1. Section 10202 of the
Affordable Care Act
Mission Analytics Group and HSRI in collaboration with
the Centers for Medicare and Medicaid Services (CMS)
November 2011

2. Presentation Outline
1. Overview of the Program
2. Applying to the Program
3. Reporting Requirements
4. Frequently Asked Questions
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3. Benefits of the Program
• Support States in providing
quality care in the most
Purpose appropriate, least restrictive
settings
• +2% FMAP: States that spend
less than 50% of Medicaid LTSS
State dollars on community LTSS
Benefits • +5% FMAP: States that spend
less than 25% of Medicaid LTSS
dollars on community LTSS
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4. • Streamlined and
coordinated system
NWD/SEP for eligibility
System determination and
enrollment into
services
• Standard assessment
Three Core instrument(s) used for
Structural Standardized a given population
Assessment • Captures domains &
Changes
topics
Conflict-Free • Separation between case
Case management & provision
Management of community LTSS
services
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5. Oversight
•State Medicaid Agency
NWD/SEP System
Agency
Operating •Delegated by the
Agency Medicaid Agency
• Aging and Disability Resource
Centers
NWD/SEP • Centers for Independent Living
Network • Area Agencies on Aging
• Non-profit organizations
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6. Two-Stage Eligibility Determination
NWD/SEP System
• Composed of basic functional
Level I and financial questions
Screen • Determines potential eligibility
for community LTSS
• Composed of a full functional
Level II and financial assessment
Assessment • Determines actual eligibility for
community LTSS
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7. • Contains information
NWD/SEP about community
LTSS, 1-800 number,
System Website and location of
NWD/SEPs
• Ideally, provides
Level I self-screen
• Links individual to a
1-800 NWD/SEP for
Entry Points Number information and Level
I screen
NWD/SEP • Staff conduct Level I
Physical screen and coordinate
Location Level II assessment
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8. Core
Standardized Determine
Assessment eligibility
Three Goals Determine
support
needs
Inform
service
planning
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9. CSA Must Capture Domains and Topics
1. Activities of Daily Living 2. Instrumental Activities
of Daily Living
Preparing Meals Transportation
Eating Toileting
Housework Shopping
Bathing Mobility Managing Money
Dressing Positioning Telephone Use
Hygiene Transferring Managing Medication
Three Goals
of the CSA
3. Medical Conditions/Diagnoses
4. Cognitive Functioning/ 5. Behavior Concerns
Memory Injurious Uncooperative
Diagnoses tied to Cognitive Destructive Other Serious
Function Socially Offensive
Memory
Judgment/Decision-Making
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10. Conflict-Free Case Management
 Separation of case management from direct
service provision
 Separation of eligibility determination from
direct service provision
 Individuals performing evaluations, assessments, and plans of
care cannot be:
 Related by blood or marriage to the individual or any of the
individual’s paid caregivers
 Financially responsible for the individual
 Empowered to make financial or health-related decisions on
behalf of the individual
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11. Presentation Outline
1. Overview of the Program
2. Applying to the Program
3. Reporting Requirements
4. Frequently Asked Questions
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12. • States submit
applications on a
Application rolling basis though
August 1, 2014 or
$3 billion exhausted
Applying to • States must submit a
the Work Plan
Work Plan six months
after submitting the
Program application
Technical • CMS and contractors will
provide technical
Assistance assistance to States
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13. Work Plan (Page 59 of Manual)
Due Date (from time
Category Major Objective / Interim Tasks of Work Plan Lead Person Status of Task Deliverables
submission)
All individuals receive standardized information and experience the same eligibility determination and enrollment
General NWD/SEP Structure
processes.
Develop standardized 3 months Informational materials
informational materials that
NWD/SEPs provide to
individuals
Train all participating 18 months Training agenda and
agencies/staff on eligibility schedule
determination and enrollment
processes
A single eligibility coordinator, “case management system,” or otherwise coordinated process guides the individual through
the entire functional and financial eligibility determination process. Functional and financial assessment data or results are
accessible to NWD/SEP staff so that eligibility determination and access to services can occur in a timely fashion. (The timing
below corresponds to a system with an automated Level I screen, an automated Level II assessment and an automated case management
system. NWD/SEP systems based on paper processes should require less time.)
