LTC Bullet: Kansas Study
July 17, 2006
Comment: The Center for
Long-Term Care Reform and the Wichita, Kansas-based Flint Hills Center
for Public Policy are collaborating this week on a study of long-term
care service delivery and financing aimed at understanding the potential
state-level impact of the Deficit Reduction Act among other objectives.
Details after the ***news.***
THE FUTURE OF LONG-TERM CARE AND MEDICAID.
Last week, we reported to you on Steve Moses's testimony before a
hearing in Hagerstown, Maryland. Also
testifying that day was Grace-Marie Turner, President of the Galen
Institute and a voting member of the National Medicaid Commission.
Here's how the Galen Institute described her testimony:
Turner testified before a field hearing of the House Small Business
Committee in Maryland on Monday, offering ideas about incentives for
working-age people to plan ahead for their long-term care needs.
She recommended that Congress encourage states to participate in
the recently-expanded Long-Term Care Partnership program, create new
federal and state tax incentives for people to purchase long-term care
insurance, encourage the use of reverse mortgages, and enforce new laws
that block affluent seniors from giving away their assets to qualify for
Medicaid. She also
recommended that a new Medicaid Advantage program be created for seniors
who are dually-eligible for Medicare and Medicaid so they have the
option of choosing from among competing private plans offering
comprehensive, coordinated care. Full text: www.galen.org/statehealth.asp?docID=907."
TO RECEIVE THIS WEEK'S LTC EMBED REPORTS, you must be a dues-paying
member of the Center for Long-Term Care Reform.
Steve Moses says: "All
this coming week, I'll be exploring the state-level ramifications of the
national policy directions we studied last week in Washington, DC. Tune in." To
join the Center and ensure you receive all Steve's reports from the
policy front, contact Damon at 206-283-7036 or firstname.lastname@example.org.
He'll answer any questions you have, get you a user name and
password for The Zone, send you current and recent LTC Embed reports,
and sign you up to participate in our new LTC Forum online bulletin
board. Get involved, get
connected, get going. Join
the Center. ***
BULLET: KANSAS STUDY
Comment: The Center for
Long-Term Care Reform has a longstanding relationship with the State of
Kansas. A Kansas state
legislator served on our predecessor organization's Board of Directors.
Center president Steve Moses has testified before the state
legislature three times over the years.
Last year, he joined the Chairman of the Kansas House
Appropriations Committee to present three "Legislative Long-Term
Care Academies" across the length and breadth of the Sunflower
Since 2002, the Center has been invited three times
to propose a project toward the goal of controlling Kansas's Medicaid
long-term care costs while improving the program's access, quality and
coverage. Following below
is the most recent such proposal we've offered.
We present it here as a quick and reasonable facsimile of the
briefer and more focused project the Center for Long-Term Care Reform is
about to conduct in Kansas at the behest and with the support of the
Flint Hills Center on Public Policy.
Unlike the project described in the following
proposal, the current study will involve only one week of field work.
We'll interview most, but not all of the stakeholder groups
listed below. We'll visit
two instead of three Medicaid field offices. Our focus will be on the status of and potential for the
Deficit Reduction Act of 2005 instead of OBRA '93, HIPAA '96, and BBA
'97. Nevertheless, the
philosophy behind and the goals motivating this current effort are much
So, to give readers the flavor of what we're doing
in Kansas this week, we offer the following for your review and
consideration. Our "LTC
Embed" reports from the state-level long-term care policy front in
Kansas will fill in the details throughout the coming week.
We expect to complete our report on long-term care service
delivery and financing in Kansas within three weeks of finishing this
week's field work. Stay
Medicaid Long-Term Care Costs; Submitted to Members of the Kansas State
Legislature on November 19, 2003 by Stephen A. Moses, President, Center
for Long-Term Care Financing
Objective: Produce a
step-by-step plan to save the State of Kansas $60 million per year in
Medicaid nursing home expenditures while simultaneously assuring
universal access to top quality long-term care for all citizens (rich
and poor alike) across the spectrum from home and community-based to
nursing home care.
nursing home expenditures in Kansas nearly doubled from $160.5
1991 to $302.5 million
in 2001. This rapid cost
increase severely impairs the state's ability to maintain generous
Medicaid nursing home eligibility criteria, to expand the home and
community-based services often preferred by seniors, and to sustain
adequate financing for other critical state services such as
corrections, education, and highways.
Medicaid nursing home eligibility rules in Kansas (and elsewhere),
although well-intentioned and politically popular, have gradually
converted a means-tested public assistance program (welfare) into an
expensive, de facto long-term care entitlement program. Consequently, private out-of-pocket and insurance financing
of home, community-based, and nursing home care have languished while
Medicaid costs for these programs have skyrocketed.
