Extension of Increased Federal Medicaid Matching (FMAP)

NAELA Public Policy Guidelines

The following public policy guidelines supplement the NAELA public policy guidelines on “Financing Long-Term Care” and “System for Delivering Long-Term Care” and the NAELA white paper: "Reforming the Delivery, Accessibility and Financing of Long-Term Care in the United States."

A. General
Based on the experiences of NAELA’s members with millions of clients who are seniors or individuals with disabilities, NAELA supports a national long-term care system that provides comprehensive services, including home and community-based and institutional services, to people with serious physical and cognitive impairments. NAELA believes that the federal government has a fundamental role in guaranteeing access, setting quality standards, and financing this system. NAELA recommends that the Medicare program be expanded to become the primary provider of long-term care based on level of impairment. NAELA believes that until a comprehensive system for long-term care financing and services for all Americans is in place, Medicaid should continue its role in that regard as a federal-state program, with a guarantee of coverage of specific benefits to all individuals eligible under state plans, income eligibility rules that take into account out-of-pocket medical expenses including long-term care, protections against impoverishment of spouses and dependent and disabled children of nursing home residents, and funding to accommodate growth in the need for assistance.

1. NAELA supports:

a. A guarantee of health care to the most vulnerable populations: low income older people, people with disabilities and families with children;
b. The roles of both the public and private sectors in providing for long-term care and in reducing a person's risk of impoverishment when paying for long-term care; and

2. NAELA believes that the following would help to improve the current system:

a. Congress should authorize and encourage states to use Public-Private Partnership models to assist individuals in meeting the cost of long-term care; and
b. NAELA has supported and continues to support efforts to expand the Long-Term Care Partnership Program. NAELA also acknowledges and supports other innovative efforts at the state level to expand the Partnership model to recognize self-insurance options and other sources of payment, in addition to Long Term Care Insurance, to qualify for Partnership Medicaid coverage and preservation of assets benefits. These efforts, such as the New York Compact, should be fair to all persons in need of long-term care, provide innovations that can help Medicaid financially, and preserve all existing due process protections; and
c. The Centers for Medicare and Medicaid Services (CMS) should encourage research and demonstration waivers to expand opportunities for access to long-term care insurance, such as through guaranteed access (e.g., the "Medigap" model) and tax relief.

B. Medicaid Restructuring

1. NAELA supports increased federal contributions to Medicaid in order to assist states.

2. NAELA recognizes the financial burden that states face, but opposes any structural or financial changes in the Medicaid program that would weaken the current obligation that the federal and state governments have to provide a comprehensive set of benefits to all individuals who meet eligibility criteria.

3. NAELA believes that any restructuring of Medicaid must:

a. Maintain the government's guarantee that all people who qualify for Medicaid will be covered whether in a facility or community-based setting;
b. Ensure that the Nursing Home Reform provisions are retained in Medicaid law, not weakened, and that they are
c. Maintain and improve current federal and state due process protections, most specifically in the area of outlining circumstances of undue hardship, which would deprive otherwise eligible individuals from receiving needed care;
d. Ensure that financing policies and payment strategies do not compromise access and quality;
e. Include efforts to provide Medicaid coverage to the working poor; and
f. Ensure that consumers have a voice in the restructuring process.

4. NAELA opposes any restructuring that would:

a. “Block grant” or otherwise cap the amount that states receive from the federal government for Medicaid including both “super-waivers” or waiver agreements between states and the federal government;
b. Allow states to reduce the populations they serve under the Medicaid program or drop current program beneficiary protections, including the requirement that the same benefits be offered throughout the state;
c. Charge beneficiaries more than minimal co-payments;
d. Reduce the requirement that all nursing homes receiving Medicaid funding adhere to federal standards, including residents’ rights; or
e. Lift the prohibition against placing liens on Medicaid beneficiaries’ property except in certain situations, lift the prohibition against placing liens on the property of family members, lift the prohibition against recovering from estates of Medicaid beneficiaries except in explicit circumstances, or lift the prohibition against recovering from the estates of family members.

C. Benefits and Coverage

1. NAELA believes that Medicaid’s benefit package should provide access to the most current and effective medical treatments and technologies, a comprehensive range of facility-based and community-based health, social, and support services, and should include health promotion and preventive care for all beneficiaries, including those with chronic illness.

2. NAELA strongly supports the current standard for nursing facility services paid for by Medicaid that each resident receives the long-term care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with a comprehensive plan of care or self-directed care plan. This standard should apply to all long-term care services, regardless of where they are provided.

3. NAELA supports a Medicaid system in which:

a. Services must be required to be provided in sufficient scope and quantity to achieve their purpose in the least restrictive environment appropriate for the individual receiving services; and
b. The needs of persons with dementia or other mental disabilities are met effectively; and
c. Expansion of models like the Programs of All-Inclusive Care for the Elderly (PACE) for people age 55 and older is a priority.