Design system (initial 0 months (submit Description of the system
overview) with Work Plan)
Design system (final detailed 6 months Detailed technical
design) specifications of system
Select vendor (if automated) 12 months Vendor name and
qualifications
Implement and test system 18 months Description of pilot roll-out
System goes live 24 months Memo indicating system is
fully operational
System updates Semiannual after 24 Description of successes
months and challenges
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14. Completing the Work Plan
1. Review/modify tasks
2. Change # of months to actual dates
3. Add lead person
4. Add status (i.e., not started, in
progress, finished)
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15. Deliverables Due with Work Plan
1. Initial Overview of NWD/SEP System
2. Name of Operating Agency and NWD/SEP types
3. Completed CDS Crosswalk
4. Description of case management and potential
conflict
6. Data collection protocols
7. Sources of funding to implement structural changes
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16. Presentation Outline
1. Overview of the Program
2. Applying to the Program
3. Reporting Requirements
4. Frequently Asked Questions
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17. Quarterly Reports
• Provides information on share of
LTSS dollars spent on
Form community LTSS
CMS-64 • Allows CMS to monitor progress
toward community LTSS targets
• Submitted online
• Includes Work Plan deliverables
Progress with a summary sheet
Reports • Allows CMS to monitor progress
on structural changes and
provide technical assistance
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18. • All community LTSS at the individual
Services level
• States should already have mechanisms
Data
Data Collection
in place for collecting these data (e.g.,
Requirements
claims/encounter data)
• Clinical measures that capture the
Quality extent to which service providers are
supplying comprehensive, quality care
Data • Example: Medicaid Adult Health Quality
Measures
• Measures of beneficiary and family
Outcomes caregiver experience and satisfaction
Measures with providers
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19. Presentation Outline
1. Overview of the Program
2. Applying to the Program
3. Reporting Requirements
4. Frequently Asked Questions
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20. Frequently Asked
• How is a State’s eligibility for the
Question Program determined?
Questions
• Share of Medicaid LTSS spent on
Answer community LTSS
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21. Frequently Asked
• How was this percent calculated for
Question each State?
Questions
• State Medicaid expenditures
reported on CMS-64 from FY 2009
Answer • You may:
 Request information on your State
calculations
 Propose your own calculations
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22. Frequently Asked
• When does the enhanced FMAP
Question begin?
Questions
• The first day of the first full quarter
Answer after the application is approved
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23. Frequently Asked
• Do rural areas with few providers
Question have to meet the conflict-free case
Questions
management requirements?
• If a rural area has very few
providers, the State must have
Answer mechanisms to reduce
conflict, e.g., administrative
separation and State and consumer
oversight
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24. Frequently Asked
• What about conflict-free case
Question management in managed care
Questions
environments?
• If the managed care environment does
not permit the complete separation
between case management and
Answer service provision, the State must have
mechanisms to reduce conflict, e.g.,
administrative separation and State
and consumer oversight
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25. Frequently Asked
• How can my State fund the
Question structural changes?
Questions
• Enhanced FFP for Eligibility and
Enrollment (E&E) Systems
Answer • Money Follows the Person (MFP)
administrative and savings funds
• ADRC grants
See p. 44 of the Manual for more
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26. Frequently Asked
• What can the enhanced FMAP be
Question used for?
Questions
• “For purposes of providing new or
expanded offerings of non-
Answer
institutionally-based long-term
services and supports.”
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27. •balancing-incentive-
CMS
program@cms.hhs.gov
TA Resources
TA •info@balancingincentive
Contractors program.org
• http://www.balancingincentiveprog
ram.org/
Websites • https://www.cms.gov/smdl/smd/it
emdetail.asp?itemid=CMS1252041
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