The public policy dilemma is to contain Medicaid long-term care
spending in a politically sensitive way without increasing taxes or
solution to this quandary, proposed in a long series of reports by the
US-DHHS Inspector General, the United States General Accounting Office,
LTC, Incorporated, and the Center for Long-Term Care Financing is to
retain generous Medicaid eligibility criteria while controlling asset
transfers and shelters, enhancing estate recoveries, and encouraging
private long-term care financing alternatives.
The difficulty with this solution, however, is that it is
complicated to achieve and it is often opposed by various long-term care
interest groups. Therefore,
a two-fold public policy intervention is needed:
the Medicaid program must ensure (1) that every federal and state
statutory, regulatory and administrative remedy is fully employed to
target public assistance resources to the most needy while diverting
more prosperous people to private financing options and (2) that every
stakeholder in the long-term care financing issue understands the
benefit to its constituency of implementing the necessary measures.
These are the specific goals that this project would seek to
Work Plan: To
achieve the objective and goals of this project, we propose the
A. Examine Medicaid
nursing home eligibility criteria in Kansas with attention to federal
and state statutory, regulatory and policy guidelines.
Thoroughly study and review all relevant state and federal
statutes, regulations and policy manuals and compare them to eligibility
policies in other states. Provide recommendations for state legislation, program policy
changes and federal waivers to achieve a stronger and tighter asset
B. Review the
state's implementation of OBRA '93 (Omnibus Budget Reconciliation Act of
1993), HIPAA '96 (Health Insurance Portability and Accountability Act of
1996) and BBA '97 (Balanced Budget Act of 1997) authorities.
Interview responsible state staff and study existing plans,
proposed legislation, and policy options under consideration.
Recommend ways that the State of Kansas can take full advantage
of this powerful federal legislation.
C. Appraise the
status of Medicaid estate planning (the artificial impoverishment of
frail seniors to qualify them for publicly financed nursing home
benefits) throughout the state. Review
the legal literature on Medicaid planning in Kansas and interview
influential elder law attorneys. Recommend
measures to control Medicaid estate planning and to encourage attorneys,
financial planners, accountants and other senior advisers to suggest
private long-term care financing alternatives while their clients are
young and healthy enough to afford and qualify for them.
D. Plan and conduct
site visits to at least three local Medicaid nursing home eligibility
local offices (urban, suburban, and rural).
Interview supervisors and eligibility workers; review eligibility
policies and procedures; examine a judgmental sample of Medicaid nursing
home eligibility case records; compile examples of Medicaid estate
planning techniques; explore the potential impact of possible
alternative solutions on affected field staff; and obtain ideas and
recommendations from front line workers.
E. Analyze Kansas's
lien and estate recovery strategy including statutory authorities,
regulations, administrative policies, program activity, and collections.
Interview key program staff; analyze procedures; examine the
integration of front-end eligibility controls with back-end collection
efforts; estimate maximum recovery potential; research best practices
from other states and explore the possibility of applying them in
initiatives to maximize non-tax revenue to the State of Kansas from lien
and estate recovery programs.
F. Study long-term
care insurance regulation in Kansas.
Interview representatives of the State Insurance Commissioner's
office; review laws, regulations and policies governing the content and
sale of long-term care insurance products in the state; interview agents
and brokers who market home health and nursing home insurance policies
concerning the obstacles they face; compare policies and practices in
Kansas with other states; and analyze the chilling effect of easy
Medicaid eligibility on the marketability of private insurance
statutory, regulatory and policy changes to enhance early planning for
private long-term care insurance as an affordable, high quality
alternative to reliance on Medicaid nursing home benefits by default.
G. Investigate the
potential of home equity conversion (HEC) as a source of private
financing for long-term care services and as an income supplement to
help older Kansans to afford private insurance for long-term care.
Identify sources of reverse annuity mortgages (RAMs) in Kansas;
interview representatives of banks and other financial institutions that
offer RAMs; determine the current and potential utilization of home
equity conversion as a source of financing for long-term care to relieve
the burden on public programs; recommend ways to encourage the use of
home equity conversion to help seniors obtain quality long-term care
services in the private market.
H. Interview and
brief key long-term care stakeholders:
e.g., senior and consumer advocates; Governor's staff; key
legislators and staff; proprietary and non-proprietary nursing home,
assisted living and home health providers; long-term care insurers;
Medicaid planners; taxpayer representatives; the Chamber of Commerce and
other business interests; Medicaid management, line and legal staff; and
any other group which the state believes would be appropriate. It is critical to meet with each group separately to avoid
adversarial confrontations between groups in the early stages of
discussion and to target each group's special interests.
