Abstract The State of Maryland proposes to implement a Money Follows the Person Demonstration Program statewide, beginning July 1, 2007 through December 31, 2011 for eligible persons who express a desire to transition to qualified community residences from nursing facilities (NF), intermediate care facilities for the mentally retarded (ICF/MR), chronic care hospitals, and public institutions for mental diseases (IMD). The State is committed to transitioning a total of 5,832 individuals during the demonstration period, and is estimating that half, or 2,916, of these individuals will be eligible demonstration participants. The State proposes to implement an aggressive identification and transition assistance program throughout the State from day one of implementation, using transition teams of professionals as well as peer counselors who have experienced institutionalization themselves to canvass facilities and identify potential individuals for transition to the community. Transition services will include, in addition to aggressive, comprehensive outreach, increased efforts to make community-based options information available to persons living in institutions, identification and follow-through with individuals expressing a desire to transition, assistance with eligibility determination process for community-based services, assistance with identifying and securing affordable and accessible housing, help with establishing a household, assistance in securing home- and community-based (HCB) services and providers as well as non-Medicaid services (food stamps, etc.), peer-counseling and mentoring prior to and after transitions, and an evaluation of nutritional needs and coordination with nutrition services. Demonstration participants will receive a full-range of qualified HCB services and HCB demonstration, aligning with the rich service packages of existing HCB waivers to ensure that all demonstration participants will have equal access to the full range of services. In addition, the State is proposing to include supplemental non-Medicaid demonstration services, such as housing subsidies and non-Medicaid transportation services. Thus, in sum, each participant will have available a comprehensive set of services from the moment they decide they want to transition, through to a full set of supports and services. The State intends that the transition services will be “one-time-only” in nature, in that by the end of each participant’s 12-month participation, the transition services will no longer be required. All participants will seamlessly transition to waiver services at the conclusion of their demonstration participation period. The State engaged in an extensive process to gather, listen to, and incorporate stakeholder (including provider) concerns and recommendations. The State conducted two large public meetings and conducted focus groups in six institutions, and then shared two drafts of the narrative portions of the application and responded further to comments. The State is committed to the continued direct, vital participation of the stakeholder and provider communities in the implementation and decisions surrounding Maryland’s Money Follows the Person demonstration program.

PART 1: SYSTEMS ASSESSMENT AND GAP ANALYSIS Maryland has made steady progress over the past twenty-five years in rebalancing its long-term support system by expanding the network of home and community-based services (HCBS) that provide increasing opportunities for individuals to avoid institutional care and to transition out of institutions into community-based settings. Maryland has seven home and community-based service (HCBS) waivers, five of which were implemented within the last five years, and the Medicaid State Plan offers adult medical day care and personal care. In 2004, a legislative initiative established a Money Follows the Individual program that guarantees individuals in nursing homes an opportunity to transition to community-based waivers regardless of any budgetary caps on waiver enrollments. However, considerable work is still needed to fully implement our Money Follows the Individual policy to our State Residential Centers, State Psychiatric and Chronic hospitals and nursing facilities; expand community-based services; comprehensively evaluate and overhaul our eligibility system; divert individuals from nursing home or other institutional care; and intensify efforts to identify and successfully transition individuals from institutional placement into community settings. 1. Current Long-Term Support Systems In FY 2005, approximately 26,000 people received Medicaid long-term care services in institutions. An additional 26,352 received community-based long-term care services through HCBS waivers or the Medicaid State Plan. Although this section is focused primarily on Medicaid programs, there are also a number of State funded programs that provide community-based services to over 7,000 people annually.

program, called “CommunityChoice”, is discussed in detail below and in Part 2. SB620 (2004) Money Follows the Individual Accountability Act: DHMH will identify and assist nursing facility residents who are interested in transitioning to the community. SB754 (2006) Caregivers - Voluntary Tax Withholding: DHMH must provide voluntary withholding of any applicable federal and State income taxes for self-employed providers of health care services such as attendants, personal care aides, personal care providers, and respite care workers who provide services to recipients participating in HCBS waivers or the Medicaid state plan community services. 2. Current Efforts to Rebalance Maryland’s Resources In the last five years, Maryland has received seven Real Choice Systems Change grants on specific issues including transition from nursing homes to the community, discharge from hospitals to the community rather than to nursing homes, and streamlining eligibility processes. (See Appendix C) Populations targeted by the grants include adults with physical disabilities, older adults, and children with disabilities. Three Systems Change grants were directed toward diverting people from nursing home care or assisting people to transition from nursing homes to the community. One grant provided valuable information and experience in working with hospital discharge planners to help transition people to the community from acute care rather than to nursing homes. Two grants, one through a State agency and another through Making Choices for Independent Living to the six centers for independent living (CILS), were directed toward working with individuals in nursing homes to transition to community-based services. Maryland also received a Systems Change grant to develop an Aging and Disability Resource Center (ADRC) Project known as Maryland Access Point (MAP). This year, the ADRC

