Rethinking Paris Data Match: Connecting Veterans on Medi-Cal to Federal Benefits

Rethinking PARIS Data Match: Connecting Veterans on Medi-Cal to Federal Benefits MAC TAylor • le g i s lA Ti v e A n Al y sT • A ugusT 6, 2013 Summary There are approximately 170,000 military veterans enrolled in Medi-Cal, the state-federal program providing medical and long-term care services to low-income persons. Of these veterans, more than 150,000 served in World War II, the Korean War, and/or the Vietnam War, and likely qualify for their Medi-Cal coverage as seniors and persons with disabilities (SPDs). Since 2009, the Department of Health Care Services (DHCS) has used a computer data matching process known as the Public Assistance Reporting Information System (PARIS) to identify certain veterans who receive Medi-Cal services and may be able to voluntarily shift to health care services provided by the U.S. Department of Veterans Affairs (USDVA). California Does Not Pursue a Major Source of PARIS Veterans Savings State’s Current Treatment of USDVA Monetary Benefits and Medi-Cal Estate Recovery in the In-Home Supportive Services (IHSS) Program Limits Potential Savings From PARIS Veterans Activities. The state of Washington achieves the majority of its savings from the PARIS Veterans activities by counting a type of USDVA monetary award known as aid and attendance (A&A) toward the costs of providing home- and community-based services (HCBS) through Medicaid. In contrast, California does not count A&A toward the costs of the state’s largest Medi-Cal HCBS program, IHSS. Relatedly, the state does not include the IHSS costs of certain IHSS recipients when it recovers Medi-Cal costs from the estates of deceased beneficiaries. The state would need to change both its treatment of A&A in the IHSS program as well as its approach to estate recovery for IHSS recipients in order to achieve savings similar to Washington. There are fiscal and policy implications to consider before making such a change. Recommend Reexamination of Treatment of A&A and Medi-Cal Estate Recovery in IHSS Program. We recommend that the Legislature require DHCS and the Department of Social Services (DSS) to jointly report to the Legislature with information that addresses the issues we An LAO RepORt raise regarding the state’s treatment of A&A in the IHSS program and the state’s approach to estate recovery for IHSS recipients. The information reported should specifically provide (1) the policy and legal rationale for the state’s current approach as well as (2) an analysis of the fiscal and policy implications of changing the state’s approach in a manner conducive to realizing additional savings from PARIS Veterans activities. Additional Benefits From Expanding Current PARIS Veterans Activities State Can Realize Savings From Transfer of Certain Veterans Receiving Medi-Cal Skilled Nursing Facility (SNF) Care to USDVA SNF Care. The PARIS Veterans activities can be used to identify veterans who are receiving SNF care paid for by Medi-Cal but who may also be eligible to receive SNF care paid for by USDVA. By facilitating the voluntary transfer of such veterans to SNF care funded by USDVA, the state would realize General Fund savings and the veteran would likely experience certain financial benefits. PARIS Veterans Activities Are Constrained by Resource Limitations and Problematic Approach. While the state currently pursues the above voluntary health care transfers through PARIS Veterans activities, it has not provided additional resources to DHCS, the state Department of Veterans Affairs (DVA), or County Veteran Service Offices (CVSOs) to conduct the outreach necessary for such transfers to occur. When outreach to PARIS Veterans clients does occur, the state presently intends for it to focus on encouraging veterans to voluntarily discontinue Medi-Cal coverage and rely solely on USDVA health care. This can be problematic for certain veterans who may need services that are difficult to access through USDVA health care, making it difficult for CVSOs—which are advocates for veterans—to make the case for discontinuing Medi-Cal coverage. Recommend Modified Pilot With Additional Resources. We recommend that the Legislature establish a new pilot of PARIS Veterans activities, with additional staff resources at DHCS, DVA, and three CVSOs to pursue a modified outreach approach. To achieve General Fund savings, the outreach conducted by DVA and CVSOs should focus on facilitating transfers of certain veterans to SNF care funded by USDVA. To provide policy benefits to the state, the outreach should also assist PARIS Veterans clients in receiving USDVA monetary benefits. 2 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt INtRoDuCtIoN There are approximately 170,000 military transfer when the veteran discontinues his or her veterans enrolled in California’s Medicaid program Medi-Cal coverage and relies solely on USDVA (known as Medi-Cal), the state-federal program health care. As part of the 2008-09 budget, the providing medical and long-term care services Legislature authorized a two-year pilot program to to low-income persons. Of these veterans, more evaluate PARIS’ effectiveness. than 150,000 served in World War II, the Korean This report contains our updated analysis of War, and/or the Vietnam War, and most likely PARIS Veterans in light of findings from (1) the would qualify for Medi-Cal coverage as seniors pilot evaluation and (2) our own research and and persons with disabilities (SPDs). About 5,000 discussions with state and local agencies involved in of these wartime veterans receive long-term care PARIS Veterans activities. Our findings incorporate in SNFs funded by Medi-Cal, and over 4,000 have best practices from Washington State, which uses difficulty performing activities of daily living PARIS to mutually benefit that state’s general fund (ADLs) such as bathing, eating, and toileting. and resident veterans who are enrolled in Medicaid. In our 2007-08 Analysis of the Budget Bill, In the first part of the report, we provide an “Data Match Increases Veterans’ Access to Benefits overview of USDVA health care and monetary and Reduces State Costs,” we recommended that benefits that are available to certain veterans and the state participate in a computer data matching their family members—especially to those who process known as PARIS to (1) identify certain are aged or disabled and who may also qualify for veterans who receive Medi-Cal services, and Medicaid as a result of their low-income status. (2) facilitate a voluntary shift, or transfer, of In the second part, we examine the potential level these veterans to the USDVA health care system. of state savings associated with certain types of (Hereafter, we collectively refer to PARIS data PARIS Veterans outreach. Finally, we present matching, identification, and outreach activities our recommendations regarding the future related to veterans as “PARIS Veterans.”) The state implementation of PARIS Veterans. currently tracks Medi-Cal savings from such a BACkgRouND O verview Of M edi -C al the cost of each state’s Medicaid program. The Medi-Cal Program generally receives one dollar of Medicaid Is a Joint Federal-State Program. federal funds for each state dollar it spends on those Medicaid is a joint federal-state program services. that provides health coverage to low-income Medi-Cal Provides a Wide Range of Health- populations. In California, the Medicaid program Related Services. Federal law establishes some is primarily administered by DHCS and is minimum requirements for state Medicaid known as Medi-Cal, although some benefits are programs regarding the types of services offered administered by other state departments such as and who is eligible to receive them. Required DSS. The federal government pays for a share of www.lao.ca.gov Legislative Analyst’s Office 3 An LAO RepORt services include hospital inpatient and outpatient Medi-Cal will then pay for any additional covered care, SNF stays, emergency services, and doctor expenses once the share of cost has been met. visits. California also offers an array of medical Medi-Cal Long-term Services services considered optional under federal law, such and Supports (LtSS) as coverage of prescription drugs, durable medical equipment (DME), HCBS, hearing aids, and dental Medi-Cal provides LTSS to Medi-Cal services. beneficiaries who meet certain eligibility Medi-Cal Operates