NAMI Minnesota Legislative Update – June 24, 2012
DHS Unveils Far-Reaching Medical Assistance Reform Proposal
Early this week, the Minnesota Department of Human Services (DHS) released a package of proposed reforms to Medical Assistance (MA), the state’s Medicaid program. The 140-page proposal, also known as MA Reform 2020, is seeking permission from the Federal government to reshape MA in a number of ways. The 30-day public comment period on the Reform 2020 section 1115 waiver request began June 18, 2012.
The 2011 Minnesota Legislature directed the Department of Human Services (DHS) to develop a proposal to reform the Medical Assistance Program. Goals of the reform include: community integration and independence; improved health; reduced reliance on institutional care; maintained or obtained employment and housing; and long-term sustainability of needed services through better alignment of available services that most effectively meet people's needs.
DHS has developed the section 1115 Medicaid waiver request entitled Reform 2020 in order to implement several key components of the overall Medicaid reform initiative.
A copy of the Reform 2020 section 1115 waiver request is posted on the DHS website at https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6535A-ENG. A copy of the notice announcing a 30-day comment period on the Reform 2020 section 1115 waiver request was published in the Minnesota State Register on June 18, 2012.
DHS is holding two public hearings to gather input on the proposal. The first hearing, held Friday, featured testimony from over a dozen individuals, almost exclusively parents of children with Autism who were concerned about potential reductions to their children’s services as a result of the proposal. At the conclusion of the hearing, DHS sought to clarify that the proposal was not intended to reduce any services.
NAMI Minnesota and other members of the Mental Health Legislative Network (MHLN) will be testifying at a second hearing on Monday to highlight the concerns of the mental health community. Both NAMI and MHLN will be submitting written comments as well, which will be included with the proposal when it is submitted to the Federal government for approval.
The overall goals of the reforms are to:
· Achieve better health outcomes
· Increase enrollee independence
· Increase community integration
· Reduce reliance on institutional level of care
· Simplify administration and access to program
· Create a program that is more financially sustainable
NAMI Minnesota has read over the document. Here are the major components that will impact people with mental illnesses and our brief initial comments.
Community First Services and Supports: This will replace the current Personal Care Assistance (PCA) program. There will be a program for people who do and do not meet the nursing facility level of care criteria. For those that don’t meet the NFLOC, they will need to have one Activity of Daily Living or a Level One Behavior. MNChoices will provide the basis upon which to assess and plan for a person. People can use a provider or self-direct services. NAMI is concerned that this may not address the key issue affecting people with mental illnesses, that being that the number of units of service per day (often a half hour) is too little to truly help keep people in the community.
Children’s Demonstration: There would be a pilot project with schools to provide services coordination for children using PCA services in and out of school and year round. The children must have high need or complex medical/health care problems or mental health needs. NAMI wants to know how this coordinates with school-linked mental health services and how schools would be able to bill for services provided in the home.
Employment supports: These would be targeted to adults ages 18 – 26 with a severe mental on illness on MA or MA-EPD, certain people on MFIP (Minnesota’s welfare program) or identified as in transition from the Department of Corrections or youth exiting foster care. They would have to be employed, been employed within the last year or lost hours/wages within the past year. The services would include outreach (letters and phone calls to them), navigators providing help in accessing services, phone assistance for employment and life planning, and problem solving. This will be tied to the Disability Linkage Line. NAMI is extremely concerned that since this is being targeted to people with mental illnesses that the IPS model, an evidence-based practice for assisting people with mental illnesses obtain employment, is not being considered.
Housing stability: New services would be developed in three categories: outreach/in-reach, tenancy support services and service coordination. This would be targeted to people who have a functional impairment are homeless, are at risk of being homeless, or need housing to move out of a hospital, CD residential treatment, jail/prison, or nursing facility. NAMI is concerned with the qualifications of the providers and that existing excellent outreach workers for homeless programs would not be able to be funded under this program.
In addition, they propose to fund the Project for Assistance in Transition from Homelessness (PATH) and Critical Time Intervention (CTI ) models.
Anoka: They are asking for an exclusion of the Medicaid IMD (institute for mental disease) which bars Medicaid funds from being used in institutions that treat people with mental illnesses (more than 15 beds). Because Minnesota has largely reduced its state hospital beds and developed community based hospitals and residential facilities, the state is arguing that the IMD exclusion should be waived by the feds. By doing this, people will be able to be on MA, and utilize programs like “the money follows the person” so that they transition more easily into the community.
Children with Autism: They are seeking to deliver early intervention services for children ages birth to 7 with Autism.
Mental Illness: They are asking to target services to people with a serious and persistent mental illness that have at least two of the following that is specifically related to symptoms of the person’s mental illness
a. assaults,
b. verbal aggression,
c. active or recent chemical dependency that exacerbates mental illness symptoms,
d. past criminal behavior,
e. symptoms of mental illness that do not respond to treatment and require more than eight hours of supervision per day to assure safety.
f. the presence of another illness, condition or disability that, when combined with the persons mental illness, results in inability to function in the community or inability to find supportive services in the community as a result of similar or other issues and
They must also have difficulty in finding and maintaining community services and living arrangements as evidenced by extended stays at a hospital after the staff have determined that they no longer need hospital level of care. This is tied to the Anoka proposal above.
This option would include additional services for individuals with the very high needs noted above. These services would include In-depth Assessment of Functioning; Clinical Direction of Services; Development of a Recovery-Oriented Service Plan; Tenancy Supports including in-reach services (e.g., engagement, risk assessment, transition services), assistance locating and retaining housing and other housing-related service coordination; Mental Health Symptom Management; Assistance with Substance Abuse and Dependency Issues; Family support and education; Supported Employment; Community integration services; Caregiver support and respite; Medication education, assistance and administration; Primary health care and dental care coordination; Financial and Health Care Benefits Navigation; Basic living skills; Transportation; Oversight, and supervision.