Maryland is the Maryland State Disability Navigators Program to better inform beneficiaries and other people with disabilities about the work support programs now available to achieve seamless, comprehensive, and integrated services, and to expand the workforce to serve customers with disabilities and employers. Maryland has also fully funded a Medicaid buy-in program enabling people with disabilities to keep their Medicaid benefits or be eligible for them by going to work. 3. Current Funding Mechanisms to Support Individuals Living in the Community Maryland has significantly expanded funding mechanisms for home and community-based services in the past five years. Five of the seven HCBS waivers became operational within the last five years: Older Adult; Living at Home; Autism; Traumatic Brain Injury, and Independence Plus-New Directions. The Older Adult and Living at Home waivers serve a limited number of individuals up to 300 percent of supplemental security income (SSI), although individuals transitioning from a NF who meet the community-eligible Medicaid standards (up to 100 percent of SSI) are guaranteed the opportunity to participate in either waiver regardless of budgetary caps. State Plan services in Maryland include Medical Day Care and a Personal Care Program. In addition, the State provides State-only funded long-term support services such as respite, attendant care, and supportive housing to approximately 7,000 people annually. Although Medicaid funding for community-based services has expanded, it is not currently structured in a way that creates flexibility to support individuals in the community. Nursing home funding is covered by the Medicaid State Plan, as is Medical Day Care and Personal Care. However, funding for HCBS waivers comes through State appropriations for each waiver. Each HCBS waiver receives a specific amount of

funding for services that are allocated to that specific waiver. There is no integrated budget for all long-term care Medicaid services. There are operational enrollment caps for the HCBS waivers based on budgetary constraints. Thus, Medicaid institutional care is funded without operational caps while the majority of community-based care is funded within established budgetary limits. This fragmentation of funding in Medicaid creates barriers both for integrating services and reallocating Medicaid funding to community-based services. In addition to the difficulty of looking at long-term care funding in an integrated manner regardless of whether it is institutional or community-based, each HCBS waiver has unique eligibility criteria based on population type, e.g. older adults, younger adults with disabilities, unique services, and unique reimbursement rates for similar services. 4. Systems of Care, Waivers, and SPAs Utilized by Maryland Beginning in the early 1980s, Maryland implemented a variety of HCBS waiver programs that provide a rich array of services to varied populations that include children and adults of all ages with disabilities. During this time, the State shifted from offering only State Plan Personal Care and Adult Medical Day Care to offering a range of community supports through HCBS waivers listed below. (See Appendix E for more details.) 1. Children with Autism Spectrum Disorder Waiver (Ages 1 -21 2. Older Adults Waiver (age 50+) 3. Living at Home Waiver (adults age 18-59 with physical disabilities) 4. Community Pathways (Developmental Disabilities) Waiver

functions. The MAP program also is working to develop pilot testing of fast-track eligibility processes for people in institutions or at risk of institutional placement. In addition, the project is developing both virtual and actual single-points-of-entry for people seeking long-term care information, supports, and services. (See Appendix G) The University of Maryland, Baltimore County (UMBC) Center for Health Program Development and Management, developed a web-based system to track the application process for the 1915(c) Waiver for Older Adults. (See Appendix: H) The Maryland Department of Disabilities (MDoD) was established in 2004 and is required by law to develop an annual strategic plan to assure that all State agencies comply with the Americans with Disabilities Act and that all State agencies that operate programs that affect people with disabilities prepare an annual report for review by MDoD. MDoD also is charged with leading the State Disabilities Inter-Agency Board to reform long-term care so as to rebalance care to community settings and self-direction. 5. Current Expenditures on Long-Term and Community-Based Care The following table shows FY05 and FY06 spending in dollars and percentages for all populations combined in millions (excluding acute care costs). FY05 Total All Medicaid Programs (millions) FY06* Total All Medicaid Programs (millions) Institutional $1,023.9 (64.5%) $1,070.7 (64.2%) Community $ 562.6 (35.5%) $ 596.9 (35.8%) * NOTE: FY06 expenditure totals may vary slightly after final FY reconciliations are made.

Over the last four fiscal years, the percentage trend increased community-based Medicaid spending over institutional spending has averaged 2.3% per year. 6. Current Efforts to Provide Individuals with Opportunities to Self-Direct Consumer direction is infused throughout Maryland HCBS waivers. Consumers play an active role developing service plans and selecting personal care providers. A large percentage of Maryland’s personal care is provided by independent (non-agency) providers. The Older Adult and Living at Home Waivers allow for participant selection of a personal care provider, which may include a relative. The Living at Home Waiver allows individuals to hire, fire and train personal care workers. Additionally, consumer-directed personal care is a cornerstone of the State’s new CommunityChoice waiver application that will pilot a managed long-term care program. Consumer choice is also available in the State-funded Attendant Care Program, which is considered a model of consumer direction, and in the Senior Care Program. Two additional demonstrations that involve consumer-directed options include a demonstration program funded under the Administration on Aging’s (AoA) National Family Caregiver Support, which allows local case workers to offer funds to families to purchase their own care when caring for elderly family members and when appropriate providers are scarce or non-existent. In another initiative, the Department of Aging was funded under the federal Alzheimer’s Disease MFP demonstration Grants to the States to provide funds to families and caregivers providing care to people with Alzheimer’s disease to purchase their own respite services. (See Appendix: I)

The Independence Plus: New Directions Waiver for people with developmental disabilities has consumer-directed mechanisms utilizing fiscal intermediaries and consumer control over individual budgets. The Living at Home waiver for young adults with disabilities allows individuals to hire, fire, and supervise their personal care workers. To support the movement toward self-direction, the Maryland Developmental Disabilities Administration (DDA in DHMH) and the Maryland Developmental Disabilities Council are funding the My Life: Going FAR project. The purpose of the project is to foster the personal and collective empowerment of individuals and family members in Maryland. Activities in the project involve self-advocates, parents, staff from DDA regional offices, Resource Coordinators, and providers as active partners. In the 2006 legislative session, the General Assembly passed a law to help individuals employ staff directly. Senate Bill 754 requires DHMH to provide voluntary withholding of any applicable federal and State income taxes for self-employed providers of health care services such as attendants, personal care aides, personal care providers, and respite care workers for recipients participating in HCBS waivers and Medicaid state plan community-based services. Maryland recognizes that there are shortcomings in the allowance of consumer choice and control in the already existing programs that are considered person centered, self or consumer direction. The Money Follows the Person Demonstration will allow Maryland to develop improvements to its consumer-directed model. 7. Current Institutional Diversion and/or Transition Programs or Processes In 2004, the Maryland legislature enacted SB 620 the Money Follows the Individual Accountability Act. (See Appendix J) This legislation requires the Department

