Changes to WI Budget Impacting Elderly and Disabled

Wisconsin State Budget Overview:

Just over one year ago, the Governor issued a letter to all state agency heads instructing most agencies to prepare 2015-2017 budgets using zero-growth targets and encouraging them to reform or eliminate obsolete or outdated programs to free up funding for new initiatives within their current base. Agency budgets were due to the State Budget Office by mid Sept. ’14. On Feb. 3, 2015, Governor Walker delivered his budget address and released his 2015-’17 Executive Budget.

We immediately began a review of the budget to assess its impact on older adults and aging programs/services. Significant changes proposed to SeniorCare, ADRCs and long term care, BadgerCare Plus and transportation (among others) made it clear there was much advocacy work to be done!

The aging network immediately prioritized a SeniorCare campaign as their starting point. Communications directly with members of the Joint Finance Committee, heavy contacts with all state legislators, over 13,000 petitions to save SeniorCare, a motion from the SeniorCare Advisory Council, and engagement of the media led to announcements from key legislative leaders by the end of March that the SeniorCare program would not be changed and would continue operating as it does now!

Proposed changes to Wisconsin’s homegrown long-term care system led to the formation of new coalitions and advocacy and social media groups –WI Long-Term Care Coalition, ADRC Core Team, Save IRIS, and Save Wisconsin ADRCs - to help raise up the voice of older adults and people with disabilities and their advocates.

Public budget hearings conducted by the Joint Finance Committee (JFC) began in mid-March. Older adults and aging advocates turned out in droves not only for the JFC public hearings, but for town hall meetings and listening sessions conducted by legislators all across the state. Despite the many other budget areas challenged in the biennial budget, thanks to the experience, talents, and resources of the aging network and our partners in the disability and long term care communities, issues of importance to older adults and people with disabilities were among those in the forefront.

The JFC began meeting in Executive Session to take action on the budget in mid-April and continued to meet and act on the budget through July 2, 2015. Note the state fiscal year ends on June 30; however, Wisconsin has automatic continuing appropriations statutes that keep existing appropriations in effect in the new fiscal year and all subsequent fiscal years until amended or eliminated. Once the budget was approved by JFC, it was taken up by the full Senate and passed on July 7th with no further changes made to the issues taken up by the aging network. The Assembly passed an identical budget on July 9th, exactly one year to the day from when the Governor first issued his budget instructions. After making 104 vetoes, Governor Walker signed the 2015-17 budget into law on Sunday, July 12, 2015.

Our advocacy efforts do not end with the passage of the budget. Many of the important implementation details related to changes authorized in the budget have yet to be worked out and will be left to legislative committees, state departments, and/or federal agencies (where federal waivers are required) to work out. It is critically for stakeholders, including most importantly the consumers/citizens impacted by the changes, to be involved in and providing input/feedback throughout the implementation processes. Stay tuned for updates on additional opportunities for continued involvement. See below for further details on specific budget issues of interest to the aging network.

State Budget issues impacting older adults:

A. SeniorCare – Aging advocates request “no changes” to the current program.

1) Governor’s budget requires adults aged 65 and older needing prescription drug coverage to apply for, and if qualified, enroll in a Medicare Part D plan versus just automatically enrolling in SeniorCare (Wisconsin’s prescription drug program). Uses SeniorCare as a wrap- around program only and reduces state funding by over $15 million in the biennium.

2) JFC budget deletes the Governor’s recommendations to require SeniorCare enrollees to apply for and enroll in Medicare Part D and leaves the programs as it is now.

3) Senate/Assembly make no further changes to budget approved by JFC.

4) Gov. Walker does not veto changes made by JFC. SeniorCare continues as it is now!

B. MA Personal Care – Aging advocates request removing the requirement for an independent assessment for personal care and provide funding for a Medicaid Personal Care Rate increase (no increase since July ’08).

Governor’s budget requires an independent assessment for all prescribed fee-for-service (FFS) personal care services and allows third-party agencies to develop a consumer’s care plan.

1) JFC budget approves the Governor’s recommendation to require an independent assessment (which is associated with an estimated reduction in expenditures) and delays the start date for the third-party personal care assessment contract. No increase in funding for a rate increase approved (FYI a 1% nursing home rate increase was approved).

2) Senate/Assembly make no further changes to budget approved by JFC.

3) Gov. Walker does not veto changes made by JFC. MA personal care rate was not increased and FFS personal care services will require an independent assessment of personal care needs.

