The Affordable Care Act (ACA) section 10202 establishes the Balancing Incentive Payments Program or BIP. BIP offers State Medicaid programs a financial incentive to offer home- and community-based services (HCBS) as an alternative to institutional care in nursing homes. In exchange for an increased federal matching rate (Medicaid is a State-Federal jointly paid program), States must implement 3 structural changes to their long-term services and supports (LTSS) system:
1. A No Wrong Door–Single Entry Point system (NWD/SEP)
2. Conflict-free case management services
3. A core standardized assessment instrument
In March, 2013, Illinois’ State Medicaid Agency, the Department of Healthcare and Family Services, submitted a proposal to the Centers for Medicare and Medicaid Services (CMS) to participate in BIP. On June 12, 2013, CMS announced their approval of Illinois’ BIP application, which will bring in $90.3 million of Federal matching funds into the State for Illinois projected HCBS expenditures over the next 2 years.
What Does Illinois’ Proposal Look Like?
Illinois’ BIP proposal is the most comprehensive overview of the State’s various LTSS programs: from aging, to development disabilities, to physical disabilities, to mental health, to substance abuse—Illinois’ BIP proposal covers it all. For anyone who wants a crash course on what Illinois is doing in the area of LTSS balancing—the development of a LTSS system that is more home- and community-focused than institutional focused—the BIP application is a great place to start.
In reading through the BIP proposal, you will see that Illinois is planning to integrate LTSS through collaboration across governmental department silos. The BIP operating agency will be the State Medicaid Agency: the Illinois Department of Healthcare and Family Services (HFS). HFS is already working in partnership with its sister agencies on implementing BIP:
- The Illinois Department on Aging (DoA)
- The Illinois Department of Human Services (DHS)
- Division of Developmental Disabilities (DHS/DDD)
- Division of Mental Health (DHS/DMH)
- Division of Rehabilitation Services (DHS/DRS) Division of Alcoholism and Substance Abuse (DHS/DASA)
Further, Illinois’ BIP goals will build off the existing work that Illinois is doing to balance LTSS in favor of HCBS. Existing LTSS balancing projects in Illinois include:
- the closing of State institutions,
- implementation of 3 Olmstead lawsuits [Williams, Ligas and Colbert],
- the Money Follows the Person Program,
- expansion of coordinated/managed care models,
- development of the state-wide community-based Aging and Disability Resource Center (ADRC) system, and
- ongoing provision of HCBS through Medicaid 1915 (c) waivers, of which Illinois currently operates 9 waivers.
The work described in the BIP application details how Illinois will implement the 3 structural requirements of BIP: a no wrong door–single entry point system (NWD/SEP), conflict-free case management services, and core standardized assessment instrument. These 3 areas are described below briefly. It is important to note that currently Illinois has separate systems for each sub-population served in its LTSS programs: aging, physical disability, mental health, substance abuse, development disability. BIP provides Illinois with the opportunity to coordinate across the population groups from the community and consumer level, all the way up to the State government level.
1. Illinois’ No Wrong Door–Single Entry Point system (NWD/SEP)
Entry points for LTSS are not currently coordinated across aging and disability populations. Current access points include: DHS local offices, Aging and Disability Resource Centers (ADRCs), Area Agencies on Aging (AAAs), Division of Rehabilitation Services local offices, Pre-Admission Screening agencies that serve persons with intellectual/developmental disabilities, community mental health centers and regional mental health points of contact, and State agency websites.
The ADRC network offers a starting place to coordinate across all of these different access points. Under the leadership of Illinois Department on Aging, the vision for the ADRC system is “a highly visible and trusted resource for all persons regardless of age, income and disability, to access a coordinated point of entry to public long-term support programs and benefits, and to obtain information on the full range of long-term support options”. [See page 31 of the BIP proposal].
Illinois’ ADRC system is already in development with 7 ADRCs up-and-running across the state—through AAAs in collaboration with disability organizations. It is anticipated that by September 2016, all of Illinois’ 13 Planning-and-Service-Areas (PSAs) will have designated ADRCs through leadership from Illinois’ AAAs. ADRC entities also currently include Care Coordination Units, Community Care Program providers, Centers for Independent Living, and DoA’s Senior Help Line (a State-wide toll-free phone number).
The NWD/SEP system will allow for individuals to receive a level 1 screen to determine which LTSS an individual should be assessed for. Access to this level 1 screen will be available online through a coordinated network of ADRC partners.
2. Illinois’ Conflict-Free Case Management Services
Illinois has different case management systems for each population group served. To ensure conflict-free case management, per Federal guidance, Illinois will work to separate the determination of eligibility process from case management, and from the direct delivery of services.
In the BIP proposal, Illinois describes the current developmental disability and physical disability processes to be conflict-free. However, more work needs to be done in the area of mental health/substance abuse and aging to ensure conflict-free case management [see pages 23-24 of the BIP proposal].
The expansion of managed care models in Illinois will help to promote conflict-free case management. With the help of BIP funds, Illinois will also continue to work with CMS to identify potential conflicts of interest and to develop the proper firewalls between eligibility determination, case management and service delivery.
3. Illinois’ Core Standardized Assessment Instrument
Over the past year, Illinois human service agencies have collaborated with Navigant consulting to review Illinois’ current assessment tools and methodology (each population currently has their own assessment tool). With Navigant, Illinois will develop a uniform assessment tool (UAT) for access to LTSS. Recently, HFS released a Request for Information related to the development of the UAT as the State seeks out vendors who can integrate and coordinate across populations and State departments.
A UAT will allow Illinois’ to develop a more consumer-centered LTSS system. Many individuals with LTSS needs require complex care and fall into more than one category across the current Medicaid HCBS waiver system. This means that consumers with mental health needs who are also 60 years or older must access two separate programs to have their needs meet: one in mental health and the other in aging. This makes it very challenging for consumers, and cumbersome and redundant for State agencies. BIP is intended to fix this, to ease access to LTSS in a more timely and appropriate way.
Further, Illinois is also replacing the 30-year old COBOL-based system that is currently in use to determine eligibility for: Medicaid, the Supplemental Nutrition Assistance Program (SNAP, formerly ‘food stamps’), Temporary Assistance for Needy Families program (TANF), and the new Health Benefits Exchange, or Marketplace, required by the ACA. The new Integrated Eligibility System (IES) is branded as Application for Benefits Eligibility, or ABE.
What all of this means for professionals and consumers is that Illinois is moving towards a system that will significantly streamline the determination of eligibility process for a variety of different programs, including LTSS. Part of this systemic upgrade includes ensuring better Information Technology (IT) integration and easier access to data about these publicly funded programs across population types.
Stay Tuned as Illinois Continues to Balancing LTSS in Favor of HCBS
As Illinois implements BIP and its other LTSS balancing programs, the State’s goal is to develop a new HCBS infrastructure that is consumer driven and easy to access and navigate. We look forward to reporting back as consumers across the State find it easier to live and receive care in their homes and communities.
Please let me know if you have questions, comments or responses to this blog post. You can reach me at: 312.372.4292 or email@example.com.