Medicaid Redesign Team II Proposals: How the Proposals will Impact Older Adults and People with Disabilities

submitted by Kelly Barrett Sarama, Esq. and Lindsay Heckler, Esq.

The Medicaid Redesign Team II (MRT II), a panel comprised mainly of industry representatives and one Medicaid consumer, was created and charged by the Governor to achieve $2.5 billion cuts to New York’s Medicaid program without harm to Medicaid recipients. The MRT II has finalized and sent these proposals to the Governor. These proposals and major cuts will harm Medicaid recipients, and are currently being considered by the legislature.

As New York proceeds with the budget process, we urge the public and the legislature to remember the following: people who use Medicaid are not a burden to the state or the taxpayer. They are our parents, grandparents, children, and friends, all of whom are an important and essential part of society and our lives.

Medicaid is the primary payer of long-term care services and supports and there are currently little to no other alternatives that are affordable. Without Medicaid, the elderly and people with disabilities are at high risk of being institutionalized in nursing homes, abused and neglected in the community, and premature death. Medicaid enables families to remain together, people to remain in the community, and remain in the workforce. The proposed cuts and changes to Medicaid could have a dire impact on our communities.

You can read more about the Human Impact of Proposed Cuts here:

Impact on Home Care

MRT II Proposal: Elimination of coverage for supervision and cuing

The proposed changes will significantly decrease the ability to access home care services, proposing to disqualify those who need supervision and cuing to manage their activities of daily living. This change will most significantly impact people with cognitive impairments, whether their condition is a result of a traumatic brain injury, Alzheimer’s disease, or any other conditions which create the need for this vital assistance. Currently, this type of coverage allows individuals with cognitive impairments to receive Medicaid-covered home care services, which include supervision of personal hygiene activities like dressing and bathing, meal preparation, household chores, medication management, and other daily functions. The termination of this coverage could lead to unnecessary hospitalizations, rapid decline in health, premature nursing home institutionalizations, and even premature death.

MRT II Proposal: Elimination of coverage for personal care including household chores

As proposed, the changes would eliminate coverage for Level I personal care services, which include up to 8 hours per week of assistance with “housekeeping” – this coverage currently includes assistance with laundry, grocery shopping, cooking, and other critical support so that individuals can remain independent and living in their community.

MRT II Proposal: Enrollment growth caps on Managed Long-Term Care (MLTC) Plans

A cap on enrollment will incentivize MLTC plans to keep their enrollment numbers under a target percentage, this will lead to plans choosing only to recruit and enroll low need members. This will put individuals with higher care needs at greater risk of unnecessary hospitalizations and premature nursing home institutionalization, as the plans are likely to cite the cap as one reason they cannot serve these individuals.

MRT II Proposal: Limits imposed on the Consumer Directed Personal Assistance Program (CDPAP)

The current proposal eliminates the requirement for local Departments of Social Services and MLTC plans to provide consumers with information about CDPAP, a program which enables family, friends, neighbors and other acquaintances to become aides, provide vital care, and get paid to do so. CDPAP is a crucial program which helps address the severe aide shortage experienced throughout New York State – without this program, many consumers would not have access to home care. The current public health crisis is a perfect demonstration of how this program helps ensure no interruptions in home care – people can continue to rely on their family, friends and neighbors, and those individuals can keep their jobs during the pandemic.

Impact on Eligibility

MRT II Proposal: Elimination of Spousal Refusal

Spousal Refusal helps married couples avoid having to choose between their marriage and financial ruin when one spouse is sick and needs assistance through Medicaid, and the other is well and does not need Medicaid. If eliminated, this could force the ill spouse to choose between their marriage or receiving vital health care either in their home or in a nursing home, which may result in premature nursing home institutionalization in order to prevent financial ruin. Couples would be forced to consider divorce in order to avoid the loss of their home and impoverishment of the well spouse.

MRT II Proposal: Reduction of Spousal Impoverishment protections

Spousal impoverishment protections help married couples preserve marital assets instead of forcing them to deplete their life savings on health care when one spouse becomes ill and needs long-term care coverage for home care or nursing home care. The current proposal is to cut the amount a well spouse can keep in half. This severe reduction could put couples at risk of losing their homes, losing financial stability, and force both spouses to need Medicaid and other public benefits as a result of financial loss.

MRT II Proposal: Imposition of look-back period for community-based long term cases

This proposal would expand the 5 year look-back rules applicable to nursing home Medicaid applications to also apply to all long-term care Medicaid applications for those seeking home care. Currently, when someone applies for Medicaid for institutionalized coverage, they must provide their last 5 years worth of financial documents to the local Department of Social Services (DSS), to be reviewed for major asset transfers. Where asset transfers are found, the DSS may impose a penalty period during which the applicant does not qualify for Medicaid and will incur charges at the nursing home’s daily private pay rate until the penalty is period runs out. The larger the asset transfer, the longer the penalty period.

Expanding this rule to home care cases will cause harmful delays in accessing home care services, which puts seniors and people with disabilities at risk of preventable hospitalizations and institutionalizations. This will also put pressure on spouses and informal caregivers, and prevent the ability to do some general estate planning.

Of note, this rule would be particularly unfair to the vast majority of applicants who are destitute and never had any assets to transfer in the first place. The burdensome review of 5 years of information for each applicant will overload DSS caseloads for no logical reason when there are already major delays in processing applications without this rule.

Application approvals for nursing home cases can often take 6 months or more to process, but those individuals are often already institutionalized and will receive retroactive coverage. For home care, approvals for care will not be issued until eligibility is confirmed – the entire system will buckle under this added weight and those in desperate need of home care will suffer and risk decline.

Impact on Prescription Coverage

MRT II Proposal: Elimination of “prescriber prevails” concept, which defers to treating physicians’ personalized knowledge of their patients

This proposal would eliminate the essential prescriber prevails protections for certain medications. Prescriber prevails protects individuals and ensures that they have access to medications their provider knows is the most effective treatment. It ensures that the medical provider has the final say when it comes to medical decisions. While prescriber prevails is not an option for all medications, it is available and essential for therapeutic classes of medications for complex conditions including: antidepressants, anti-retroviral, anti-rejection, seizure, epilepsy, endocrine, hematologic and immunologic.

Eliminating prescriber prevails means, if the Medicaid Managed Care Plan or Medicaid FFS denies an above listed medication/therapy, the individual will have to appeal the denial, which will disrupt the continuity of a vital medication and will harm the individual.

Limitation of coverage for over the counter (OTC) drugs

This proposal would reduce coverage of certain OTC products and increase copayments, with the exceptions for the most vulnerable populations. There are many medications that are now OTC whereas previously they were prescription. These actions would limit individual access to necessary medications as part of an individual’s medical treatment.

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