C. BadgerCare – Medicaid (MA) for Childless Adults – aging advocates request accepting Medicaid Expansion which would keep childless adults enrolled in BadgerCare Plus without requiring premiums or other proposes program changes and would provide coverage for all childless adults between 100%- 138% of the Federal Poverty Level (FPL)

1) Governor’s budget seeks a waiver from the federal government to impose monthly premiums, as well as premiums for “risky” behaviors for childless adults enrolled in Medicaid, requires childless adults to have a health risk assessment and to be screened for drug use to receive benefits and calls for limiting enrollment to no longer than 48 months.

2) JFC budget approves the Governor’s recommendations.

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker approves budget recommendations as final. The Department of Health Services (DHS) is directed to seek a federal waiver to impose monthly premiums and additional

“risk based” premiums for childless adults in Medicaid. In addition, childless adults enrolled in MA will be required to have a health risk assessment and be screened for drug use. Their enrollment will be limited to 48 months (if the waiver request to CMS is approved).

D. ADRCs - Aging advocates seeking to keep ADRCs local, nonprofit, and “one-stop” comprehensive community resources.

1) Governor’s budget eliminates the current structure that gives counties first right of refusal to operate the ADRC and opens the door for the state to contract with other entities to operate the ADRC (county, non-profit, for-profit, etc.), allows the state the flexibility to contract with single or multiple entities to operate ADRCs in regions or statewide, eliminates long-term care districts as eligible ADRC operators (currently ADRC of the Northwoods is the only ADRC in the state organized as a LTC district), allows the state the flexibility to contract with multiple entities to provide ADRC services, eliminates ADRC governing boards and regional advisory committees, allows the state Department of Health Services (DHS) to contract with a resource center or a private entity for some or all of the services—anticipates bidding out the administration of the Family Care functional screen via a statewide contract, and provides funding at the same level (no increases in cost or savings anticipated from this change).

2) JFC budget deletes all of the Governor’s recommendations to modify the statutory requirements of ADRCs and to eliminate the ADRC governing boards, requires DHS to evaluate the functional screen and options counseling functions for reliability and consistency among ADRCs and provide a report regarding these activities by Jan. 1, 2017 and requires DHS to assess which responsibilities of ADRC governing boards are duplicative with current DHS procedures and to propose changes to the statutory requirements of these boards to remove duplication no later than July 1, 2016. In addition JFC deletes the Governor’s recommendation to eliminate the long-term care advisory committee and requires DHS to study the integration of income maintenance consortia and ADRCs and present a report no later than April 1, 2016 with recommendations regarding potential efficiencies that may be gained and whether such a merger would be appropriate.

3) Senate/Assembly make no further changes to budget approved by JFC.

4) Gov. Walker does not veto changes made by JFC. DHS is required to: evaluate the functional screen and options counseling functions for reliability and consistency among ADRCs and provide a report regarding these activities by Jan. 1, 2017; assess which responsibilities of ADRC governing boards are duplicative with current DHS procedures and propose changes to the statutory requirements of these boards to remove duplication no later than July 1, 2016; and study the integration of income maintenance consortia and ADRCs and present a report no later than April 1, 2016 with recommendations regarding potential efficiencies that may be gained and whether such a merger would be appropriate.

E. Family Care/IRIS – Aging advocates are seeking to make the current Family Care program available in every county and to maintain the current level of legislative oversight and meaningful involvement of stakeholder that has occurred throughout the redesign process.

1) Governor’s budget expands a new version of the Family Care program (2.0) statewide by January 1, 2017, allows DHS the ability to choose whether managed care organizations (MCOs) include both acute and primary care services along with the current long-term care services, eliminates the IRIS (“Include, Respect, I Self-Direct”) program as an alternative to the Family Care program for those who wish to fully self-direct their long-term services and supports and provides all enrollees a “self-directed services option” within Family Care and within guidelines established by the department, eliminates long-term care districts as eligible MCO entities (currently 4 MCOs are LTC districts), moves some of the administrative functions and oversight of Family Care and MCOs from DHS to the Office of the Commissioner of Insurance (OCI), regulates CMOs as insurance entities under OCI, and eliminates the state requirement to solicit proposals for CMO contracts under a competitive sealed proposal process.