of Health and Mental Hygiene to identify and assist individuals to transition from nursing homes to community services. In response to the Legislation, the Department now has a contractor discussing options and making referrals to two of Maryland’s HCBS waivers with nursing home residents who have expressed a preference to move to the community. This work builds on previous nursing home transition projects developed under federal grants, specifically the hospital discharge planning initiative that provides augmented discharge planning services for patients at-risk of nursing facility placement. (See Appendix K) While there is much work to do, the State has made inroads in demonstration pilots related to the goals of diversion and transition from institutional care. Discussions among stakeholders concern how to, (1) develop more community living options based on principles of self-determination and (2) assist people to move from institutions to community-based services. 8. Gaps That Will be Addressed in the Demonstration Program Through the two larger stakeholder meetings, four areas of concern were identified: • Housing • Barriers to transition from institutions (nursing homes, ICFs/MR, chronic hospitals and institutions for mental diseases) into the community • Lack of mental health/substance abuse services affecting both institutional and community-dwelling older adults and persons with disabilities • Transportation The consumer sessions conducted at institutions conveyed an overarching concern that individuals need to have information that is timely and accurate (“truthful) so that they can make the best choice for themselves regarding home and community services. Participants stressed that the services should be individualized to meet their needs. Many

of them want to be assured that if they require assistance; care coordination will be available during and after the transition. (See Appendix L for a summary of stakeholder comments.) A discussion of these gaps in services is discussed in more detail below under three major areas: (1) housing transition assistance; (2) streamlined eligibility; and (3) specific on-going post-transition services. (a) Housing Transition Assistance Gaps: include assistance with locating, selecting, and securing housing and with setting up housekeeping. In some cases, home or vehicular adaptations are needed to make it possible to live in the community. Housing: The biggest expressed gap in transitioning to the community is housing, including assistance to locate and transition from institutions to the community and the availability of affordable accessible housing. At this time, only the Living at Home and DD waivers provide assistance with housing location for people transitioning to the community. Both also offer transition services, which may include security deposits, utility turn on, and furniture. A centerpiece of this MFP demonstration will be the expansion of housing transition services and one-time expenditures for setting up housekeeping to all individuals who are being targeted for the demonstration. However, the State provides a myriad of housing and housing-related programs to assist Marylanders to find and secure affordable and accessible housing, as noted below (see Appendix M for full details of the following initiatives, as well as additional housing efforts): Governor’s Commission on Housing Policy

Governor Ehrlich, established the Governor’s Commission on Housing Policy in 2003 to make recommendations to the Governor to address the needs of seniors and individuals with disabilities, which found that, over the next 10 years, Maryland faces a shortage of 157,000 units of affordable and available housing. Homeownership Program for Individuals with Disabilities: Stakeholders have identified homeownership as a desired choice for community living. In Maryland, rental housing opportunities for individuals with disabilities are limited and subsidies for rental housing have long waiting lists. DHCD currently administers the Homeownership Program for Individuals with Disabilities and the More House 4 Less (MH4L) programs. The program provides below market rate financing (currently 3%) and provides an exception for individuals who have poor credit due to medical expenses. The More House 4 Less Program provides competitive financing and closing cost assistance through several programs. Through these programs, DHCD has agreed to explore the possibility of providing a one-time down payment sum to match contributions from participants or other non-Medicaid sources for demonstration participants. This closing cost assistance could assist qualified individuals to purchase their first home soon after transitioning from an institution into the community and making valuable rental housing available to other transitioning individuals. Bridge Subsidy Demonstration Program: The Governor’s Commission on Housing Policy recommended the Bridge Subsidy Demonstration Program. The Governor has committed to expand the program to serve 300 persons. The program provides State-funded short-term rental assistance for eligible individuals with disabilities who are

receiving SSI or SSDI cash payments, while these individuals await permanent housing assistance. The Bridge Subsidy Program will target demonstration participants. The Maryland Housing Rehabilitation Program: The Maryland Housing Rehabilitation Program- Single Family (MHRP-SF) provides loan funds for the rehabilitation of single family owner-occupied homes and one-to-four unit rental properties. MHRP-SF is funded at $2 million for FY07. Group Home Financing Program (GHFP): The GHFP, funded at $3 million annually, assists with the construction or acquisition and modification of existing housing to serve as a group home for income-eligible persons with special housing needs. Low Income Housing Tax Credits: In Maryland, Low Income Housing Tax Credit (LIHTC) and Rental Housing Funds (RHF) are awarded competitively one to two times annually. Bonus points are awarded for targeting units to individuals with disabilities. Partnership Rental Housing Production Program (PHRP): The PRHP Program encourages local governments and public housing authorities to develop, own and manage affordable rental housing. PHRP provides funding for the cost of development with no repayment required. Effective October 1, 2006 private sector participation is now allowed. The goal is for an increase in independent housing developments. Affordable Housing Database In order to increase access to available affordable and accessible housing in the community, DHCD has created an RFP for an online searchable affordable rental housing database, administered by DHCD, that will have the capacity to list accessible apartments. Stakeholders will be educated on the new database and discussions will be 16