Under a State Plan and requirements. The LTSS are commonly categorized Several Waivers. Generally, states must obtain into two types: (1) institutional care such as SNFs federal approval for changes to a state’s Medicaid that provide nursing, rehabilitative, and medical program using one of two methods: (1) State care, and (2) HCBS to maintain people in their Plan amendments or (2) waivers. The State Plan homes and communities. is the state’s primary contract with the federal IHSS Is the Largest HCBS Program. The IHSS government. Waivers allow states to waive federal program, which offers personal care as well as Medicaid requirements in order to have the domestic and related care services in the home, is flexibility to modify their Medicaid programs in by far the most commonly utilized form of HCBS ways that are favorable to beneficiaries. among SPDs. All IHSS recipients are eligible to Services Are Provided Through Two Main receive up to 283 hours per month of assistance Systems. Medi-Cal provides health care through with tasks such as bathing, housework, meal two main systems: fee-for-service (FFS) and preparation, and dressing. The DSS oversees the managed care. In a FFS system, a health care IHSS program at the state level. provider receives an individual payment for each The IHSS program is comprised of four medical service provided. In a managed care subprograms. Three of these—Personal Care system, managed care plans receive a capitated rate Services Program (PCSP), Community First Choice in exchange for providing health care coverage Option (CFCO), and the IHSS Plus Option (IPO)— to enrollees. For a large proportion of Medi-Cal receive federal Medicaid matching funds and beneficiaries, enrollment in managed care is are included in California’s Medicaid State Plan. mandatory. Currently, about one-half of the IHSS caseload (or Some Medi-Cal Beneficiaries Pay a Share 225,000 recipients) receive services through PCSP, of Cost. The income threshold used to determine 40 percent (or 176,000 recipients) receive services Medi-Cal eligibility varies depending on several through CFCO, and 7 percent (or 32,000 recipients) factors, including age, disability status, or whether receive services through IPO. (The small remaining an individual is pregnant. Beneficiaries who percentage of IHSS recipients receive services meet the basic eligibility standards have little or through the IHSS Residual program, which does no cost-sharing for services provided through not receive federal financial participation.) Medi-Cal. However, beneficiaries with incomes Medi-Cal third Party Liability too high to qualify for Medi-Cal may be eligible (tPL) and Estate Recovery for share-of-cost Medi-Cal. These individuals must pay for a predetermined amount of heath Medi-Cal Is the Payer of Last Resort. Federal care expenses—or their “share of cost”—in each law requires Medicaid to be the payer of last resort. month the individual incurs health care expenses. If another insurer or program has the responsibility 4 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt to pay for health care or long-term care costs indicated to us that they seek to recover IHSS costs incurred by a Medicaid beneficiary, that entity is through estate recovery for recipients who receive generally required to pay all or part of the costs IHSS through subprograms besides PCSP. We note prior to Medicaid making any payment—a concept that IHSS recipients are generally unaware of the known as TPL. If, for instance, a Medi-Cal enrollee subprogram in which they are enrolled and are has another source of health coverage, the other therefore unaware of whether their IHSS costs will health coverage (OHC) is the primary payer for the be included in the Medi-Cal estate claim. enrollees’ health care, with Medi-Cal covering costs O USdva M B verviewOf Onetary enefitS and services that are not otherwise covered. Medi-Cal Pursues Estate Recovery Against The USDVA administers and delivers two Certain Beneficiaries. Federal law requires all major types of cash benefits to certain veterans and, state Medicaid agencies to recover health care costs upon these veterans’ deaths, their eligible surviving paid on behalf of certain Medicaid beneficiaries spouses, children, and dependent parents. The from a deceased’s estate. In particular, Medicaid first type of benefit, known as compensation, is beneficiaries who were either (1) age 55 and paid to veterans on the basis of disabilities that older when they received Medicaid benefits or were caused or aggravated by specific events that (2) permanently institutionalized—regardless occurred during their military service (hereafter of age—are subject to the state’s estate claim. In referred to as “service-connected disabilities”). California, DHCS pursues an estate claim for the The second type of benefit, known as pension, is amount of the Medi-Cal benefits paid or the value paid to wartime veterans with limited income of the estate—whichever is less—upon the death and resources who are aged and/or disabled of a Medi-Cal beneficiary, with exceptions in the from conditions that are not service related. An event that the deceased is survived by a spouse, a individual who is potentially eligible for both minor child, or a disabled adult child. Federal law compensation and pension payments cannot requires that states recover costs for the following receive both types of benefits at the same time. services: (1) SNF or other long-term institutional Compensation services; (2) HCBS provided under a Medicaid waiver; (3) hospital and prescription drug services The basic compensation paid to each veteran provided while the recipient was receiving SNF care varies according to the combined degree of the or HCBS; and (4) at the state’s option, any other veteran’s service-connected disabilities, rated by items covered by the Medicaid State Plan, such as USDVA as a percentage of total function lost. The optional personal care services (PCSP, CFCO, or current monthly payment for basic compensation IPO within IHSS). ranges from $129 to $2,816 for a single veteran with IHSS Costs of PCSP Recipients Are Exempt no children. From Estate Recovery. In California, the IHSS Pension costs of recipients receiving services through PCSP have been exempt from estate recovery since 2000. Disability/Age-Based Pension for Veterans. The state’s policy of exempting PCSP from estate Basic pension is a needs-based benefit intended to recovery is allowed under federal law that grants provide certain wartime veterans a minimum level states the option to recover costs from certain items of income to raise their standard of living. Pension covered by the Medicaid State Plan. The DHCS has may be available to veterans with qualifying www.lao.ca.gov Legislative Analyst’s Office 5 An LAO RepORt wartime service who are (1) age 65 or over, and/ Enhanced Compensation for Veterans and or (2) totally and permanently disabled from Spouses Needing A&A. A single veteran who conditions that are not related to military service. requires A&A to perform ADLs due to his or To receive pension, a wartime veteran who meets her service-connected disability may receive an age and/or disability requirements must also meet enhanced compensation rate that ranges from financial requirements regarding income and net $3,504 to $8,059 per month, depending on the worth. The current maximum annual pension rate veteran’s level of service-connected disability. (MAPR) for a single veteran with no dependents is Veterans who receive compensation may also $12,465, or $1,039 per month. receive an additional payment for spouses who Survivors Pension. The survivors pension require A&A. This monthly payment ranges from benefit is available to a low-income surviving spouse $43 to $144 depending on the veteran’s level of who has not remarried and/or the unmarried service-connected disability. children of a deceased veteran with qualifying Enhanced Pension From A&A Payments. wartime service. Eligibility for survivors pension is The USDVA offers enhanced pension rates for also subject to income and net worth limitations. veterans and surviving spouses who meet the The current MAPR for a surviving spouse with no disability criteria for A&A and pension as well as dependents is $8,359, or $697 per month. the nonfinancial criteria for basic pension. The A&A benefit increases the effective MAPR—and Enhanced Monetary Benefits From