2) JFC budget deletes all of the statutory changes recommended by the Governor, but retains the projected cost-savings from statewide expansion and requires DHS to submit a waiver to CMS requesting changes to the Family Care and IRIS waiver and if the new waiver is approved to eliminate COP, CIP, and CORP when the new Family Care benefit is available statewide (by

Jan. 1, 2017 or date determined by DHS, whichever is later). In addition, to statewide expansion, require the waiver submitted by DHS to: specify that consumers receive both long-term care and acute care services, include Medicare-funded services to the extent allowable by CMS from integrated health agencies (IHAs), increase the size of the regions currently served by MCOs – no less than five regions, require multiple IHAs in all regions of the state, require IHAs to make available a consumer-directed option under the long-term care program which shall include the ability to select, direct and/or employ persons offering any of the services currently available under the IRIS program and the ability to manage (utilizing the services of a IHA serving as a fiscal intermediary) and individual home-and community-based service budget allowance, allow for audits of providers, preserve the “any willing provider” requirement for long-term care providers for a minimum of three years after the implementation date of the program in each region, establish an open enrollment period for the program that coincides with the open enrollment period for Medicare, and require the rates paid to IHAs to be set through an independent actuarial study. Later action taken by JFC in a clean-up bill (motion #999) requires DHS to submit, as part of the MA quarterly reports submitted by September 30, 2015, and December 30, 2015, progress reports regarding the development of the waiver proposal. The reports must include, but are not limited to, information regarding outcomes from discussions with representatives of consumers of long term care, long term care providers, and the federal Centers for Medicare and Medicaid Services. DHS is also required to hold no less than two public hearings regarding the proposed Family Care waiver prior to its submission to JFC.

3) Senate/Assembly make no further changes to budget approved by JFC.

4) Gov. Walker does a partial veto of the changes made by JFC. The Governor: vetoes the language requiring no less than 5 managed care regions and gives DHS the authority to determine the number of managed care regions (no minimums)- (This makes it possible for DHS to move forward with one statewide area or 2-3 large regions, but does not prevent DHS

from recognizing and securing the current managed care regions.); vetoes the requirement for rates paid to Integrated Health Agencies (IHAs) to be set by actuarial study; and vetoes the requirement for the Family Care open enrollment period to coincide with the Medicare open enrollment period and gives DHS the authority to set the period. DHS is required to submit a waiver to CMS requesting changes to the Family Care and IRIS waiver and if the new waiver is approved to eliminate COP, CIP, and CORP when the new Family Care benefit is available statewide (by Jan. 1, 2017 or date determined by DHS, whichever is later). Prior to submission of the waiver, DHS is required to submit, as part of the MA quarterly reports submitted by September 30, 2015, and December 30, 2015, progress reports regarding the development of the waiver proposal and hold no less than two public hearings regarding the proposed Family Care waiver prior to its submission to JFC. (Advocacy will be needed throughout the waiver application and implementation process to ensure meaningful involvement and input opportunities for consumers and other stakeholder.) In addition, to statewide expansion, require the waiver submitted by DHS to: specify that consumers receive both long-term care and acute care services, include Medicare-funded services to the extent allowable by CMS from integrated health agencies (IHAs), require multiple IHAs in all regions (number to be determined by DHS) of the state, require IHAs to make available a consumer-directed option under the long-term care program which shall include the ability to select, direct and/or employ persons offering any of the services currently available under the IRIS program and the ability to manage (utilizing the services of a IHA serving as a fiscal intermediary) and individual home-and community-based service budget allowance, allow for audits of providers, pres erve the “an y willing provider” requirement for long-term care providers for a minimum of three years after the implementation date of the program in each region.

F. LTC Ombudsman – Aging advocates support providing funding and position authority to the Wisconsin Board on Aging & Long Term Care for a lead ombudsman specialist and two additional

ombudsman specialists to provide services and assistance to some of Wisconsin’s most vulnerable citizens - residents of long-term care facilities and consumers of home and community-based services.

1) Governor’s budget recommends providing expenditure and position authority for a lead ombudsman specialist and two ombudsman specialists to provide services and assistance to residents of long-term care facilities and consumers of home and community-based services.

2) JFC budget approves the Governor’s recommendations.

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker approves budget recommendations as final.

G. Dementia Care Specialists (DCS) – Aging advocates support funding of these valuable DCS positions and support expansion of Dementia Care Specialists into the remaining 46 counties. (There are currently 20 DCS positions serving 26 counties – This budget item relates to 16 DCS positions currently funded by DHS.)

1) Governor’s budget recommends providing one-time funding to support the costs of dementia care specialists in selected ADRCs across the state. (Funds 12 grant positions in FY ‘17).

2) JFC budget approves the Governor’s recommendation. (*This approval leaves the funding allocation short four positions and a six month gap between the current funding for DCS positions and funding available in the next biennial budget.)

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker approves budget recommendations as final.

H. Health Aging Grants – Aging advocates are seeking a $600,000 annual appropriation to fund a private, non-profit entity (such as WIHA) to serve as a statewide clearinghouse for evidence-based disease prevention and health promotion programs in healthy aging.

1) Governor’s budget does not include funding for Healthy Aging Grants.

