reimbursement. They would have to try to set eligibility levels in terms of functional impairment at a level they could afford. We have insurance programs in other countries where expenditures have not run out of control. Germany, Japan, Netherlands all have social insurance programs for long-term care and have not had runaway expenditures. That is clearly the issue that is on the mind of many states and why they found waivers so attractive. They have been able to do a broad range of services, meet the needs of a higher income population but know they can control expenditures at the end by limiting the number of people. That obviously leaves people who qualify but are on the waiting list in a difficult position.

Lewis: before we take the next question, I want to encourage people as they leave to please do go to the address on your screen for our feedback. This is the way for us and for our funders to understand how effective we have been in presenting this to you. That is on your screen http://www.pascenter.org/webcast/feedback.php

From Donna at ABILITY: what assessment tool will be used to determine needs?

Josh: for the CLASS act, that is to be decided. But, in the legislation they will rely heavily on consumers' individual provider rather than having the assessment done independently through a third-party. For the state balancing initiatives incentive program it is up to the state to come up with the assessment program. In that program they have to establish a uniform assessment system. That is something all states have since they need that to determine eligibility for the waiver and for their other home and community based services.

Lewis: okay. Next question also, let me remind the people on teleconference, please mute your phone. We can hear you talking.

August asks the next question: has this enhanced the family care program in Wisconsin? My county was phased in April 1, 2010.

Josh: what is the question?

Lewis: august asked: has it enhanced the family care program in Wisconsin? My county was phased in April 2010.

Josh: the family care program in Wisconsin is already a fairly comprehensive benefit. There may be some way for Wisconsin and family care program to take advantage of some of these additional options. But they already have a pretty comprehensive set of systems. The legislation, to the best of my knowledge, was not geared in any particular way to address the situation in Wisconsin.

Lewis: next question from Aaron: in a review of the legislation, it is not clear to me, what point of community choice first component clearly states you have to be eligible for facility care to be eligible for cfc attendant services, although it seems to reference the ability to support people at a higher income eligibility for those at risk. Is this definite?

Josh: I would have to go back and take another look at the legislation. That was my reading of it.

Lewis: we'll do these last two questions from the access center and then see if anyone on the phone has questions.

You gave a lot of information and programs in this presentation. What programs are especially employment related?

Josh: well, the health insurance is still largely although there is an individual mandate, it does continue to build on the employer based system we have. It is still the expectation the vast majority of people in the united states will get their health insurance through their employers. As I noted in the beginning, about 80% of people with disabilities are not in the workforce and not working. They will not be necessarily part of that. There is nothing specifically in the health reform legislation that's designed to get people with disabilities more into the workforce except that eligibility for the CLASS act is very much geared to being in the workforce. If you are not in the workforce you can't enroll. I suspect that will focus the attention on many advocates with people with disabilities to find ways to move people with disabilities into the workforce so they can sign up for the program. Otherwise, they are going to be left out.

Lewis: okay. Finally, where can we get information about the programs in other mentioned countries?

Josh: Well, I've written several pieces for AARP which are available on their web site. You could also try looking at web sites of the organization for economic cooperation and development. If you send me an e mail, I'm at jwiener@rti.org. I would be happy to send you references.

Lewis: if you later decide you want to write to josh or any of us at the PAS center you can write e mails to us when you go to PAScenter.org, under about the center, contact the staff.

Anyone on the telephone, if you have a question, this is your chance. Anybody on the phone?

Yes, I have a question. This is Colin I'm calling from Hawaii. There is a heavy emphasis in CLASS act with regards to nursing home reform with quality care issues. Right now nationally it seems there is greater use of small residential homes in lieu of nursing homes in lieu of nursing homes. You see this in Oregon, Washington, California, and Hawaii did a lot in this area as well. At the same time we see huge quality issues cropping up. Is there anything in the CLASS act that will address this as well?

Josh: there is nothing specifically that addresses anything like community care homes like you have in Hawaii or adult foster homes or assisted living. There are provisions in the accountable care act affordable care act regarding elder abuse, which is generic. And could apply within those settings but they are not specifically targeted to those settings. That is a good point. We have a proliferation of new approaches to home and community based services. We have not really thought hard yet about how we will do quality assurance in those settings.

Lewis: any other questions on the telephone? Great. Thank you so much, everyone, for your attendance. Thank you, josh, for a great presentation. Once again, please do provide feedback on this webinar. There are four quick questions it will take no more than two minutes of your time. We will be writing to you more about other webinars we will be having. I'm going to put up the link to I guess I can't do it now.

All right, thank you very much for attending. Please go to http://www.pascenter.org/webcast/feedback.php

Thank you very much. Enjoy the rest of your day.