held on how the database can assist or augment information on the availability of affordable/accessible housing. The database is scheduled to be available in 2007. Peer Mentoring and Counseling: Another transition gap identified by stakeholders is the lack of peer mentoring for persons in institutions. Individuals who have lived in institutions for a period of time need personal encouragement and support from other people who have been in the same situation and successfully transitioned to the community. This is another service envisioned under this MFP demonstration. Access to Options Information: Consumers and stakeholders consistently identified the need for a single-point-of-entry that would provide accurate and timely information and counseling on community care options, peer mentoring and transition assistance, including a streamlined eligibility system. Currently, individuals must navigate a confusing array of possible programs alone or through different state agencies in an attempt to identify needed services, subsidized service programs, and eligibility criteria and application processes. In addition, eligibility processes are prolonged and each program has a unique application and application review process. The Aging and Disability Resource Center known as MAP in Maryland is specifically charged with developing a single-point-of-entry service that includes a statewide web-based searchable database to provide comprehensive information on long-term care services and programs and quick access to program and provider information. The MFP demonstration project will work closely with MAP. Identification and Follow Through: Currently, Maryland identifies individuals in NFs who have stated a preference for community living on the federal Minimum Data Set (MDS). Nurses meet with individuals who have indicated this preference and make

progress of applications. This demonstration will work with the MAP project to incorporate the MAP goals and services. (c) On-going Services Gaps include the expansion of HCBS waiver services across all target populations and the expansion of in-home substance abuse and mental health services. Inconsistent Services Across HCBS Waivers: Each HCBS waiver has a unique set of services, and even where there is overlap between waivers, the same services are delivered and reimbursed differently. For example, housing transition assistance services are only available through the Living at Home Waiver. The demonstration will work with stakeholders to identify those most needed services that exist in the different home and community-based waivers and the State Plan and will make that core of services available to all MFP demonstration participants. Substance Abuse and Mental Health: Although some in-home mental health services are offered through the Medicaid State Plan and one service includes assisting where there is co-morbidity with substance abuse, the services are not deemed accessible and adequate. The MFP demonstration will work with stakeholders and agencies to expand information on and access to existing programs, and where needed, to expand services, especially those related to substance abuse. Transportation: Transportation services exist under the HCBS waivers and in the State Plan to assist individuals to get to medical appointments. In addition, subsidized transportation services exist for individuals with disabilities. Major gaps identified by consumers are the unreliability of transportation services and the ability to obtain

transportation services that cross county lines. Governor Ehrlich has pledged additional resources to addresses these issues. 9. Collaborations Among State Agencies and Programs to Ensure Success The Maryland Departments of Health and Mental Hygiene, Aging, Disabilities, Human Resources, and Housing and Community Development have collaborated in developing this proposal and are committed to continue this collaboration in the pre- and post-implementation stages of the MFP demonstration. The Secretaries of these departments have committed themselves and their agencies to the objectives of the MFP demonstration as well as other systems change initiatives required to rebalance long-term care services toward community settings. This collaboration has been on-going and building over the last five years in work on systems change grants, legislative initiatives, the Governor’s New Freedom Initiative, the development of the Department of Disabilities and the Governor’s Cabinet-level Interagency Disability Board on Long-Term Care (IADB). 10. Systems, Procedures, and Policies to Monitor and Quality Assurance The State has moved toward a more comprehensive quality management process across all HCBS programs and is using the CMS Quality Framework to form the basis for program evaluation. (See Appendix N) In 2005, a cross-agency quality committee called the Waiver Quality Council was developed to share information across waiver programs to identify systemic issues and make improvements. A statewide grievance and incident reporting process was implemented statewide in August 2005. The Participant Experience Survey (PES) was used to measure experiences of home and community-

based waiver participants. (See Appendix O). The CommunityChoice program will strive to enhance quality of care and consumer safeguards. However, there is no consistent strategy to measure and enhance performance across community long-term-care programs and services, though there is agreement throughout all the State agencies and stakeholder groups that modifications need to be made in the following areas: (a) create a more evidenced-based quality management system, (b) improve the ability of the State and HCBS administering agencies and case managers to monitor service provision, (c) improve the capacity of the State to monitor and improve the quality of service from providers, (d) monitor the quality of care and life at the individual consumer level, (e) develop more and better quantifiable indicators of quality, (f) improve infrastructure to collect and distribute data on quality indicators for those individuals at the State and local levels who can impact quality, (g) create more comprehensive and standardized quality reports for improving program operations, and (h) work more closely with counties to create more uniform expectations and incorporate quality information into program improvements. 11. State Legislative/Other Changes Necessary to Implement the Demonstration During the pre-implementation phase consideration will be given to amending the existing Older Adult and Living At Home waivers in order to provide access to the same services for both eligible populations. Consideration also will be given to enhancing the community supports for individuals with mental health disease who transition into the community under this demonstration. Maryland does not anticipate having to change its State Plan. 21