NAMI’s concern is that it is so limiting and does not include young adults who may have experienced their first psychotic episode and who could really benefit from short-term intensive supports and treatment. We must provide the necessary intensity early on to prevent people from becoming disabled from their mental illness. In addition, we are concerned that it is tied to being in an institution instead of supporting people to live in the community and prevent institutionalization.
Complex needs: They are proposing specialized services to people who have co-occurring developmental disabilities, cognitive impairments, serious mental health conditions, and diagnosed with a sexual disorder and/or antisocial personality.
NAMI and others will be meeting with the Mental Health Division in July to provide further input into the state’s proposal. NAMI has long advocates for a Medicaid waiver that is specifically for people with mental illnesses to better meet their needs.
If you have any thoughts or concerns, please share them with us by emailing us at
Access Work Group – Essential Benefit Set
This past Thursday the Access Work Group – a joint workgroup of the Health Care Exchange Task Force and the Health Care Reform Task Force met to discuss affordability and the essential benefit set. The group generally agreed that the premiums should be made more affordable than those levels provided in MinnesotaCare. Phillip Cryan recommended that for individuals with and without children premiums should be at 0% of their income and for adults without children between 151% to 200% of poverty it should be between .11% and 5.62% and for individuals with children it should be .075% to 3.76%.
Grace Tangjerd Schmitt and Pat Kiland from Guild Incorporated testified to the importance of providing specific mental health services, particularly the model mental health benefit set. Mark Sander from Hennepin County provided information on the need for children’s mental health services and the success of theschool-linked mental health grants. Two individuals who live with a mental illness shared their stories regarding how important access to mental health treatment is, including making sure premiums and co-payments are affordable.
Sue Abderholden, from NAMI Minnesota, who is a member of the task force, provided information to the work group about the costs of various services and the listing from the Minnesota Mental Health Action Group on recommendations for the model mental health benefit set. Ron Brand provided a letter from the MN Association of Community Mental Health Program expressing their support for including the model mental health benefit set in the exchange.
At the end of the meeting, the task force voted to include the model mental health benefit set. Thanks to every one who helped in this effort.
Housing
The Minnesota Department of Human Services and the Minnesota Housing Department arecollaboratingon proposal for ademonstration project to create around 250-300 new supportive housing units for people ages 18-62 with a disability (including a serious mental illness). The funding would be available under the revised Section 811 federal housing assistance program. Here is information about the program:
· Competitivefunding for states to do new and innovative demonstration projects with the eventual goal of helping states "systematically and effectively create integrated and highly cost-effective supportive housing units."
· Project-based, rental assistance approach using existing housing units. Multi-family properties only, with a limit of 25% of a building's units being used for the project.
· Eligibletenants:
o 30% of Area Median Income or below
o Household must include at least one individual age 18-62 with a disability
o Eligible for community-based, long-term care services (including but not limited to Medicaid waivers, Medicaid state plan options or state funded services)
They are now working through the process of figuring out what populations of people to target, what support services should be included and how to work the outreach andreferralcomponents. There is a meeting this Monday (June 25) to keep gathering input about the proposal. It will be from 1:30-3:30pm at DHS (444Lafayette Road).
NAMI is interested in your feedback:
· Are there any particular populations that MN should focus on with the demo project (e.g. geographic areas, disability type, people experiencing homelessness, people leavinginstitutions, people leaving corrections, age, etc.)?
· What are some best practices for integrating services and housing?
· What types of services need to be made available?
· What issues should be considered when designing the services integration model?
· What considerations should be made when choosing housing developments to be part of the program?
· What should the outreach and referral process for prospective tenants look like?
· What types of innovations should MN propose?
· What things should be considered when evaluating the project?
Please e-mail your thoughts to
U.S. Senate Hearing Explores Impact of Solitary Confinement on Mental Health
The U.S. Senate Judiciary Committee held on hearing Wednesday to gather testimony about the impact of solitary confinement on prisoners. Ron Honberg, Director of Policy and Legal Affairs at NAMI’s national office, testified before the committee about the devastating toll solitary confinement takes on a person’s mental health, particularly someone with a pre-existing mental health condition. “Placing individuals with severe psychiatric symptoms in solitary confinement is akin to pouring gasoline on a fire,” he explained, “It is an almost sure fire guarantee to lead to a worsening of symptoms.” Solitary confinement has been shown to greatly exacerbate the symptoms of mental illnesses, such as paranoia and hallucinations and increase the likelihood of self-harm and/or suicide.
Mr. Honberg highlighted the fact that the correctional system is woefully unequipped to serve prisoners with mental illnesses, which only makes the situation worse. The U.S. Department of Justice estimates 24 percent of prisoners in the U.S. have a diagnosed mental illness, however most corrections systems lack the expertise and resources to address the symptoms of these individuals’ illnesses. This often leads to an unnecessary and excessive reliance on solitary confinement, either as punishment for the behaviors resulting from the symptoms of an untreated mental illness or because a person isn’t able to function in the general population. “Whatever the reason, these placements are highly inappropriate and cause extreme suffering and often long term damage,” Mr. Honberg said.
While several states have enacted legislation to limit the use of solitary confinement, NAMI called on the federal government to take action as well. Mr. Honberg offered several recommendations to help reduce the use of solitary confinement as well as divert children and adults with mental illnesses away from the criminal justice system to ensure they can access the treatment and services they need:
· Mandate meaningful reforms and reductions in the use of solitary confinement by tying federal funding for corrections to efforts by states to establish alternatives to solitary confinement and reduce number of people placed in these settings.