A&A therefore the income eligibility limits—for Veterans and surviving spouses who receiving a pension. Thus, a claimant whose income meet nonfinancial criteria for basic forms of is too high to qualify for basic pension may still compensation or pension may also be eligible for qualify for an enhanced pension from A&A. the enhanced forms of these benefits if they meet The difference between the basic and enhanced certain additional disability requirements. In order monthly pension rates for a given claimant is to receive a type of enhanced benefit known as also known as the A&A payment. Currently, the A&A, the claimant must meet at least one of the maximum A&A payment for a single veteran following disability criteria. with no dependents is $694. Figure 1 compares the MAPRs for the basic pension and the • The claimant requires A&A of another enhanced pension under A&A and provides the person to perform ADLs. corresponding maximum A&A payment. • The claimant is required to remain CvSO bedridden due to disability. S The CVSOs—located in 56 of California’s • The claimant is in a SNF due to mental or 58 counties—are staffed by local veterans service physical incapacity. representatives whose mission is to advocate for • The claimant is blind or has certain visual veterans and their family members and provide impairments. assistance in accessing state and federal veterans’ benefits. While CVSOs have a cooperative Below, we briefly describe how USDVA applies relationship with DVA, CVSO representatives are these A&A enhancements to basic compensation county employees. The CVSO representatives assist and pension payments. veterans and their family members in accessing 6 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt Figure 1 MAPR for Basic and Enhanced Pension by Family Composition Maximum Monthly Basic Enhanced Pension Enhancement Pension MAPR Pension MAPR From A&A Single veteran $12,465 $20,795 $694 Veteran with spouse/dependent 16,324 24,652 694 Two veterans married to each other 16,324 32,115 1,316 Surviving spouse 8,359 13,362 417 Surviving spouse with one dependent 10,942 15,940 417 MAPR = maximum annual pension rate and A&A = aid and attendance. USDVA pension, compensation, A&A, and other from individual to individual, depending on each benefits. veteran’s unique eligibility status. Generally, an individual who served in active military service— t f f M - hree OrMSOf ederal ilitary for two years or for the full period for which r h C elated ealth are they were called to active duty—and who was There are three forms of federally funded discharged or released under conditions other than health care related to military service: (1) USDVA dishonorable qualifies for some level of USDVA health care available to certain veterans; health care benefits. (2) TRICARE available to active duty personnel, The USDVA assigns a veteran to one of eight reservists, and retirees with 20 or more years enrollment priority groups based primarily on of military service and their dependents and veteran status, service-connected disability, and survivors; and (3) the Civilian Health and Medical income. Pursuant to federal law, the priority groups Program of the Department of Veterans Affairs serve as a means for USDVA to balance demand (CHAMPVA) available to dependents and survivors for services with limited funds appropriated of deceased or disabled veterans. Below, we provide by Congress. If Congress does not appropriate an overview of USDVA health care, which operates sufficient funds for USDVA to provide care for under a unique system in which certain veterans veterans enrolled in all eight priority groups, then receive priority for certain services. Later in this veterans enrolled in lower priority groups may lose report, we address how the state may realize coverage. Eligibility for the eight priority groups is Medi-Cal savings by transferring certain veterans described in Figure 2 (see next page). to USDVA long-term care. The eligibility restrictions that the USDVA USDVA Health Care System Not Intended to health care system imposes on access to certain Be a Veteran’s Sole Source of Health Coverage. services means that veterans cannot necessarily Unlike health care plans like TRICARE, depend on USDVA health care as their sole source CHAMPVA, or Medi-Cal, the USDVA health of health care coverage. For example, certain care system is not considered a health insurance veterans enrolled in priority group one may still plan because it does not provide a standard set not receive SNF care since this benefit has strict of benefits to all enrolled beneficiaries. Access eligibility requirements that we describe later in to certain benefits—including SNF care, dental the report. Further, HCBS administered by USDVA care, hearing aids, eyeglasses, and DME—vary (such as home health aide services) may not be www.lao.ca.gov Legislative Analyst’s Office 7 An LAO RepORt available for veterans who need such services care facility (in order for USDVA to be billed) because of the high demand for this type of care. or (2) because a Medi-Cal beneficiary already For these reasons, USDVA advises veterans in its accessing a USDVA health care facility would be benefits materials to consider their total health care unlikely to incur significant Medi-Cal costs. We needs and to keep any existing health coverage note that the state is able to use OHC to realize they have. Veterans residing in rural areas or some Medi-Cal savings from beneficiaries enrolled in communities that are geographically distant in FFS, but generally not from those enrolled in from the nearest USDVA health facility also face managed care. challenges in relying on USDVA as their primary or O PariS verviewOf sole source of health coverage. USDVA Health Care Not Considered OHC by PARIS consists of three types of computer Medi-Cal. The state realizes Medi-Cal savings from matches—Interstate, Veterans, and Federal— OHC by entering “OHC codes” into its Medi-Cal involving data on individuals who receive or have Eligibility Data System, which enables the OHC applied for (1) certain public assistance benefits to be billed prior to Medi-Cal for the provision of provided by state-administered programs, and/or health care services. In the case of USDVA health (2) certain federally administered benefits. States care, DHCS has not attempted to create an OHC submit the data on recipients of and applicants code because of a perception that Medi-Cal savings for certain public assistance benefits provided by would be limited, either because (1) a Medi-Cal state-administered programs. These include major beneficiary could not access a USDVA health programs that are jointly funded by the states Figure 2 USDVA Health Care Enrollment Priority Groups for Veterans Ranked Highest to Lowest Priority Group 1: Veterans with service-connected disabilities rated 50 percent or more and/or veterans determined by the U.S. Department of Veterans Affairs (USDVA) to be unable to work due to service-connected conditions. Group 2: Veterans with service-connected disabilities rated 30 percent or 40 percent. Group 3: Veterans with service-connected disabilities rated 10 percent or 20 percent, veterans who are former prisoners of war or were awarded a Purple Heart medal or the Medal of Honor, veterans awarded special eligibility for disabilities incurred by treatment or vocational rehabilitation, and veterans whose discharge was for a disability incurred or aggravated in the line of duty. Group 4: Veterans receiving aid and attendance or housebound benefits and/or veterans determined by USDVA to be catastrophically disabled. Group 5: Veterans receiving USDVA pension benefits or eligible for Medi-Cal, and veterans with zero percent service-connected disabilities but with income below USDVA’s established means tests. Group 6: Veterans of World War I, veterans exposed to ionizing radiation in Vietnam, veterans of the Persian Gulf War, for any illness associated with combat service in a war after the Gulf War or during a period of hostility after November 11, 1998, for any illness associated with participation in tests conducted by the Defense Department as part of Project 112/Project SHAD, and veterans with zero percent service-connected disabilities who are receiving compensation benefits. Group 7: Veterans with gross household income below the geographically-adjusted income threshold for their resident location and who