D. Eligibility

1. NAELA supports a single, uniform minimum federal standard of eligibility and administration for Medicaid. Uniform laws and regulations are necessary for approval of Medicaid applications, denial of coverage, and the appeals process.

2. NAELA believes that:

a. All states should be required to provide full Medicaid coverage for all people living at or below 100 percent of the federal poverty level and to have a “medically needy” program that provides full Medicaid benefits to people of all ages with high medical bills; and
b. States should be encouraged to liberalize their income and Medicaid asset rules for eligibility beyond the minimum required by federal law.

E. Affordability
Until such time as the federal government takes full responsibility for all the health care of low-income Medicare beneficiaries, NAELA supports current policy that requires Medicaid to pay premiums and cost-sharing for Medicare beneficiaries with incomes at or below 100 percent of federal poverty levels. NAELA also supports a change in the law to provide Medicare Part B premium protection to all Medicare beneficiaries with incomes up to 200 percent of poverty.

1. NAELA believes that:

a. Medicaid services must continue to be provided with only nominal cost-sharing and should not place financial hardship on beneficiaries, their spouses and dependents;
b. The Federal and state governments should ensure that all people covered by Medicaid have access to health care providers; and
c. The Federal and state governments should continue to refine their understanding of who does and does not participate in the Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB) programs for the purpose of targeting outreach to those eligible but not participating.

F. Consumer Protections and Quality

1. NAELA supports impartial decision-making accomplished by a system of both internal and external review and that each person or his/her health care proxy, if applicable, must receive meaningful notice of all major decisions affecting his or her care in language that is easily understood, full access to information, and assistance with appeal to an impartial decision maker in a timely manner.

2. NAELA believes that:

a. Medicaid quality assurance standards must, at a minimum, include internal and external quality review, grievance and appeals procedures, monitoring and oversight by the state and sanctions for violations of quality standards;
b. Medicaid beneficiaries must have the right and opportunity to enforce their guarantee of coverage in federal and state courts;
c. Medicaid must work to find new ways to prevent under use, overuse, and misuse of health care services;
d. Medicaid providers must consistently offer high-quality care under strong national and state standards that are effectively enforced; and
e. Medicaid must support consumer choice and participation with respect to all decisions regarding the nature, timing, and setting for delivery of care.

G. Waivers

1. NAELA believes that Section 1115 Medicaid Waivers should be evaluated and approved based on their prospects for expanding services or populations served, improving quality of service or delivering service more effectively and efficiently.

a. In particular, Section 1115 Medicaid Waivers should, where appropriate, favor the provision of services in a community-based setting over the provision of services in a facility setting.
b. Section 1115 Medicaid Waivers designed to enhance the independence and dignity of those living in the community should be given preference.

2. NAELA opposes block grants or otherwise capping the amount that states receive from the federal government for Medicaid including both “super-waivers” or waiver agreements between states and the federal government.

3. NAELA believes that all Section 1115 Medicaid Waivers should meet the following criteria:

a. Services that would be covered under Medicaid must continue (at a minimum) in the same amount, duration, and scope for all eligible people;
b. Beneficiaries eligible for both Medicare and Medicaid must retain full rights under both programs, including consumer protections and grievance procedures;
c. Applications should include a beneficiary impact statement and a plan for ongoing monitoring of the impact on each category of beneficiary, including access and quality; and
d. States must not be permitted to make federal income and asset rules or spousal impoverishment rules more restrictive under waivers.
e.  Consumers/the public must be involved in the waiver process at the state and federal levels, and public input must be a part of the state’s application,

i. Consumers/the public must be involved in the waiver process at the state and federal levels, and public input must be a part of the state’s application, specifically;
ii. States should create a waiver implementation commission or process for ensuring public input throughout the process–review and comment on initial waiver request, review and approve final waiver request, etc.; and
iii. The Centers for Medicare and Medicaid Services (CMS) should establish a waiver review panel of consumers, providers, and federal and nongovernmental technical experts to receive testimony and comments and to make recommendations regarding waiver applications to CMS.
iv. States which provide for “medically needy” eligibility for institutional services under their regular Medicaid State Plan should be required to provide the same “medically needy” income criteria under their Section 1115 Medicaid Waivers.

H. Education

1. NAELA supports public education about the possible need for long-term care and the availability of financing options, including long-term care insurance.

2. NAELA believes that states should:

a. Conduct outreach activities and promote Medicaid and the State Children’s Health Insurance Program (SCHIP) in order to improve participation; and
b. Establish legal assistance programs to help Medicaid beneficiaries who have trouble obtaining services or paying their medical bills or face incorrectly processed claims.

I. Administration

1. NAELA believes that the Medicaid program must:

a. Be administered fairly, adequately, and efficiently, and that appropriate funds must be provided for program administration; and

b. Reduce waste, fraud, and abuse to ensure value for the program and for the beneficiaries.

Resolutions adopted by the NAELA Board of Directors July 11, 2003
Revised November 11, 2004 and June 29, 2007
Posted March 2013