Medicaid Community-based Attendant Services And Supports Act of 2003 (MiCASSA)
April 2003

Contact Senator Harkin or Senator Specter's office, or Representative Danny Davis or Representative John Shimkus' office.

With Medicaid Reform on the front burner, now is a good time to contact members of Congress about MiCASSA. Contact information available at:
U.S. Congress Website
U.S. House of Representative Website

A SUMMARY

MiCASSA gives people real choice in long term care options by reforming Title XIX of the Social Security Act (Medicaid) by ending the institutional bias. MiCASSA allows individuals eligible for Nursing Facility Services or Intermediate Care Facility Services for the Mentally Retarded (ICF-MR) the opportunity to choose instead a new alternative, "Community-based Attendant Services and Supports." The money follows the individual!

In addition, by providing an enhanced match and grants for the transition to Real Choice before October 2005 when the benefit becomes permanent, MiCASSA offers states financial assistance to reform their long term service and support system to provide services in the most integrated setting.

Specifically what does this bill do?

1. Provides community-based attendant services and supports ranging from assistance with activities of daily living (eating, toileting, grooming, dressing, bathing, transferring), instrumental activities of daily living (meal planning and preparation, managing finances, shopping, household chores, phoning, participating in the community), and health-related functions.
2. Includes hands-on assistance, supervision and/or cueing, as well as help to learn, keep and enhance skills to accomplish such activities.
3. Requires services be provided in THE MOST INTEGRATED SETTING appropriate to the needs of the individual.
4. Provides Community-based Attendant Services and Supports that are based on functional need, rather than diagnosis or age; provided in home or community settings like -- school, work, recreation or religious facility; selected, managed and controlled by the consumer of the services; supplemented with backup and emergency attendant services; furnished according to a service plan agreed to by the consumer; and that include voluntary training on selecting, managing and dismissing attendants.
5. Allows consumers to choose among various service delivery models including vouchers, direct cash payments, fiscal agents and agency providers. All of these models are required to be consumer controlled.
6. For consumers who are not able to direct their own care independently, MiCASSA allows for "individual's representative" to be authorized by the consumer to assist. A representative might be a friend, family member, guardian, or advocate.
7. Allows health-related functions or tasks to be assigned to, delegated to, or performed by unlicensed personal attendants, according to state laws.
8. Covers individuals' transition costs from a nursing facility or ICF-MR to a home setting, for example: rent and utility deposits, bedding, basic kitchen supplies and other necessities required for the transition.
9. Serves individuals with incomes above the current institutional income limitation -- if a state chooses to waive this limitation to enhance the potential for employment.
10. Provides for quality assurance programs that promote consumer control and satisfaction.
11. Provides maintenance of effort requirement so that states cannot diminish more enriched programs already being provided.
12. Allows enhanced match (up to 90% Federal funding) for individuals whose costs exceed 150% of average nursing home costs.
13. Between 2001 and 2005, after which the services become permanent, provides enhanced matches (10% more federal funds each) for states, which begin planning activities for changing their long term, care systems, and/or include Community-based Attendant Services and Supports in their Medicaid State Plan. SYSTEMS CHANGE
14. Provides grants for Systems Change Initiatives to help the states transition from current institutionally dominated service systems to ones more focused on community based services and supports, guided by a Consumer Task Force.
15. Calls for national 5 to 10 year demonstration project in 5 states to enhance coordination of services for non-elderly individuals dually eligible for Medicaid AND Medicare.

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Talking Points on MiCASSA

1. The demographics of our country are changing. More and more people with disabilities are living, and could be thriving! Reasons for these changes include:
   • the aging process, the graying of America,
   • children born with disabilities are living,
   • and young adults, who previously would have died from accidents or illnesses, are living -- thanks to medical technology and other advances.
2. Our long-term service system must change. Created over thirty years ago it is funded mainly by Medicare and Medicaid dollars. These are medical dollars that were not originally conceived to meet people's long-term care needs. We must think out of the box to a new system that empowers people and allows REAL choices.
3. The money should follow the individual, not the facility or provider. A national long-term service policy should not favor any one setting over the other. It should let the users choose where services should be delivered. Our current system is not neutral, and it doesn't reflect people's choices.
4. The current system is needlessly expensive. Cost-effective ways to meet people's needs must be explored. Community services have been shown to be less expensive on average than institutional services, and better liked by individuals. In FY 2000 73% of our long term care Medicaid dollars ($49.5 billion) is spent on nursing homes and other institutional services, leaving only 27% ($18.2 billion) for all community services (waivers, personal care, home health, etc.)
5. People with disabilities both old and young, even those with severe mental and/or physical disabilities, want services in the most integrated setting possible.
6. People with disabilities and their families want REAL choice, which means:
   • equitable funding opportunities,
   • no programmatic or rule disincentives to community services, and
   • options for services delivery which include agency based services, vouchers, and fiscal intermediaries.
7. Family values keep families together:
   • communities take care of their own.
   • children belong in families.
   • Mom and Dad together with their grandkids.
8. Money following the individual can eliminate overburdening rules and regulations by government regulators.
9. A functional system based on need instead of medical diagnosis could end FRAGMENTATION of the service delivery system.
10. Keeping people in the community allows the possibility for individuals with disabilities to train for work so they can become TAXPAYERS instead of TAX USERS.
11. Overwhelmingly people prefer community services to stay in their own home. The federal government needs to work in partnership with the states to create flexible delivery systems that gives people with disabilities REAL choice.
12. Change can cause fear of the unknown. There are some long time providers of services and families who believe REAL choice would threaten what they have. We cannot continue the system as it is today. It is expensive, fragmented, over medicalized and disliked by almost everyone.

Principles of MiCASSA

ADAPT believes the following principles should be incorporated as minimum standards in any national attendant services program passed by Congress and attendant programs run by the states:

1. Maximum control by the consumer to select, manage and control their attendant services, regardless of the employer of record.
2. Attendant services must be community-based, in other words, non-institutional.
3. Eligibility based on functional need, not medical diagnosis, disability and/or age.
4. Services must be available in-home and other locations.
5. Attendant services must be available 24 hours a day, 7 days a week.
6. Back up and emergency attendant services must be available as well as assistance with locating attendants as needed.
7. Program must allow for co-pay/cost sharing for people with higher incomes.
8. Delivery of service must include vouchers; direct cash payment, fiscal intermediary models, as well as consumer directed agency model.
9. Health related maintenance tasks could be delegated to, assigned to, or done by unlicensed personal attendants.
10. Voluntary training should be available for consumers.
11. Attendants should receive a livable wage and benefits.
12. Attendant services should be based on an agreed upon individual service plan.

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