agree to pay co-pays. Group 8: All other veterans with gross household income above USDVA’s means tests who agree to pay co-pays. 8 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt and the federal government, such as Medicaid. federal matching payments for duplicate benefits. Federal agencies submit the data on recipients of Similarly, states may participate in the Veterans and applicants for certain federally administered and Federal matches to identify any payments from benefits. These benefits include pension income USDVA or USDOD received by—but incorrectly for former civilian and military employees of the recorded for—beneficiaries of state-administered federal government (the subject of the Federal programs. Federal or state rules may require match), and USDVA monetary benefits for veterans that a portion of these payments be considered (the subject of the Veterans match). income for the purpose of determining an The Defense Manpower Data Center (DMDC), individual’s eligibility or share of cost for public a computing facility operated by the U.S. assistance benefits. Again, both the state and the Department of Defense (USDOD), receives all data federal government may benefit fiscally from submissions from states and federal agencies and any subsequent adjustment or termination of the conducts all PARIS matches at no cost to the states. individual’s public assistance benefits. The DMDC may match each state’s data against Increasing Residents’ Participation in Federal data submitted by other states. This process, which Benefits, Potentially Creating State Savings. describes the Interstate matches, identifies any A state may also use the Veterans and Federal individual who appears in data submitted by more matches to identify individuals potentially eligible than one state. The DMDC may also match states’ for—but not yet receiving—federal monetary data against data submitted by federal agencies. or health care benefits. The state may use this This process, which describes the Veterans and information to help connect these individuals to Federal matches, identifies any individual who benefits fully funded by the federal government. appears in both the states’ data and federal While such activities generally do not create agencies’ data. federal savings and may increase federal costs, they may also (1) offset state costs for providing Reasons for States to Participate in PARIS public assistance benefits to these individuals, and/ Savings From Reducing Improper Benefit or (2) promote policy goals of the state to improve Payments. When PARIS began as a federal-state residents’ access to federal benefits. partnership in 1993, the original intent was How PARIS Matches operate for both states and the federal government to achieve savings from detecting and reducing Quarterly Data Submissions Contain Two improper benefit payments. For example, an Types of Information. Data submissions for PARIS individual’s eligibility for Medicaid and other state- occur in February, May, August, and November administered benefit programs is based on his or of each year. Generally, the state or federal agency her state of residence. A state may participate in responsible for administering a benefit program the Interstate match to identify beneficiaries in its submits a dataset that includes the following Medicaid program who are simultaneously enrolled information on the program’s recipients and in other states’ Medicaid programs. The state may applicants. further determine that some of these individuals • Identifying information, such as each no longer reside in the state, and move to terminate individual’s name, address, phone number, their Medicaid eligibility. This action may result in and Social Security number (SSN). The (1) reduced costs for the state and (2) discontinued SSN, as the unique identifier for the www.lao.ca.gov Legislative Analyst’s Office 9 An LAO RepORt recipient or applicant across data from participate in. The file contains all matched SSNs, multiple sources, forms the basis of each or “hits,” that the state received from the match, as Graphic Sign Off PARIS match. well as administrative information pertaining to these hits from other benefit programs. Figure 3 Secretary • Administrative information specific to the illustrates the process for generating each type of Analyst benefit program, such as the case number match file. assigned to an individual and his or her Director Three Types of Match Files. Below, we briefly eligible dependents, the type and amount Deputy describe the match files specific to each of the three of benefits received, and the category of types of PARIS matches. eligibility. • Interstate Match File. This match file DMDC Sends Match Files to States. Each identifies individuals listed in the state’s state receives a file of results known as the “match data who are also listed in the data file” for each Interstate, Veterans and/or Federal submitted by other states. match that the state has signed an agreement to Figure 3 PARIS Matching Processes Federal and Veterans Matches USDOD USDVA USOPM Federal Civil Service/ Military Income Data Monetary Benefits Data DMDC Federal Veterans Match File Match File Public Assistance Federal Match Data Veterans Match State Interstate Match Interstate Match File Interstate Match File State A DMDC State B Public Assistance Data Public Assistance Data PARIS = Public Assistance Reporting Information System; USDOD = U.S. Department of Defense; USOPM = U.S. Office of Personnel Management; USDVA = U.S. Department of Veterans Affairs; and DMDC = Defense Manpower Data Center. ARTWORK #130258 10 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt • Veterans Match File. This match file comes from its records system on claimants for provides USDVA monetary benefit records monetary, educational, vocational rehabilitation, associated with individuals listed in the and employment assistance benefits. These records state’s data. This includes whether the do not directly address USDVA health care benefits. individual receives compensation or Because the data submitted by USDVA cover pension and the total amount of the award. only veterans, dependents, or survivors who are listed in this records system, the Veterans match • Federal Match File. This match file is unable to identify any individual who, although provides federal payment records from eligible for USDVA monetary benefits, does not USDOD and/or the U.S. Office of Personnel have a recorded history of submitted claims for Management associated with individuals such benefits. Moreover, PARIS does not match listed in the state’s data. The Federal match state public assistance data against health care file also identifies individuals in the state’s records maintained by USDVA. Any discovery data who are listed in the federal data as of an individual’s eligibility for or enrollment in active duty members or retirees of the USDVA health care is usually based on inferences military, and thus likely eligible for health made from monetary benefit information in the coverage under TRICARE. match files. For example, a claimant with a high While this report focuses on the analysis and use compensation award likely has a high level of of results from the Veterans match file, we also service-connected disability and may be eligible discuss the use of results from the Federal match for USDVA-funded long-term care. Despite file as they relate to TRICARE eligibility. these limitations, the state of Washington has Only Claimants for USDVA Monetary pioneered—and attributed significant savings to— Benefits Are Included in Veterans Match. All various applications of the Veterans match, as we information that USDVA discloses to DMDC describe in the next section. VEtERANS BENEFIt ENHANCEMENt (VBE) IN WASHINgtoN StAtE Since 2002, the state of Washington has 62,000 individuals receiving SNF care and about explored and refined many activities related to the 440,000 receiving HCBS through IHSS. Like Veterans match. Washington currently conducts California, Washington generally receives one these activities under a concerted effort known dollar of federal funds for each state dollar it spends as VBE to generate state savings in its Medicaid on services covered by its Medicaid program. program. VBE Is an Interagency Collaboration In Washington, the total number of Medicaid that Receives ongoing Resources enrollees is approximately 