PART 2: DEMONSTRATION DESIGN The State of Maryland will use the opportunities afforded by the MFP demonstration program to build on its current and historical efforts to ensure that individuals living in nursing facilities (NFs), intermediate care facilities for the mentally retarded (ICFs/MR), chronic care hospitals, and institutions for mental diseases (IMDs) for persons 65 and older and under 21 are able to transition to community-based supports and services programs, should they choose to do so. The Maryland Legislature has provided the funding for guaranteed enrollment in approved Medicaid home- and community-based waivers for eligible individuals who choose to transition to community-dwelling status from NFs. The principle approach of Maryland’s MFP demonstration program will be to provide an enhanced, aggressive, accelerated and more tightly coordinated program to identify persons interested in transitioning, along with a full array of pre- and post-transition services to help ensure successful community living, and needed supports and services to help individuals live more fulfilling lives with improved health status. A major organizing impetus for Maryland’s MFP demonstration project will be the implementation of CommunityChoice, a pilot managed long-term care program that will include older adults and persons with physical disabilities in geographic areas that cover approximately 66 percent of the statewide eligible population. Thus, the State will implement the MFP demonstration program partly in a fee-for-service, home- and community-based services environment and partly in a managed long-term care environment, affording the State the opportunity to examine the efficiency and

effectiveness of both approaches to increasing transitions to the community for persons who reside in NFs. Maryland’s MFP demonstration program application reflects the comprehensive participation of State agency partners, including the Department of Health and Mental Hygiene, which includes the Medicaid agency, the Developmental Disabilities Administration and the Mental Health Administration; the Department of Disabilities; the Department of Aging; the Department of Human Resources; and the Department of Housing and Community Development. Most importantly, the application reflects the participation of consumer and provider stakeholders from the disabilities community and the aging community. The State held two stakeholder meetings to listen to concerns and recommendations, conducted focus groups in four nursing homes and two chronic care hospitals and advocates for persons with developmental disabilities met with families and individuals in the State’s ICFs/MR. The application reflects their collected concerns and recommendations. Stakeholders will play a vital role in the pre- and post-implementation phases of the demonstration program, including gathering and sharing information and community feedback, future planning and decision-making recommendations. 1. Pre-Implementation Phase a. New Infrastructure Interventions Needed Maryland has in place a robust system for helping people transition from institutions, along with a rich program of community-based supports and services through home- and community-based waivers and optional Medicaid State Plan services. Maryland will be looking to increase its transition services and to look at opportunities to offer similar benefits across its different waivers. Maryland’s CommunityChoice

program will further increase the availability of community services. The State is awaiting final approval of its 1115 waiver application in order to implement the pilot program with an expected implementation date of December, 2007. (see Appendix P for Maryland’s Waiver Application) CommunityChoice, when implemented, will consist of a managed long-term care program for adults who are dually eligible for both Medicare and Medicaid, Medicaid-eligible adults with physical disabilities who meet nursing-home level of care standards and all persons over the age of 65. The CommunityChoice’s Community Care Organizations (CCOs) will receive capitated payments to provide Medicaid acute care services (for those who are not Medicare eligible), NF services, chronic care hospital services and community-based supports and services for all participants. Specialty mental health services will be provided on a fee-for-service basis through the Public Mental Health System. Incentives will be established to encourage CCOs to actively work with individuals who want to transition back into the community as well as providing the necessary supports to allow individuals to be served in the community for as long as they desire. The additional supports and services under MFP will only further enhance our efforts under CommunityChoice. In addition, MFP will be a statewide demonstration whereas CommunityChoice is only a pilot. b. Pre-Implementation Period Requested Maryland proposes to use the first six-months after the approval date of the demonstration (expected to be January 1, 2007) for pre-implementation activities. Working as a team with agency partners and consumer stakeholders, as well as providers, this time will be used to develop the needed improvements in the State’s existing

infrastructure to ensure the tightly coordinated, aggressive system of participant identification, transition, and service program needed to achieve success and to meet the State’s performance goals. During the pre-implementation period, the State will, with its partners, (1) develop and implement all operational policies and procedures, (2) develop a plan to improve eligibility processes (especially timeframes for eligibility determinations for waiver or state-plan services), (3) build on the current waiver quality management system (QMS) to incorporate the MFP demonstration, (4) develop and implement coordination structures in both fee-for-service and CommunityChoice with the State’s “Maryland Access Point (MAP)”, to increase the visibility and utility of the “one-stop shopping” virtual and physical portal for persons seeking information about community-based supports and services; and (5) the State will especially focus on efforts to coordinate the MFP demonstration with housing services to ensure that demonstration participants are not impeded in their efforts to return to the community because of a lack of affordable and accessible housing in all areas of the State. 2. Implementation Phase a. Target Populations In keeping with the philosophy that all Medicaid individuals who reside in institutions should have the opportunity to choose to live in the community, the State is proposing to include the following target populations of Medicaid-eligible persons in the MFP demonstration: residents of (1) NFs, (2) ICFs/MR, (3) chronic care hospitals, and (4) IMDs. Potential participants must have lived in one or more of these settings continuously for six months or longer and been Medicaid eligible for 30 days as of the

first day of their participation in the demonstration. Each participant must continue to maintain the institutional level of care they held while residing in the institution in order to maintain eligibility to participate in the demonstration. All participants will transition to qualified community residences as required by the demonstration. b. Number of Projected Transitions by Target Population The following table provides the State’s total projected transitions by target population from State FY 2008 through FY 2012 (July 1, 2007 through June 30, 20121). Target Population Current Population Total (Demonstration and Non-Demonstration) Transitions FY 08 FY09 FY10 FY11 FY12 Total NF 24,531 784 941 1,0821,244 1,431 5,482 ICF/MR 368 50 50 50 50 50 250 Hospital 1,036* 5 5 5 5 5 25 IMD 80 15 15 15 15 15 75 The following table provides the State’s projected demonstration transitions by target population from State FY2008 through FY 2012 (July 1, 2007 through June 30, 2012). Current Population Demonstration Transitions FY 08 FY09 FY10 FY11 FY12 Total NF 24,531 392 470 541 622 715 2,741 ICF/MR 368 50 50 50 50 50 250 Hospital 1,036* 5 5 5 5 5 25 IMD 80 15 15 15 15 15 75 * Only approximately 80 individuals are currently eligible to participate in the Demonstration, as the remainder have fewer than six months continuous residency. 1 The State recognizes that all MFP enhanced funding ends on December 31, 2011.