2) JFC budget includes $200,000 in one-time GPR funding in each year of the biennium (2015-2017) to fund a private, non-profit entity to coordinate implementation of health promotion programs in healthy aging, coordinate research on healthy aging, serve as a statewide clearinghouse on evidence-based disease prevention and health promotion programs, provide training and technical assistance to county departments/administering agencies and other providers of service to aging populations, collect and disseminate information, coordinate public awareness activities, and advise DHS on public policy issues concerning disease prevention and health promotion in aging. In addition, JFC calls for DHS to create an annual GPR appropriation for “Healthy Aging; evidence-based training and prevention.”

3) Senate/Assembly make no further changes to budget approved by JFC.

4) Gov. Walker does a partial veto of the changes made by JFC. The Governor: removes the grant administration requirements from the budget language and provides DHS the flexibility to "best address healthy aging issues." Funding for Healthy Aging Grants remains in the budget ($200,000 in each year of the budget). DHS will have increased flexibility in how the funds are used, including support for an evidence-based clearinghouse for healthy aging programs and training and technical assistance to aging units and other aging service providers as originally proposed.

I. Specialized Transportation – Aging advocates request an increase in funding to the Elder and Disabled Transportation Assistance Program (s.85.21) of 10% ($1.36 million) with ongoing annual increases to account for growth in the older adult population in Wisconsin.

1) Governor’s budget increases funding by $438,000 (1%) for elderly and disabled aids to local governments and nonprofit organizations and renames the program “Seniors and Individuals with Disabilities Specialized Transportation Aids.”

2) JFC budget approves the Governor’s recommendation.

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker approves budget recommendations as final.

J. Mass Transit – Aging advocates support investment in public transit to provide a 4% increase in calendar year 2016 equaling $5,537,100 for the biennium and to fully fund the 4 new tier C transit programs ($485,900).

1) Governor’s budget funds Mass Transit Operating Aids at current levels.

2) JFC budget approves the Governor’s recommendation.

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker approves budget recommendations as final.

K. Complete Streets – Aging advocates support Complete Streets policy which ensures pedestrian and bike ways are considered in all new and reconstructed road projects and therefore are requesting the legislature to remove the repeal of the Complete Streets policy from the budget.

1) Governor’s budget repeals the policy commonly known as Complete Streets.

2) JFC budget repeals the Complete Streets policy and replaces current law with a provision specifying that the Department would be required to give due consideration to establishing bikeways and pedestrian ways in all new highway construction and reconstruction projects funded in part or in whole with state or federal funds. Specify that the Department may not establish a bikeway or pedestrian way as part of a new highway construction or reconstruction project if either of the following apply: (a) bicyclists or pedestrians are prohibited by law from using the highway that is the subject of the project; or (b) the project is funded in whole or in part from state funds, unless the governing body of each municipality in which a portion of the project will occur has adopted a resolution authorizing the Department to establish the bikeway or pedestrian way. JFC also deleted $190,500 annually from the appropriation for the program to reflect anticipated savings from the modification of the law.

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker makes a partial veto of the requirement prohibiting DOT from constructing bike or pedestrian facilities unless municipalities pass resolutions approving such projects. This requirement will no longer apply to projects that are already underway. For all new highway construction and reconstruction projects (excluding those currently underway), the Department of Transportation must give due consideration to establishing bikeways and pedestrian ways if the project is funded in part or in whole with state or federal funds. However, DOT may not establish bike- or pedestrian ways as part of the project if bicyclists or pedestrians are prohibited by law from using the highway that is the subject of the project or the project is funded in whole or in part from state funds, unless the governing body of each municipality in which a portion of the project will occur has adopted a resolution authorizing the DOT to do so.

L. Non-emergency Medical Transportation (NEMT) – Aging network advocates support a regional brokerage model operating on a fee-for-service basis.

1) Governor’s budget makes no changes to NEMT.

2) JFC budget requires DHS to modify the current NEMT contract, to the extent permitted by the contract to exclude Jefferson, Kenosha, Milwaukee, Ozaukee, Racine, Walworth, Washington and Waukesha county MA beneficiaries from the contract and make alternative arrangements for the provision of NEMT services for beneficiaries in those counties.

3) Senate/Assembly make no changes to budget approved by JFC.

4) Gov. Walker does a partial veto of the JFC changes by removing the language excluding the specific counties (8 SE) from the current NEMT contract. No changes have been made to the NEMT contract or services. MTM’s original three year contract expires in July 2016, with an option to extend it for two additional one year periods. Aging network advocates, in cooperation with disability advocates and transportation advocates and providers, continue to work with legislators and DHS to address issues identified in the recent LAB audit report and make recommendations for a longer term solution to improving customer satisfaction, financial sustainability and CMS compliance by considering a new regional brokerage model.