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December 2013 Policy Study, Number 13-12


Iowans Want to Age in Place


Balancing Incentives Program



In 2010, with the passage of the Patient Protection and Affordable Care Act (PPACA), the Balancing Incentives Program (BIP) was outlined.[66] BIP was designed to aid states in providing high-quality care in the most appropriate and least restrictive settings. Incentivizing states to “balance” their spending between HCBS and institutionalized care, the program allows states to receive additional funds in the form of their Federal Matching Assistance Percentage (FMAP).[67] States who spend less than 50 percent of their Medicaid budget on LTSS for HCBS receive an additional 2 percent FMAP. States that spend less than 25 percent of their Medicaid budget on LTSS for HCBS can receive an additional 5 percent FMAP.[68]


The BIP requires states to establish a no wrong door/single entry point system that creates a statewide system of access points for LTSS. This type of system is intended to be streamlined and coordinated for eligibility determination and enrollment into Medicaid-covered HCBS.[69] They must also adopt conflict-free case management (that means the agency that provides options counseling should not also be engaged in providing direct-care or case-management services) unlike a PACE program and “utilization of core standardized assessment instruments for determining eligibility for non-institutional services and supports used in a uniform manner throughout the state.”[70] Also, the application and eligibility determination tool must include a standard assessment instrument that is used for a given patient population. There is now a two- part or two-level assessment process to determine eligibility for benefits. Level I is comprised of basic functional and financial questions that will determine a patient’s potential eligibility for HCBS.[71] Level II is comprised of a complete functional and financial assessment that determines a patient’s actual eligibility for HCBS.[72] Many states that applied for BIP funds have been working on, or have completed expansion of, Aging and Disability Resource Networks (ADRNs) throughout their states. They need to have multiple entry points for patients including web access, a single toll-free telephone number, and a physical location for patients to receive Level I assessments and to coordinate the more extensive Level II assessment and subsequent referrals.[73]


One of the central components to making this whole plan work is the connection between the “single point of entry and the community partners/coalitions that deliver the required services to the population.”[74] The state requires that this pillar ADRN agency be an area agency on aging, center for independent living, mental health DS, or other NGO within the region it serves. Conflict-free case management means that there must be a separation of case management from direct-service provision and separation of eligibility determination from direct-service provision.[75] The staff that conduct these evaluations and assessments and develop care plans are prohibited from being blood relatives or spouses of the patient or paid caregivers. Staff cannot be financially responsible in any way for the patient and are prohibited from making financial or health-related decisions for patients.[76] In a managed-care environment, conflict-free case management may be difficult to achieve. If it is difficult to separate case management from service provision, then CMS requires a state to implement conflict-reduction mechanisms such as increased state and consumer-level oversight and administrative separation.[77]


BIP can facilitate new methods of reaching out to and serving more individuals with HCBS as mandated by the Olmstead Act in accordance with the Americans with Disabilities Act (ADA). The aggregate of financial support to states awarded BIP grants between October of 2011 and September of 2015 cannot exceed three billion dollars in FMAP-enhanced payments of 2 percent or 5 percent as previously noted. In addition, participating states must provide new and expanded HCBS using the enhanced FMAP funds.[78] They may not restrict eligibility criteria in excess of the program standards already in place by the end of 2010 in their state. Currently, there are thirteen states, including Iowa, participating in BIP grants; and seven currently have submitted work plans with CMS.[79]




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