c. Qualified Residences All participants will transition to qualified residences as defined by the Section 6071 of the DRA. The State currently licenses assisted living units as small as four beds and less, and the State expects that some participants will choose qualified assisted living units as their transition housing of choice. The State recognizes that assisted living units serving five or more individuals would not meet the definition of a “qualified residence”. d. Services to be Offered All participants will be provided an enhanced set of transition services both prior to and following a transition to the community. Stakeholders have indicated that the State needs to make changes to the current Options Counseling Program. The State will work with stakeholders to design these changes during the six-month pre-implementation period. Participants will also be offered the wide array of existing waiver and community-based Medicaid State Plan services they need and for which they are qualified. The following are the services that will be offered to demonstration participants: 1. Transition Services. Services already covered by the Department will be enhanced under the Demonstration. These services as well as new transition services include: (a) increased efforts to make community-based options information available to persons living in institutions, (b) identification and follow-through with individuals expressing a desire to transition, (c) assistance with the eligibility determination process for community-based services, (d) assistance with identifying and securing affordable and accessible housing,

are eligible and which they need in order to succeed in community living. For those individuals who will receive these services through CommunityChoice, the CCOs will provide equivalent services to FFS, as well as any enhanced, more flexible services that their care management teams and the consumers devise together. During the pre-implementation phase, the State and the stakeholders will consider whether or not it would be desirable or necessary to align the HCBS packages for the Older Adult and Living at Home waivers. Likewise, strategies will be developed to provide better access to substance abuse and mental health services. The following are currently approved HCBS waiver services: Older Adult Waiver a. Personal care b. Respite care c. Environmental accessibility adaptations d. Family or consumer training e. Personal care nurse monitoring f. Personal emergency response system g. Home-delivered meals h. Dietitian/nutritionist services i. Assistive devices/technology j. Environmental assessments k. Senior center plus l. Behavior consultation m. Case management including intake, assessment, planning, and coordination Living at Home Waiver a. Attendant care b. Environmental accessibility adaptations (this includes vehicular modifications) c. Family or consumer training d. Personal emergency response system e. Assistive devices/technology f. Case management/care coordination includes assessment and planning and coordination of services g. Transition services includes security deposits, utilities turn-on, furniture, linens, etc. to set up house keeping h. Fiscal intermediary (for self-directed care)

Community Pathways Waiver (DD Waiver) a. Personal support b. Respite care c. Environmental accessibility adaptations d. Family and individual support services e. Assistive devices/technology f. Behavioral support services g. Residential habilitation h. Day habilitation i. Supported employment services j. Transportation k. Resource coordination l. Transition services New Directions Waiver (Self-Directed Model for DD services) a. Self-Directed Services includes: supports brokerage, fiscal management service, respite, day habilitation, personal support, transportation, accessibility adaptation, family and individual support services, and assistive technology and adaptive equipment. b. Non-Self Directed Services include: resource coordination, day habilitation, transition services, and behavioral supports. Optional State Plan Long-Term Care Services a. Personal care b. Adult medical day care c. Occupational therapy d. Physical therapy e. Speech/language services f. Transportation for medical services g. In-home psychiatric rehabilitation program services h. Mobile treatment services for serious mental illness and may have co-occurring substance abuse disorder i. Disposable medical supplies j. Durable medical equipment 4. Improved Transportation Services. Transportation services exist under the HCBS waivers and in the State Plan to assist individuals to get to medical appointments. In addition, subsidized transportation services exist for individuals with disabilities, but concerns have been

raised about the reliability of transportation services and the ability to obtain transportation services that cross county lines. Also, vehicular modifications, which are provided under the Living at Home Waiver, may need to be enhanced or expanded to other waivers. Governor Ehrlich has pledged additional resources to streamline cross-jurisdictional transportation as well as enhancing human services transportation through regional grants to encourage newly configured solutions for consumers. Both of these efforts appear in the 2007 State Disabilities Plan as transportation initiatives. 5. Self-Direction Maryland already utilizes a self-direction model in the Living at Home Waiver, Attendant Care program, and its New Directions developmental disabilities waiver. Consumer or Self Direction is defined as any service or program, which gives the consumer complete and total control over his/her life. Consumers are any persons who use goods and services. Consumers of consumer-directed services are people with disabilities of all ages, including persons with: • Cognitive needs which include autism, mental retardation, brain injury, dementia (including Alzheimer's Disease, AIDS-related dementia); • Physical needs due to accidents, injuries, illnesses, age-related conditions, developmental conditions such as muscular dystrophy, and sensory impairments (including vision and hearing losses, deafness, blindness). • Mental (behavioral) health needs which includes psychiatric disorders. Consumer choice is provided when there is a range of service options to meet the diverse needs of consumers. The degree to which consumers have choice must go beyond

the range of service choices and include opportunities for consumers to decide when and where services will be provided, and how and by whom tasks will be performed. Consumer direction describes programs and services where people are given maximum choice and control. Consumer direction may also be called "self-determination" or "independent living." When people say they want to be "independent" or they want "autonomy" or "self-direction," they are talking about consumer direction too. In consumer-directed programs, consumers can choose to select, manage and dismiss their workers. • "Select" means consumers choose who will work for them. This is true when they hire the person. It is also true when another person or an organization helps them in the hiring process. The important thing is that consumers make the final decision about who will work for them. • "Manage" means the consumer trains and directs the worker about what to do. Consumers may choose to have someone assist them with training and supervising. The important thing is that the consumer decides what, when and how things will be done. • "Dismiss" means that consumers make the final decision about letting a worker go if the relationship is not working out. The consumer may be the one who fires the worker or they may tell a person or organization that they are dissatisfied and get them to do the actual firing.