1.2 million, including 17,000 individuals receiving SNF care and 26,000 The VBE began in 2003 as a pilot initiative individuals receiving HCBS. By way of comparison, of the Washington State Health Care Authority there are currently about 7.9 million beneficiaries (HCA), the state Medicaid agency. For purposes of enrolled in the Medi-Cal Program, including the pilot, HCA entered into an interagency contract www.lao.ca.gov Legislative Analyst’s Office 11 An LAO RepORt with the Washington State Department of Veterans for LTSS—usually HCBS. Second, the costs of all Affairs (WDVA) to provide outreach to certain HCBS are subject to Medicaid estate recovery in individuals identified in the Veterans match. Washington, along with the cost of institutional Based on the success of the pilot, the Washington care. This provides the incentive for Medicaid State Legislature subsequently provided ongoing HCBS recipients to apply for A&A, thereby resources for WDVA to continue its partnership reducing the amount of possible claims against with HCA, including: their estates. For Washington’s state fiscal year of • A continuous appropriation of $1.5 million 2011-12, VBE program staff reported facilitating biennially to WDVA (Washington enacts monetary benefit enhancements, such as A&A, budgets on a two-year cycle), partly to for 220 Medicaid recipients, and estimated support contracts with local Veterans $4 million in state savings from the portion of Service Organizations (VSOs) that assist these enhancements counted as TPL for LTSS. with VBE outreach and claims filing. Since 2006, Washington has facilitated monetary • Four full-time staff positions at WDVA to enhancements for 1,600 recipients—and recorded work exclusively on VBE activities. $18.9 million in cumulative TPL-related LTSS savings—as a result of this component of VBE. three Components of VBE Create Modest Savings From Shifting State Medicaid Savings for Washington Costs to Federal Payers. The VBE program staff at HCA identifies Medicaid beneficiaries who are The VBE focuses on aged and disabled potentially eligible for TRICARE and CHAMPVA Medicaid recipients in Washington who use from the Federal and Veterans match files, LTSS—particularly HCBS—and who may be respectively. The VBE staff refers these cases to the eligible for USDVA benefits. Below, we describe the TPL division at HCA, which confirms whether three principal components of VBE in descending any beneficiaries are already enrolled in TRICARE order of savings attributed to them. These savings or CHAMPVA and updates their records for are summarized in Figure 4. OHC accordingly. As a result, providers must bill Substantial Savings From Treating A&A TRICARE or CHAMPVA before Medicaid will Payments as TPL. Based on information from the pay for any services provided to these beneficiaries. Veterans match file, HCA refers to WDVA any Finally, HCA performs outreach activities, such Medicaid beneficiaries who may not be receiving as mailing notification letters to individuals who their maximum entitlement to USDVA monetary are eligible but not enrolled in TRICARE or benefits. The WDVA provides outreach to facilitate CHAMPVA. new or increased compensation, pension, or A&A For Washington’s state fiscal year of 2011-12, awards for these beneficiaries. VBE program staff reported establishing OHC Two key Medicaid policies in Washington from TRICARE or CHAMPVA for 975 Medicaid allow the state to realize substantial savings from recipients, resulting in an estimated $2.3 million facilitating A&A payments through VBE. First, in in state savings. Since 2006, Washington has 2004 the Washington Medicaid program adopted established OHC for 4,000 Medicaid recipients— a policy of treating A&A as TPL for LTSS. Thus, and recorded $11.4 million in cumulative savings— Washington requires that any A&A payments as a result of this component of VBE. to beneficiaries must be used to offset state costs 12 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt Limited Savings From Discontinuing collectively referred to as “PARIS Veterans clients”) Medicaid for Veterans With High Service- receive USDVA benefits for which they are eligible. Connected Disability. The HCA uses the Veterans HCA Is the Lead Agency for Sending and match file to identify Medicaid recipients who are Receiving Veterans Match Data. The HCA—the veterans with service-connected disabilities rated at lead entity responsible for the state’s PARIS Graphic Sign Off 70 percent or higher. Because these veterans usually Veterans activities—conducts some initial filtering qualify for full USDVA coverage of long-term of the PARIS Veterans file before sending it to Secretary care—including institutional care—they may not WDVA. Broadly, two HCA staff members conduct Analyst require Medicaid coverage. Washington reports two main activities: (1) overseeing PARIS Veterans Director that around 30 veterans in this category have activities and (2) tracking the amount of savings Deputy discontinued their Medicaid coverage as a result resulting from PARIS Veterans. of VBE to date, and estimates annual state savings WDVA Manages PARIS Veterans Outreach. from shifting each individual to USDVA long-term Four full-time WDVA staff conduct two main care coverage at $24,000 per individual. activities: (1) outreaching to PARIS Veterans clients who appear to be eligible but not enrolled Washington State Model for PARIS in CHAMPVA and (2) conducting initial outreach Veterans Implementation to clients who appear to be eligible for additional The implementation model used in Washington USDVA monetary benefits. In terms of outreaching State for PARIS Veterans can best be understood Figure 4 as a coordinated Majority of PARIS Veterans Savings in Washington State Come From Monetary Enhancements partnership among three (In Millions) entities: HCA, WDVA, and local Savings From Shifting State Medicaid Costs to Federal Payers VSOs providing $7 Savings From Applying A&A as TPL for Home- and Community-Based Services assistance to 6 veterans in filing USDVA claims. 5 As explained below, each of 4 these entities 3 perform distinct functions to ensure 2 that veterans, 1 dependents, and survivors identified by the 05-06 06-07 07-08 08-09 09-10 10-11 11-12 PARIS Veterans PARIS = Public Assistance Reporting and Information System, A&A = aid and attendance; TPL = third-party liability. match (hereafter www.lao.ca.gov Legislative Analyst’s Office 13 ARTWORK #130258 An LAO RepORt to PARIS Veterans clients who appear to be eligible By providing warm leads that are likely to result in for CHAMPVA, the WDVA staff generally make an award, WDVA creates an incentive for VSOs to phone calls to these individuals and provide develop and file claims for PARIS Veterans clients. assistance in completing the USDVA application. HCA Tracks Amount of Savings Resulting In terms of PARIS Veterans clients who appear to From All PARIS Veterans Activities. The HCA staff be eligible for USDVA monetary benefits, WDVA receive results from all PARIS Veterans activities staff will make initial phone calls to these clients. conducted by WDVA and VSOs. In terms of the Information ascertained about a client in this PARIS Veterans clients enrolled in CHAMPVA by manner constitutes a “warm lead” that is sent WDVA, the TPL division of HCA will code this to local VSOs who follow up with clients to file coverage as OHC and then track any reduction in USDVA monetary claims. utilization of Medicaid-covered services in order to VSOs Assist PARIS Veterans Clients by Filing quantify the resulting amount of Medicaid savings. USDVA Monetary Claims on Their Behalf. The In terms of the PARIS Veterans clients who are VSOs have entered into performance contracts with awarded A&A, the HCA staff track the amount of WDVA, which compensates these groups for the Medicaid savings that result from counting A&A as administrative costs associated with all claims they TPL for HCBS. file on behalf of veterans and their family members. PARIS VEtERANS IN CALIFoRNIA: PILot AND CuRRENt oPERAtIoN Chapter 758, Statutes of 2008 (AB 1183, the pilot and then describe how PARIS Veterans Committee on Budget) directed DHCS to continues to operate in select counties. establish a two-year pilot program to use h f dhCS P r ighlightS rOM ilOt ePOrt PARIS to (1) identify veterans, dependents, and survivors enrolled in Medi-Cal; and (2) assist DHCS Set Up Pilot as Required by these