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Some Questions and Answers About the Medicaid Community Attendant Services And Supports Act

  1. How are community attendant services and supports defined in MiCASSA?  
  2. In MiCASSA, the term community attendant services and supports means help with accomplishing activities of daily living (eating, toileting, grooming, dressing, bathing, and transferring) instrumental activities of daily living (meal preparation, managing finances, shopping, household chores, phoning, and participating in the community), and health-related functions (which can be delegated or assigned as allowed by state law). These can be done through hands-on assistance, supervision and/or cueing. They also include help with learning, keeping and enhancing skills to accomplish such activities.PHOTO: Mike Oxford of ADAPT

    These services and supports, which include back-up, are designed and delivered under a plan that is based on a functional needs assessment and agreed to by the individual. In addition they are furnished by attendants who are selected, managed, and dismissed by the individual, and include voluntary training for the individual on supervising attendants.

    MiCASSA specifically states that services should be delivered, "in the most integrated setting appropriate to the needs of the individual" in a home or community setting, which may include a school, workplace, or recreation or religious facility.

  3. If someone can't manage their attendant services completely independently are they still eligible for MiCASSA services?
  4. Yes! People who have difficulty managing their services themselves, due to a cognitive disability for example, can have assistance from a representative, like a parent, a family member, a guardian, an advocate, or other authorized person.

  5. Do you have to be impoverished to be eligible for MiCASSA?

    No. If you are eligible to go into a nursing home or an ICF-MR facility you would be eligible for MiCASSA. Financial eligibility for nursing homes is up to 300% of the SSI level (roughly $1,500 for a single person). In addition, states can choose to have a sliding fee scale for people of higher incomes; MiCASSA specifically references this as an incentive for employment. This sliding fee scale can go beyond the current Medicaid eligibility guidelines.

  6. Is MiCASSA biased towards an agency delivery model?

    No. MiCASSA assumes that one size does not fit all. It allows the maximum amount of control preferred by the individual with the disability. Options include: vouchers, direct cash payments or a fiscal agent, in addition to agency delivered services. In all these delivery models the individual has the ability to select, manage and control his/her attendant services and supports, as well as help develop his/her service plan. Choice and control are key concepts, regardless of who serves as the employer of record.

  7. Will MiCASSA replace existing community-based programs?

    MiCASSA does not effect existing optional programs or waivers and includes a maintenance of effort clause to ensure these programs are not diminished. Waivers include a more enriched package of services for those individuals who need more services. With MiCASSA, people who are eligible for nursing homes and ICF-MR facilities can choose community attendant services and supports as a unique service that is a cost-effective option. The money follows the individuals not the facility.

  8. Is MiCASSA a new unfunded mandate?

    No. MiCASSA is a way to make the existing mandate for nursing homes, and the virtual mandate for institutions for people being served by the various state Mental Retardation/Developmental Disability systems, responsive to the needs and desires of the consumers of these services. MiCASSA says the people who are already eligible for these services will simply have a choice of where they receive services. MiCASSA would adjust the current system to focus on the recipients of service, instead of mandating funding for certain industries and facilities.

  9. Why is MiCASSA needed?

    Our current long term services system has a strong institutional bias. Seventy five percent of Medicaid long term care dollars go to institutional services, leaving 25% to cover all the community based services. Every state that takes Medicaid funds must provide nursing home services while community based services are completely optional for the states. MiCASSA says, let's level the playing field, give the person, instead of government or industry, the real choice.PHOTO: Syndy Sharp of ADAPT

  10. Will MiCASSA bust the bank? What about the "woodwork" effect?

    MiCASSA assures that a state need spend no more money in total for a fiscal year than would have been spent for people with disabilities who are eligible for institutional services and supports.

    There is a lot of discussion about the people who are eligible for institutional services, would never go into the institution, but would jump at the chance to use MiCASSA. (This is called the woodwork effect.) The states of Oregon and Kansas have data to show that fear of the woodwork effect is blown way out of proportion. There may be some increase in the number of people who use the services and supports at first, but savings will be made on the less costly community based services and supports, as well as the decrease in the number of people going into institutions.

    Belief in the woodwork effect assumes a lot of "free care" is now being delivered by caregivers. There is a real question whether this care is truly "free". Research on the loss to the economy of the "free" caregivers is beginning.

  11. What are the transitional services?

    Currently Medicaid does not cover some essential costs for people coming out of nursing homes and ICF-MR facilities. These include deposits for rent and utilities, bedding, kitchen supplies and other things necessary to make the transition into the community. Covering these costs would be one of the services and supports covered by MiCASSA.

  12. How is Quality Assurance addressed in MiCASSA?

    States are required to develop quality assurance programs that set down guidelines for operating Community Attendant Services and Supports, and provide grievance and appeals procedures for consumers, as well as procedures for reporting abuse and neglect. These programs must maximize consumer independence and direction of services, measure consumer satisfaction through surveys and consumer monitoring. States must make public results of the quality assurance program public as well as an on-going process of review. Last but not least sanctions must be developed and the Secretary of Health and Human Services must conduct quality reviews.

  13. What is the purpose of the Real Choice Systems Change Initiatives section of the bill?

    PHOTO: Suzanne Colsey of ADAPTMiCASSA brings together on a consumer task force, the major stakeholders in the fight for community-based attendant services and supports. Representatives from DD Councils, IL Councils and Councils on Aging along with consumers and service providers would develop a plan to transition the current institutionally biased system into one that focuses on community-based attendant services. Closing institutions, or at least closing bed spaces must be thought through by the people that have an investment in the final outcome, the consumers. The plan envisions ending the fragmentation that currently exists in our long term service system.

    In addition, the bill sets up a framework and funding to help the states transition from their current institutionally dominated service model to more community-based services and supports. States will be able to apply for systems change grants for things like: assessing needs and gathering data, identifying ways to modify the institutional bias and over medicalization of services and supports, coordinating between agencies, training and technical assistance, increasing public awareness of options, downsizing of large institutions, paying for transitional costs, covering consumer task force costs, demonstrating new approaches, and other activities which address related long term care issues.

Return to the MiCASSA Information Index


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