The purpose of these meetings is to discern the prevailing
attitudes of the various interested parties, both public and private, in
the long-term care area and to introduce them to the consensus strategy
described in the Inspector General's reports, LTC, Incorporated's
Florida, Montana, Wisconsin, Illinois, Maryland, South Dakota and New
Jersey reports, and the Center for Long-Term Care Financing's Nebraska
report and policy studies. We will conduct approximately two-hour meetings with each
interest group that has a stake in the long-term care financing issue.
Presentations will include a summary of the problem, an
historical perspective on how America and Kansas got into the fiscal and
political LTC predicament we are in, a summary of recommendations from
the DHHS Inspector General, other government agencies, and the Center
for Long-Term Care Financing on how to resolve the situation, and an
explanation of why it is in the best interest of each stakeholder group
to work cooperatively with the others on the proposal under
consideration to the mutual benefit of all.
We will interview the attendees at these meetings to ascertain
their positions on key issues and to learn their opinion of and response
to the ideas presented. Each attendee will receive an information pack of articles
and reports on the topic similar to the one enclosed herewith.
(Folder to be provided with hard copy of this proposal.)
I. Examine the
overall social impact (upon the elderly population, families, etc.) from
the transfer of resources and assets.
We propose to explore every aspect of the potential ramifications
for seniors of the transfer of assets and resources issue and to provide
relevant recommendations on each. For
example, what effect does Medicaid estate planning have on the state's
ability to finance and the nursing homes' ability to provide access to
quality long-term care? How serious is the nursing home liability and liability
insurance crisis in Kansas and what are the ramifications for public and
private long-term care patients? Will
closing Medicaid eligibility loopholes discourage vulnerable seniors
from seeking needed care? Does
the easy availability of Medicaid benefits discourage advance planning
and purchase of private long-term care insurance products or continuing
care retirement community contracts?
To what extent are middle class people on Medicaid consuming
state tax revenues needed to fund other public needs such as education,
highways, and prisons? Are
there ways to divert the middle class to other financing mechanisms
while making Medicaid benefits more readily available to the poor than
ever before? We will
address all of these questions and many more similar ones in the final
report of this project.
J. Prepare and
submit an interim report mid-way through the project summarizing current
status, problems encountered, solutions proposed, work remaining,
preliminary findings, etc.
K. Analyze all data;
write the final report including the action plan implementation
strategy; and submit twelve original bound copies to the state.
Two sets of recommendations will be provided.
One set will suggest measures the state of Kansas can take under
existing state statutory authorities.
The other set will suggest measures the state could take with and
through a CMS (Center for Medicare and Medicaid Services) waiver of
federal requirements. The final report will be entirely substantive, clear and
readable as evidenced by our previous work products, samples of which
are available upon request. The
goal is to prepare a document suitable for presentation to the State
Legislature as a game plan to improve long-term care access and quality,
benefit seniors, reduce Medicaid expenditures and enhance the fiscal
responsibility of state government.
L. Subsequent to
publication of the final report, the principal author will be available
in Kansas for up to one week at the Legislature's convenience to present
state legislative testimony, advise on implementation strategy, conduct
media briefings, present findings to key interest group representatives,
and provide any additional follow-up work desired by the state.
M. The preceding
proposal is based on the assumption that the state will provide a desk,
phone, and meeting space during our site visits and will assist us in
obtaining necessary documentation, contacting appropriate respondents,
scheduling interviews, and making other arrangements essential to the
successful completion of the project.
We strongly recommend that a staff person representing the
sponsor of this study accompany the researcher on site visits and attend
all or most of the stakeholder briefings.
This kind of shared responsibility has worked very well in
previous projects with other states.
We estimate the total state staff time necessary to perform these
functions during the entire project to be approximately 80 to 120 person
Site Visits: We
anticipate the need to spend approximately 10 to 15 work days in Kansas
during this project for the purpose of conducting interviews and
briefings, visiting local eligibility offices, analyzing current
policies and procedures, conducting legal research, etc.
In addition, we have allowed and budgeted for a post-project
visit of five days for follow-up, testimony, briefings, etc.
Schedule: We recommend beginning this project by January 15, 2004 and
completing it by April 1, 2004.
interim status report of several pages and twelve copies of a formal,
bound final report reflecting accomplishment of all of the commitments
made within this proposal.
Proposal, Experience and Credentials, and References omitted to save