individuals in obtaining USDVA health Legislation . . . Per Chapter 758, DHCS pursued care benefits. If DHCS determines the pilot is the following activities to implement the PARIS cost-effective, then the legislation gives DHCS Veterans pilot. the option to implement the program statewide • Entered into a Memorandum of at any time and continue the operation of PARIS Understanding with DVA to perform indefinitely. pilot outreach activities through DVA’s The legislation also required DHCS to evaluate connection with CVSOs. Under the terms outcomes and savings from the pilot and provide of this agreement, DHCS was responsible the Legislature with a report on the findings and for filtering match results and sending recommendations. In April 2012, DHCS released outreach referrals to DVA. The DVA in this report, which covered the period between July turn was responsible for forwarding these 2009 and June 2011. We first review the report’s referrals to CVSOs and reporting any description of the main activities and results from outcomes to DHCS. 14 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt • Delegated to DVA the selection of three Over 16,000 Hits Translated Into consenting counties where USDVA medical 24 Discontinued Medi-Cal Cases . . . Figure 5 centers were located to participate in the (see next page) illustrates how the number of cases pilot—Fresno, San Bernardino, and San decreased at each stage of referrals and outreach. Diego. Out of the 16,387 hits received, DHCS made 3,933 referrals to CVSOs for outreach (including • Focused on beneficiaries identified by duplicate referrals). These resulted in: the match who were receiving high-cost • 990 attempts by CVSOs to contact Medi-Cal services, including long-term beneficiaries based on these referrals, care. including letters and telephone calls. . . . With Some Additional Activities . . . The report also discusses DHCS’ use of the match file • 158 beneficiaries contacted by CVSOs who to identify family members and survivors who were found to be already enrolled in both appeared to be eligible for CHAMPVA. Medi-Cal and USDVA health care. . . . And Counties . . . Halfway through the • 24 of these 158 individuals discontinuing pilot, seven additional counties requested to their Medi-Cal coverage before the end of participate in PARIS Veterans. However, as we the pilot. explain below, the final outcomes and savings in the report were concentrated within the three It is our understanding from the report that original counties. the 158 beneficiaries contacted by CVSOs with . . . Using Existing Resources. The Legislature both Medi-Cal and USDVA health coverage were did not appropriate additional funding or positions mainly distributed among the three original to implement the pilot. Thus, DHCS redirected pilot counties—117 in San Bernardino, 24 in San analytical staff and information technology Diego, and 10 in Fresno. The report did not include resources to complete PARIS Veterans workload on any further results for the remaining 832 CVSO an as-needed basis. The report estimated that over contacts. The report estimated General Fund the course of the pilot, the department redirected savings of just over $700,000 for the two-year pilot a total of $75,000 General Fund in administrative period from the 24 individuals contacted by CVSOs resources. who discontinued their Medi-Cal coverage. . . . And Three Cases With OHC Updated for Pilot outcomes and Savings CHAMPVA. The DHCS identified and established According to the report, DHCS submitted to OHC for three Medi-Cal FFS beneficiaries who were the federal government about 5.6 million Medi-Cal already enrolled in CHAMPVA, for an estimated records over the eight quarterly match periods $112,000 in General Fund savings over the two-year occurring within the pilot. From these records, pilot period. The DHCS report does not cover DHCS received 16,387 hits in the match files, savings from establishing TRICARE OHC through including some duplicate hits of beneficiaries who the Federal match. were identified repeatedly over multiple quarters. Nature of outreach (A “hit” is a SSN that was identified in both the Medi-Cal and USDVA data.) The report states that 24 discontinued Medi-Cal cases came about “as a result” of CVSO outreach. www.lao.ca.gov Legislative Analyst’s Office 15 An LAO RepORt The report also claims that during outreach, • Limited project management did not allow CVSOs explained how USDVA health care may the pilot to achieve “maximum success.” be able to provide specialty services for veterans • Existing workload does not permit DHCS that may be harder to obtain through Medi-Cal, and DVA to redirect staff to operate PARIS such as specific treatments for service-connected Veterans to its “fullest potential.” conditions. Furthermore, CVSOs contacted veterans with information about Medi-Cal estate recovery The report also cites budget constraints, requirements, and this information appeared to staffing shortages, and workload pressures at be a “powerful reason” for veterans to consider CVSOs as factors limiting the pilot’s effectGivernaepssh. ic Sign Off discontinuing Medi-Cal and/or enrolling in USDVA For example, the report notes that CVSOs Secretary health coverage. contacted only 25 percent of the nearly 4,000 Analyst referrals from DHCS. Resource Constraints Director Report Suggests More Could Be Done With Deputy According to the report, DHCS lacked the Additional Resources. The report suggests the necessary staff resources to produce an unduplicated Legislature could (1) provide new positions at count of unique hits and referrals for the report, DHCS and DVA dedicated to PARIS Veterans and making it difficult to evaluate the effectiveness of (2) consider a statewide expansion of the match the referral and outreach process. The report also with these resources. The report also claims that attributes the pilot’s limited amount of state savings with additional resources, CVSOs could follow and limited number of successful contacts on up on the remaining 832 contacts that were not inadequate resources at the state level, such as: accounted for in the final pilot results. Figure 5 Pilot Activities and Results From PARIS Veterans 2009-10 Through 2010-11, Eight Quarterly PARIS Matches 832 individuals with no reported results from pilot. DMDC 16,387 Hitsa DHCS 3 R , e 9 f 3 e 3 rralsa CVSOs 990 Contacts 158 individuals already enrolled in Medi-Cal and USDVA health care in San Bernardino, San Diego, and Fresno Counties. Three individuals with CHAMPVA coded for OHC $111,900 General Fund savings 24 individuals discontinue Medi-Cal $705,132 General Fund savings a Includes duplicate individuals over multiple quarters. PARIS = Public Assistance Reporting and Information System; DMDC = Defense Manpower Data Center; DHCS = Department of Health Care Services; CVSO = County Veterans Service Offices; USDVA = U.S. Department of Veterans Affairs; CHAMPVA = Civilian Health and Medical Program of the Department of Veterans Affairs; OHC = other health coverage. 16 Legislative Analyst’s Office www.lao.ca.gov ARTWORK #130258 An LAO RepORt C Urrent O PeratiOn Of PariS v eteranS match file results for Medi-Cal beneficiaries in 11 counties, and refers a subset of the hits for CVSO DHCS Has Not Requested Resources or outreach in these counties. Aside from Napa, Indicated Expansion Plans for PARIS Veterans. these are the same 10 counties that participated in Despite the pilot’s reported benefit of $810,000 the pilot. Figure 6 shows the total number of hits General Fund over two years—as well as the received and targeted referrals from the February report’s suggestion that more resources could 2013 Veterans match files. According to DHCS, improve outcomes for PARIS Veterans—DHCS other ongoing activities include (1) establishing has not formally requested additional funding or OHC for additional beneficiaries identified with positions to operate PARIS Veterans. Nor has the CHAMPVA and (2) income verification for USDVA department signaled any plans to exercise its broad monetary benefits by county welfare departments. authority to expand PARIS Veterans statewide on However, we have not obtained savings estimates the basis of cost-effectiveness. related to these activities. Post Pilot, PARIS Veterans Continues in 11 Counties. Currently, DHCS receives Veterans LAo FINDINgS C alifOrnia d OeS n Ot P UrSUe in Washington, the state would first