In consumer-directed programs, consumers can decide which services to use, which workers to hire, and what time of day they will come. They can decide whether to hire family members and whether to spend the available funds on things other than services (like appliances or home modifications). DHMH will be developing a consumer directed model under the Money Follows the Person Demonstration. 6. How the Process Will Work The identification process begins with aggressive outreach to advise people about community living opportunities and introduce them to people who have succeeded after leaving a nursing facility or other institutional setting. Follow up with those individuals who indicate a desire to move to the community will occur quickly to help them develop a plan for independent living. Then, each person, where needed, will be assisted to complete applications for housing (some will return to family or their own homes), registering for para-transit services and learning to use public transportation (where this is available and appropriate to the individual). The transition team will help the individual to: (a) identify and understand the home- and community-based services options that are available, (b) learn how the transition process works, (c) facilitate the eligibility process, (d) find and secure affordable and accessible housing, (e) arrange for and facilitate the setting up of a household and helping the individual through the early stages of community living, and (f) develop the needed links to service providers. During the first year of participation, the transition specialist will periodically monitor each participant to ensure that the total package of supports and services is working successfully.

As already occurs, the participant’s program of supports and services will be developed from a comprehensive, consumer-directed assessment and the development of a consumer-centered, self-directed (where chosen) plan for the delivery of identified supports and services. Peer counselors will also circle back to facilities to re-interview individuals who initially decline an interest in moving to the community to determine their reasons and to explore ways of addressing their concerns, as well as the real and perceived barriers they report as reasons for not wanting to return to the community. It is important to stress, as noted in Part 4 of the application, that no person, or family member(s) of a person, living in an institution will, in any way, be pressured or coerced into agreeing to transition to the community. The State will ensure that each demonstration participant chooses to participate based on full knowledge and consent. The State supports every effort to ensure that individuals are fully aware of the options available to them and that it is possible to overcome barriers – real and perceived – to transitioning back to the community, but the final decision to do so rests with the individual and/or her or his legal guardians and families. 3. Anticipated Waiver and State Plan Amendments As noted above, during the pre-implementation period, the State will consider whether any modifications to existing waivers will be needed (e.g., making the OAW and LAH waiver services consistent) . As was also mentioned earlier, the State has already submitted a request for approval of a Section 1115 waiver to implement the CommunityChoice managed long-term care program. Otherwise, the State does not

envision a need for any other waiver requests or for additional State Plan amendments in order to implement the demonstration. 4. Methods to be Used to Increase Expenditures and Percentages for HCBS The State will continue to work with the Legislature to develop and implement budgets that reflect the State’s commitment to continuing to improve the ratio of funds for community-based services to institutional services. In addition, the State’s ambitious goals for demonstration transition targets means that when they complete their 12 months of demonstration services, the State will transfer them into existing waivers and CommunityChoice, thereby increasing the demand for community-based expenditures. 5. Proposed Benchmarks a. Rebalancing Benchmarks The most significant rebalancing initiative going forward that the State has proposed that will, over time, result in continued reductions in the utilization of NF services is the implementation of CommunityChoice, expected to begin on December, 2007. In the State’s waiver application to CMS, the State projected the following percentage reductions in NF member-days through the first five years of the demonstration. Each percentage figure from DY01 forward is a percentage of the prior year’s percentage. Total Projected Member Months DY 01* DY 02 DY 03 DY 04 DY 05 Projected under FFS 116,161 117,903 150,786 184,630 221,920 Projected under MC 112,579 107,938 129,780 147,541 163,660 98 Percent 95.5 Percent 92.5 Percent 89.5 Percent 86.5 Percent * DY 01 = Community Choice demonstration Year 1 In other words, CCOs will provide initiatives and options that allow individuals to stay in the community as well as enable NF residents to return to the community. The State’s 36

demonstration as others. While these individuals will not greatly influence the larger rebalancing effort, it is important to ensure they have the opportunity to participate. b. Demonstration Transition Benchmarks With reference to NFs, between 2004 and 2005, the State achieved an increase of 29 percent in the number of persons transitioning from NFs to the community. The State projects that over the life of the demonstration, 5,482 persons total will transition successfully from NFs to the community, of whom 2,741 will be qualified demonstration participants. In the first year of implementation, the State projects that the percentage increase over FY2007 will again be 29 percent, while the percentage increase in FY2009 will be 20 percent, and in the remaining years of the demonstration, the increase will be 15 percent each year. The State believes that as the demonstration period goes forward, there will be fewer individuals available meeting the participation criteria who will express an interest in transitioning. At the same time, CommunityChoice CCOs will be working aggressively to divert NF placements as well as striving to help NF residents to transition back to the community. Together, over time, there will be fewer people with lengths of stay of six months or more from which to draw demonstration participants. It should be noted that the transition targets for ICFs/MR, chronic care hospitals, and IMDs are small because the base populations from which they would be drawn are very small, and those meeting the six-month continuous residence rule is even smaller (e.g., the average length of stay in a chronic care hospital is less than four months). 38

