- How are community attendant services and supports defined in MiCASSA?
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
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
- If someone can't manage their attendant services completely
independently are they still eligible for MiCASSA services?
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.
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
- 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.
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.
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.
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.
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
- 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.
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.
What is the purpose of the Real Choice Systems Change Initiatives
section of the bill?
MiCASSA 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.