need to begin w aShingtOn ’ S M ajOr S OUrCe Of S avingS counting A&A as TPL for IHSS. Second, the state would need to examine its inconsistent treatment As noted earlier, Washington State realizes of IHSS costs for the purpose of Medi-Cal estate the majority of its PARIS Veterans savings by recovery. As we note in the background, the IHSS counting A&A as TPL for Medicaid HCBS. The costs of certain recipients are exempt from the Washington example suggests that the ability to Medi-Cal estate claim while the costs of other recover the costs of HCBS (such as personal care recipients are not. Below, we further explain the services) through A&A can serve as a financial Figure 6 incentive for recipients to Medi-Cal Hits and Referrals seek A&A, which—when From February 2013 Veterans Match counted as TPL—reduces County Hits Referrals to CVSOs the amount of the Alameda 490 61 Medicaid estate claim. Fresno 430 41 In California, however, Orange 635 108 Sacramento 633 59 A&A is not counted as San Bernardino 789 175 TPL for IHSS—our largest San Diego 915 133 HCBS program—because San Francisco 401 47 San Mateo 130 9 of reasons unclear to Santa Clara 299 26 us. In order to pursue Solano 211 29 Medicaid savings from Napa 118 31 Totals 5,051 719 PARIS Veterans on the CVSOs = County Veterans Service Offices. order of those achieved www.lao.ca.gov Legislative Analyst’s Office 17 An LAO RepORt lessons from Washington’s experience, the state’s • Consistent Inclusion of IHSS Costs treatment of A&A in the IHSS program, and why in Medi-Cal Estate Claim. The state the Medi-Cal estate recovery policy is relevant to would need to begin including IHSS PARIS Veterans. costs incurred by PCSP recipients in the Medi-Cal estate claim. Policies Align to Achieve Savings in If the state were to pursue these two policies, Washington State all IHSS recipients eligible for A&A would have a In Washington, where A&A is counted as personal financial incentive to seek the award as a TPL for Medicaid HCBS and where the costs of means of minimizing their Medi-Cal estate claim. such services are included in the state’s estate claim, there is a clear financial incentive for the unclear Why California Does Not Count Medicaid beneficiary to seek A&A in order to A&A as tPL for IHSS reduce the amount of the claim that the state may IHSS Program Became Subject to Federal seek against the Medicaid beneficiary’s estate. For Medicaid Law Beginning in 1993. The IHSS VSO representatives, who serve as advocates for program shifted from an independent program veterans and their family members in Washington, funded solely by state and county funds to a assisting clients in seeking A&A aligns with their Medi-Cal benefit covered under the Medicaid core mission. Further, the state of Washington has state plan in 1993. Today, close to 99 percent of a financial incentive to devote staff resources to IHSS recipients are eligible for federal Medicaid help Medicaid beneficiaries access A&A, since the matching funds. As such, the program is subject benefit functions as TPL for HCBS. This alignment to federal Medicaid law stipulating that Medicaid of incentives among PARIS Veterans clients, the is the payer of last resort. If another insurer or VSO, and HCA enables Washington State to realize program (such as A&A) has the responsibility to the majority of its PARIS Veterans savings from pay for health care or long-term care costs incurred counting A&A as TPL for Medicaid HCBS. by a Medicaid beneficiary, that entity is generally required to pay all or part of the costs prior to Policies Do Not Align to Achieve Medicaid making any payment—a concept known Savings in California as TPL. In California, A&A is not counted as TPL in Case Law Affirms That A&A May Be Counted the IHSS program. Further, IHSS costs incurred as TPL for IHSS. Courts in various jurisdictions— by PCSP recipients—approximately one-half of the including Washington State—have ruled that a IHSS caseload—are excluded from the Medi-Cal state Medicaid agency may count A&A as TPL. estate claim. In order for California to align its Our informal consultation with staff of Legislative policies to achieve Medicaid savings on the order Counsel leads us to find that the state may count of those achieved in Washington (adjusting for A&A as TPL for IHSS recipients receiving this California’s larger size), the state would need to USDVA monetary benefit. make the following two policy changes in tandem. A&A Currently Counts in California as • Count A&A as TPL for IHSS Recipients. TPL in Institutional Care Settings. Currently in The state would need to begin counting California, a Medi-Cal beneficiary’s A&A award the A&A award as TPL for IHSS recipients can be counted as TPL when the beneficiary enters eligible for federal Medicaid matching funds. 18 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt a SNF. Based on our understanding of the IHSS excludes their cost of implementation—replaces the program as a Medi-Cal benefit governed by federal savings estimate from our Analysis of the 2007-08 Medicaid requirements, it appears to us to be Budget Bill. (In the box on the next page, we discuss inconsistent for the state to pursue A&A as TPL in how we have revised our view on PARIS Veterans institutional settings but not for IHSS. savings with respect to the Analysis of the 2007-08 Budget Bill.) State’s Estate Recovery Policy Raises Concerns Long-term Care Veterans Represent As we note, IHSS costs incurred by PCSP Major Portion of Savings From Pilot . . . recipients—who are about one-half of the IHSS caseload—are excluded when the state seeks to Around half of the savings achieved during recover Medi-Cal costs from estates. The DHCS the pilot was due to just four long-term care does recover costs for recipients who receive IHSS beneficiaries discontinuing their Medi-Cal through subprograms besides PCSP. If DHCS coverage. If these beneficiaries (1) were residing begins to count A&A as TPL for IHSS, then the in SNFs when they or their family members were state’s estate recovery policy for IHSS must also contacted by CVSOs, and (2) discontinued their be evaluated to ensure that recipients’ incentives Medi-Cal coverage as a result of this contact, then are appropriately aligned. Currently, the state’s presumably they are veterans with a high level of inconsistent treatment of IHSS costs means that service-connected disability who are eligible for certain recipients have a financial incentive to seek SNF care provided by USDVA. However, we were A&A to reduce the Medi-Cal estate claim while unable to confirm from DHCS whether any of the others—whose IHSS costs are exempt from estate four long-term care beneficiaries who discontinued recovery—do not have such an incentive. their Medi-Cal coverage during the pilot actually transferred to USDVA-operated or -contracted State Could Achieve Savings by SNFs. Mirroring Washington State Policies Clearly, small numbers of long-term care If the state were to align financial incentives beneficiaries represent disproportionate amounts facing IHSS recipients (related to TPL and of the total Medi-Cal savings to date from PARIS estate recovery policies) in a manner similar to Veterans. However, these amounts are also small in Washington, we estimate Medi-Cal savings from practical terms—roughly $180,000 General Fund counting A&A as TPL to yield at least $5 million to annually estimated from the pilot. $10 million annually in state General Fund savings. . . . But Potential Statewide Savings From M OdeSt S avingS M ay B e a ttainaBle these Veterans Are Highly uncertain, f rOM e xPanding C Urrent a CtivitieS Likely Less than $10 Million Annually In this section we (1) review PARIS Veterans The Legislature’s decisions about whether to activities that the state has pursued since the start expand PARIS Veterans activities statewide— of the pilot and (2) provide a rough estimate of the and/or whether to invest more resources in the potential General Fund benefit from expanding program—should be informed by some plausible these current activities statewide. We note this range of savings that are potentially available from estimate—which includes optimistic assumptions the current mainstay activity: shifting long-term about the success rate of these activities and care costs from Medi-Cal to USDVA. One key www.lao.ca.gov Legislative Analyst’s Office 19 An LAO RepORt question is the size of the population of