“How much of human life is lost in waiting.” — Ralph Waldo Emerson
In order to enroll in Medicaid waiver programs in Colorado, adults with intellectual or developmental disabilities (I/DD) must meet certain criteria in determining their eligibility. This criterion, determined by the Colorado Division of Disability, is also used to determine the level of support needed by the individual in order for him or her to lead an active, quality life in our Colorado communities.
Medicaid waiver programs enrollment for individuals with I/DD in Colorado are in great demand. Advocates at AdvocacyDenver oftentimes support clients with enrolling in these programs. Once applied and approved as eligible, clients can anticipate varying wait periods for actual enrollment.. If an individual with I/DD does not apply for enrollment at age 14 –and this can be the case for a plethora of reasons- he or she will end up experiencing a waiting period where access to Medicaid services and supports is limited.
During this waiting period, individuals with I/DD oftentimes refer to natural supports such as friends or family to help them participate within their communities. Community organizations can play a role in helping individuals waiting for Medicaid enrollment too. AdvocacyDenver has a long track record of supporting such individuals with I/DD in locating safe and affordable housing, access to health care, and accommodations in employment. Mission Supports, a new non-profit organization in Denver, is also working to specifically alleviate the barriers experienced by those waiting for Medicaid program enrollment. The organization provides on-going monthly check-ins with adults to identify areas in daily life that they may need support. It also is working towards providing educational opportunities to improve skills such as money management.
While there may not be any imminent decreases in waiting list periods in the near future we, as a community, can continue to be aware of the waiting list for Medicaid disability waiver program and provide our friends, neighbors, and family with support they need while they are waiting.
State Medicaid Director Suzanne Brennan Discusses Gaps in Speciality Care
Listen to Part II of the interview
What are some of the gaps that you see in the service delivery system as it is currently?
“Access to specialists for sure. There are some gaps there. There not a lot of specialists that actually take Medicaid clients. We’re also seeing that there are fewer and fewer providers that accept Medicare as well. So were seeing some general access to care issues.”
How is Colorado’s approach different from other states in coordinating care under the dual eligible program? How do you think it will differ?
“Colorado is on the forefront in terms of implementing an accountable care organization –that we call the ACC, the accountable care collaborative. And many states are coming to us to understand. what we are doing with our ACC program and how is it structured. So that is very different than other states. The other thing we’re looking at is how do we make sure that we’re connecting some different systems of care. So we have a very good PACE program in Colorado that is designed for individuals that meet nursing home level of care. We want to make sure we keep that and that we build on it. We also have Medicare special needs plans as well that do some coordination for dual eligibles, but there’s a large number of dual eligibles out there that are in the fee for service unmanaged network. We want to make sure that when we design the accountable care collaborative to meet the needs of the duals that it connects to the PACE continuum of care as well as to Medicare SNIPS. We’re working that out. So that to me is what’s kind of unique. We want to leverage what’s strong in the state and then build on that and make sure we’re keeping the connections.”
I know a lot has been said about the savings projected in the dual eligible redesign. Where would the savings come from and why do you think it would create savings for the state?
“Now we haven’t actually measured the savings but we believe the savings will come from reduced avoidable hospitalizations and reduced ER usage and reduced need for specialty care as well. So ideally, I view it I view it as the life cycle of an individual and how do you keep them healthier longer so they need less acute care? So the idea is if you’re really staying on top of what a patient needs and helping them to manage their chronic conditions like diabetes, high blood pressure, COPD, congestive heart failure, if you’re helping them to manage those conditions they’re going to need less acute care over time. So it will take time for the savings to accrue because you actually have to understand what’s happening with your patients, very proactively and then monitoring them over time. So this is not like flipping a switch in terms of cost savings – like okay we’re going to coordinate services for the duals and in six months we’re going to see savings. It’s going to take longer than that.”
State Medicaid Director Suzanne Brennan Discusses Dual Eligibles
Listen to Part I of the interview
“In Colorado we have approximately 71,000 individuals who are dually eligible for both Medicaid and Medicare. And those individuals actually represent 13% of our total Medicaid population. Those dual eligible individuals who are receiving Medicaid benefits account for 43 % of our Medicaid budget. That is about 1.2 billion dollars. It’s quite a large expenditure for a relatively small percentage of the population. Now that being said, these are very high need individuals. 60% of the individuals who are dual eligible are elderly, and 40% are actually individuals with some sort of a disability. So they have high needs and we want to make sure that we are serving them appropriately. 60 percent of those individuals actually have multiple chronic physical conditions and 20 % have more than one mental or cognitive condition. We want to make sure that we are coordinating care for them, making sure that they get all the services they need to deal with these intense physical and behavioral health conditions that they have.”
I’m aware that some states have started to design models for this Medicare/Medicaid integration. Which state would Colorado be modeling its design after and why?
“Now there are some states that are doing an excellent job in terms of redesigning their delivery system – with a focus on accountable care organizations and health homes and I’d say two of the leading states in the country are North Carolina and Vermont. Now they might not be specifically doing something around the dual eligibles but their work in coordinating care is so significant that that is really what we’re modeling ourselves after.”
In what way?
“Vermont has something called the Blueprint for Health and they have a very strong system they’ve designed that’s very integrated and systematic and has community healthcare coordinators who are very effective and work across different insurance products as well. So that’s one example. In North Carolina, their model is built on a very strong Medical Home model – and so that’s something we’ve built into our ACC for that very reason based on North Carolina’s success.”
What are the greatest challenges you foresee in creating this redesign of Medicaid and Medicare?
“I’d say some of the greatest challenges are making sure that we leverage the infrastructures we’ve already built and that they’re seamless connections. As I mentioned earlier, the idea that we do have a good PACE program in Colorado, we do have Medicare special needs plans, yet there are many people who are still in that uncoordinated fee for service system.We need to make sure we’re tying those things together and leveraging them appropriately. So that’s one challenge. I think making sure that we have an adequate provider network. Ideally, providers would take both Medicaid and Medicare so they can do a better job coordinating care for their patients.”
Part II: Interview on Health Benefits Exchange with Senator Boyd
Listen to Part II of the interview
Senator, what do you view as the biggest challenges facing the Health Benefit Exchange in Colorado?
“I think the two biggest challenges are the timelines and finding the money that it’s going to take to develop an appropriate IT system. Colorado’s had a pretty spotty record in the past with some of their IT systems. We need to have a good system for the Exchange itself, but in addition to that, there needs to be a good eligibility determination process and the reality is our current Colorado Benefits Management System is not going to be up to the task I don’t think. There are some challenges because CBMS already integrates eligibility determination for Medicaid and for human services programs. A lot of states haven’t gone that far to integrate those eligibilities but we have and as a result it’s not just making the distinction between Medicaid and those served in the Exchange because of all the other human services components. You can’t just throw them together.”
What is your opinion of the federal government throwing it to the states to establish their own essential health benefits?
“It sure does create more challenges for the state because we were assuming that there would be some really good guidance but I don’t think there is. So at the same the time the exchange itself is being developed, the rules around what that package is going to look like are working and right now the commissioner of insurance is having some town hall kinds of meetings to try and help determine what those essential benefits will be for Colorado because the exchange is really a marketplace and the commissioner of insurance still has the same role as before.”
Do you have an opinion on whether the Affordable Care Act will stand?
“I believe it will. But whether or not it does, we have said all along our intent is to create an Exchange regardless of what happened it would certainly be harder to deal with some of the financing ultimately of those participants who would be included in the Exchange because the share of the participants is anticipated to be receiving some kind of subsidy. This is the place where they should be getting their insurance.”