Donald L. Carcieri
Global Waiver Questions & Answers
What is the Medicaid Global Waiver?
The Medicaid Global Waiver is an agreement with the federal government about how Medicaid money is spent. Medicaid, a program that funds health services for qualified elderly, disabled, children, and families, is paid for by both the federal and state governments. Under this new agreement, the federal government will relax its Medicaid rules to allow Rhode Island to spend federal Medicaid money on a broader range of services through streamlined administrative processes that would not have been possible without the Medicaid Global Waiver.
- Why does Rhode Island need this waiver?
Under the current system, federal rules governing how Medicaid money can be spent do not allow for the healthcare innovations Rhode Island envisions. The Global Waiver will facilitate increased consumer responsibility and choice, more emphasis on prevention and wellness, greater reliance on home and community based care as opposed to institutional care, and simplified administration of the Medicaid dollars.
Along with improved health care the waiver is needed to ensure that Medicaid programs remain affordable. Medicaid spending accounts for 25% of the state budget and is growing at a rate of 7% a year. With state revenue only growing at a 1.8% rate, it is easy to see that Medicaid spending is outpacing our ability to pay. That means that without changing the way we provide and pay for Medicaid services, those services are in danger of being lost. By receiving this Global Medicaid Waiver, Rhode Island will be able to preserve and improve services while keeping them affordable.
- What if the recession worsens and more and more people become eligible? Will RI run out of money?
The secondary purpose of the Global Waiver is to make Medicaid programs more affordable. So, the expectation is that RI will be saving money and, ultimately, be able to serve more people. In other words, RI will better handle an influx of people into Medicaid programs through the Global Waiver than under the existing system. Although the Global Waiver has planned for many contingencies, if unforeseen and emergent conditions arise that make the Global Waiver unworkable, the State may suspend or terminate the Global Waiver.
- Will people who now receive Medicaid-funded services lose them?
No. The State of Rhode Island is bound to follow the eligibility rules that were in place as of November 1, 2008. These eligibility rules cannot be easily changed; any changes must be approved by the state legislature and the federal government.
- Will the Governor unilaterally change eligibility for certain populations?
The Governor cannot act alone without public input and legislative approval.
- Will people in nursing homes be forced to leave?
No. Anyone who is in a nursing home and continues to need a nursing home can stay in the nursing home. With this new waiver, the goal is that people will not be forced to go into nursing homes because they lack choices. The Global Waiver will enable the State of Rhode Island to develop options for people so that more can stay in their homes with the proper supports if they so choose. Under the old Medicaid rules, this was not possible; now, Medicaid money will pay for more home and community-based care options.
- Will the global waiver offer protection from a waiting list for seniors currently eligible for nursing home services?
There is no waiting list now for nursing homes and no waiting list is anticipated under the waiver. Anyone who needs nursing home level of care will receive it.
- How will this relate to residents in assisted living that are currently on an existing waiver now?
Residents in assisted living can remain in assisted living if they so choose. Under the current system, there are limited assisted living slots. Because the Global Medicaid Waiver merges all waivers, it will open up the number of assisted living slots. In addition, the “selected contracting provision” in the Global Medicaid Waiver has the potential of paying certain kinds of assisted living differently, further opening more assisted living beds.
- What is the timetable for these programs?
The Medicaid system as we know it has grown over the last forty years. Reforming that system and making it more affordable will not happen overnight; that will take a few years. The first order of business is legislative approval. After that, the Assessment Team will be assembled and new levels of care will be drafted so that Assessment Services will be operating by July 1. In the meantime, departments will be working with providers to offer more home and community based services.
- Will there be public hearings?
Yes. This is really a community effort and the input of the public will be sought – as it has been – in addition to the legislative hearings.
- Does the waiver conflict with any state laws?
No. The waiver must conform to all state and federal laws. Changes in the Medicaid program cannot be made without public notice and legislative approval.
- How many different waiting lists will there be?
There are already waiting lists for some Medicaid-funded services. That will not change initially, but the goal of the Medicaid reforms made possible by the Global Waiver is to eliminate waiting lists.
- Who will decide whether or not a person requires nursing home or residential care?
There are already state regulations that dictate whether or not a person requires residential care. The new Global Waiver will make two differences. First of all, there will now be more alternatives to residential care so that even if a person requires a high level of care, it may be possible for him/her to receive that care in the home and community. Secondly, an assessment team of medical and social service professionals will be created that will now include the individual and family in the decision-making so that all the options can be studied and the best one chosen.
- What happens if a person or family disagrees with the assessment team’s decision about what kind of care is recommended and would be paid for?
People will be able to appeal any decision to an independent board.
- What criteria are used to decide if a person needs residential care?
People are assessed for their skilled needs or their ability to perform what are called, Adult Daily Living Skills. If they require extensive or total dependence they are eligible for nursing home care. Now, with the Global Waiver, more supports will be created that will assist people with these Daily Living Skills in their home or in less restrictive settings.
- If more than one person in the family qualifies for Medicaid help is there a preference given to keep them in their homes?
The advantage of the Global Waiver is that families can be assessed as a unit and not according to separate programs. Standards will be set for these sorts of situations, but the family will also be able to weigh in on the decision.
- Are there any built-in preferences in this system? (Who gets help first?)
Priority is based on medical necessity; those in need of the highest level of care get priority.
- We’ve heard that you’re considering a proposal for the Alliance for Better Long Term Care to send staff into nursing homes to identify candidates for return to the community and do assessments. Is that so, and what can you share with us about that?
The Alliance for Better Long Term Care has been contracted to bring good news to people in nursing homes who might want to live in their own homes or more independently. No one who is in a nursing home will be asked or forced to leave. However, those who want and are able to leave nursing homes due to new home and community based options may do so if they so choose.
- Isn’t there a nursing shortage in RI? Where will all these home care professionals come from?
Now that money is available for a different range of services, agencies and companies will make the commitment to expanding services and staff. With new opportunities created, smart companies will move toward training and recruitment to take advantage of the Global Waiver.
- What kinds of home and community based services are envisioned by this Global Waiver?
They would include: housekeeping, nutrition, nursing care, medication management, financial management, medical transportation, physical and occupational therapy, day care, home companions, coordinated medical care, assisted living and other non-institutional living arrangements.