Target Population Current Population Demonstration Transitions FY 08 FY09 FY10 FY11 FY12 Total NF 24,531 392 470 541 622 715 2,741* ICF/MR 368 50 50 50 50 50 250 Hospital 1,036** 5 5 5 5 5 25 IMD 80 15 15 15 15 15 75 * Total NF transitions (persons not eligible plus eligible participants) will equal 5,482. Total NF transitions by year: FY08, 784; FY09, 941; FY10, 1,082; FY11, 1,244; FY12, 1,431. ** Only approximately 80 individuals are currently eligible to participate in the Demonstration, as the remainder have fewer than six months continuous residency. c. Quality Management Benchmarks During the pre-implementation period and the first year of implementation, the State, consumer and provider stakeholders will develop and implement improvements to the State’s existing comprehensive quality management system for community-based services that was detailed in Part 1 of this application. The State is currently engaged in a thorough review of how quality management is organized and operated within the home- and community-based services portion of the Medicaid program. The State is considering how it could utilize information technology more effectively to monitor performance, prevent and detect adverse sentinel events, define and implement performance-based quality measures, and how to capture it all within interoperable data systems. Building on these efforts, the State will develop performance benchmarks of particular importance to the successful implementation of the MFP demonstration (e.g., measurable improvements in the timeframes for speeding up eligibility for waiver services). 6. Process to Target and Recruit Individuals to Transition 39

there is an aggressive, successful program of transition services available to help them return to the community. Also, the State will develop and implement a cadre of volunteer peer counselors and mentors (whose travel and other costs will be paid by the demonstration) through community-based organizations (e.g., CDRC, CILs, etc.), including especially people who have successfully transitioned to the community. The State will seek the help of existing aging and disability agencies and organizations to identify and recruit these individuals. Contracts will be developed with community-based organizations that will provide the peer counselors with the necessary supports and training to go into institutions to assist those interested in applying for appropriate waiver services. The MAP sites and the soon to be implemented MAP web portal will also be enlisted to help find counselors and mentors to help spread the word and help individuals make the decision to seek transitions to the community. 7. Cross-Agency and Cross-Service Collaboration Throughout the Part 1 narrative, the State has provided ample evidence of the increasing cooperation and collaboration among the various State agencies and programs that serve older adults and people with disabilities across Maryland. The current Administration, as noted in Part 1, has been especially aggressive in its efforts to focus all State agencies and resources on cooperative, collaborative efforts to increase and improve the services, choices and self-direction opportunities for Maryland’s residents who rely on Medicaid and other State-funded programs for their long-term supports and service needs. The MFP demonstration is but one part of a much larger statewide, cross-agency and cross-service effort to improve the lives of older adults and persons with disabilities, so the MFP demonstration will fold into those larger efforts and build on the foundations

already laid. As noted earlier, the most important feature of the MFP demonstration is the development and implementation of an improved, expanded, accelerated transition assistance process to more effectively and rapidly bridge the gap between institutional living and community living. Thus, it will be essential that the MFP demonstration effort work with and cooperate with existing services and processes to improve them and to spread their benefits to more people more rapidly. 8. Services in the Years Following the Demonstration Year for Each Participant The State provides the assurance that no demonstration participant will experience a diminished set of program services at the end of her or his 12-month demonstration period. Since the service package (as distinguished from the “transition services” package) described above (item 2.) consists of existing HCB waiver services and optional State plan services, there will be no change in each participant’s program services in the years following the end of each participant’s “demonstration year”. The only changes that will occur will be the result of a change in the person’s needs. The transition services to be included in this demonstration are considered “one-time only”, in the sense that for each participant, by the end of the first year, the “transition” phase and services will be concluded. 9. Quality Management Strategy While the State acknowledges that a variety of opportunities for improvements are present, as outlined in Part 1, the basic approach to quality management in the MFP demonstration will be to integrate the MFP program with the broader quality management improvement strategies already described. At the same time, though the approach to the development and implementation of a more aggressive and efficient

This includes refining and expanding quality measures and indicators, ensuring that there is a mechanism to collect quantitative data on these measures and indicators on an ongoing and regular basis, and policies and procedures that ensure that any potential quality issues are identified in a timely manner and acted upon. What one entity may view as a quality concern, an individual with a disability may view as an acceptable risk. The perspective of the individuals impacted by the supports is absent from the quality management systems. There could be perfect scores on all indicators and the system could still fail those it was established to support, because what is being measured is not what matters most to individual consumers. Indicators and mechanisms for gathering the perspectives of individuals with disabilities and older adults and their families will be included and this information should be used to drive program improvement. 10. Description of Current Quality Management System A thorough discussion of the State’s current quality management system was detailed in Part 1, item 10. There is nothing additional to add in this section. 11. Description of Barriers Preventing Flexible Use of Medicaid Funds The State believes that the implementation of CommunityChoice for persons living in NFs and chronic care hospitals will address any existing barriers to the flexible use of Medicaid funds. The CCOs will have a great deal of flexibility to respond to the acute care and long-term care and supports and services needs of their enrollees within the capitation payment they will receive for the comprehensive care of these individuals. One additional feature of CommunityChoice is the requirement that CCOs also be approved as Medicare Advantage Special Needs Plans (MA/SNP) (including Part D), which will further enable CCOs to provide a seamless set of Medicare and Medicaid

services to those dual-eligibles who choose the CCOs MA/SNP. For those individuals transitioning from a long-term NF stay, the opportunities for flexible service programs are evident. 12. IT Systems The State plans to use existing eligibility, claims, encounter and Minimum Data Set data to assist in the process of identification of potential demonstration participants. The State will also use existing financial management tools to identify and track qualified long-term care service costs that are eligible for the enhanced match. The current IT system will be revised to identify by code each participant, including the start and end date of the enhanced match period. In addition, data reporting and coding to capture performance measurement and other demonstration data will be developed, tested and implemented so the evaluation and quality management component of the demonstration will be able to operate from real data on all participants. 45