long-term $7 million annually, assuming (1) there are roughly care veterans with Medi-Cal who are potentially 500 veterans in California receiving Medi-Cal- suitable for transfer to USDVA long-term care. funded SNF care who meet the 70 percent service- Using survey data collected by the U.S. connected disability threshold, and (2) up to Census Bureau between 2009 through 2011, we 50 percent of these individuals successfully transfer estimate there are around 5,000 veterans over the to USDVA long-term care. We note that 50 percent age of 65 who receive Medi-Cal-funded SNF care may represent an optimistic scenario. The limiting in California. Most of these beneficiaries likely factors on the actual rate of transfers include the would not meet the service-connected disability specific criteria for when such transfers are possible requirements for USDVA-funded long-term care. or appropriate, and the effectiveness of CVSO We believe at most 10 percent of all veterans over outreach and other steps necessary to implement age 65 with Medi-Cal coverage are rated 70 percent these transfers. We examine both of these issues or more disabled from service-connected further below. conditions, which means they are in priority group C v e OnSideratiOnSfOr eteranS nrOlledin one and receive the most access to USDVA care. B M -C USdva h C Oth edi aland ealth are (We were unable to obtain a reliable estimate of this percentage specifically for veterans with Medi-Cal In our Analysis of the 2007-08 Budget Bill, coverage residing in SNFs.) we recommended that the state implement We estimate potential General Fund savings use of PARIS Veterans to facilitate a voluntary from pursuing institutional long-term care “transfer” of certain veterans from Medi-Cal to transfers to USDVA statewide may be as high as USDVA health care. Such a transfer implies that Previous LAo Estimate of Potential Savings From Shifting Medi-Cal Costs to uSDVA No Longer Applies Our Analysis of the 2007-08 Budget Bill estimated that the state could save as much as $250 million annually if all veterans enrolled in Medi-Cal transferred to the U.S. Department of Veterans Affairs (USDVA) health care. This estimate was partly based on assumptions that (1) many veterans were seniors and persons with disabilities (SPDs) receiving care through Medi-Cal fee-for-service (FFS) and (2) the state would achieve savings not necessarily from these veterans discontinuing their Medi-Cal coverage, but rather from avoiding FFS costs when veterans chose to obtain health care services from USDVA instead of Medi-Cal. Since 2010, the state has enacted policies to shift many SPDs—including those who are veterans—into Medi-Cal managed care. The state makes monthly capitated payments for each managed care enrollee, regardless of whether that enrollee actually uses health care services. Thus, a veteran who is enrolled in both USDVA health care and Medi-Cal managed care generally would have to discontinue his or her Medi-Cal coverage for the state to realize savings. Because this method of achieving savings conflicts with our view—elaborated later in this report—that veterans living in the community should generally maintain their Medi-Cal coverage, we recognize that our previous savings estimates generally do not apply in the current managed care environment. 20 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt a veteran enrolled in USDVA health care either talk therapies for post-traumatic stress disorder, as (1) discontinues Medi-Cal coverage completely and well as certain surgeries or other treatments, may solely utilizes USDVA health care or (2) retains be more appropriately administered by USDVA. Medi-Cal coverage but primarily utilizes USDVA Ultimately, the services that a veteran may wish to health care. seek from Medi-Cal or USDVA will be determined The USDVA advises veterans against by several factors: his or her eligibility for and discontinuing coverage and relying solely on access to USDVA benefits, individual preferences, USDVA health care. This advice makes sense from health care needs, and other considerations a veteran’s perspective, given the fact—previously such as cost and quality of care. We believe it is discussed—that USDVA health care coverage is a worthwhile activity for CVSO representatives not designed to be a veteran’s sole health coverage. and other veteran advocates to continue to assist While we have concerns about veterans’ ability to veterans in enrolling in USDVA health care and for access certain needed services through USDVA— veterans to access USDVA benefits as appropriate. particularly SNF care and HCBS—we do find However, given the variability in USDVA benefits that there are certain veterans who are receiving provided to veterans based on their priority group, SNF care through Medi-Cal who may be able veterans living in the community are appropriately to successfully transfer to SNF care provided by advised not to discontinue Medi-Cal coverage USDVA. This provides the eligible veteran with altogether. This view has consequences for the certain financial benefits (discussed further below). state’s ability to realize Medi-Cal savings from PARIS Veterans. Veterans Living in the Community Should Maintain Medi-Cal Coverage It May Be Appropriate for Some Veterans in SNFs to transfer From Medi-Cal Generally, it is not appropriate for veterans to uSDVA Long-term Care . . . living in the community to discontinue their Medi-Cal coverage because the USDVA benefits Conditions for Transferring to USDVA for which they may be eligible may not provide Long-Term Care. We find that there are three comprehensive health care coverage. Take, for conditions that, if met, reflect circumstances where instance, the case of an aging veteran who suffers it may be appropriate for a veteran receiving SNF from conditions that affect his or her ability to care through Medi-Cal to transfer to a SNF funded perform ADLs but does not suffer from service- by USDVA. connected disabilities. Such an individual would • Condition One. The veteran is eligible not be given priority for USDVA health services, to receive SNF care through USDVA including HCBS, which the veteran may need to due to having a clinical need for SNF remain safely in his or her home and community. care and also meeting at least one of the In contrast, Medi-Cal would provide long-term following eligibility criteria: (1) 70 percent care, such as IHSS or other HCBS, to such an or more service-connected disability, or individual based on clinical and functional need. (2) 60 percent or more service-connected We recognize that, in some cases, USDVA disability and inability to work, or (3) a provides superior care when compared to service-connected condition that makes Medi-Cal. In particular, specialized services for SNF care necessary. veterans, such as military sexual trauma services or www.lao.ca.gov Legislative Analyst’s Office 21 An LAO RepORt • Condition Two. The USDVA has a SNF bed Veterans in Managed Care May Face available in a community preferred by the Trade-Offs From Retaining Medi-Cal Coverage. veteran. If a veteran is enrolled in managed care and retains his or her Medi-Cal coverage, the • Condition Three. The veteran is willing state would continue to make managed care and able to transfer to the USDVA-funded payments following the veteran’s transfer to SNF bed. USDVA long-term care. Moreover, the state could Financial Benefits From Transferring to potentially pursue claims against the veteran’s USDVA Long-Term Care. By transferring to a estate for the cost of these managed care payments, USDVA-funded SNF bed, a veteran would avoid which may be relatively high since they include the potentially adverse financial consequences of the average cost of institutional care. (As part of accessing SNF care through Medi-Cal. Specifically, an enacted state policy known as the Coordinated a veteran who is required to pay a share of cost Care Initiative [CCI], LTSS—including SNF each month in order to qualify for SNF care under care—will become managed care benefits in Medi-Cal would no longer face such a payment in a eight counties, with capitated payments to plans USDVA-funded facility. Further, USDVA does not reflecting the average long-term care cost per have an estate recovery policy similar to Medi-Cal. enrollee rather than actual utilization of services.) Therefore, the only way for veterans in managed . . . But Whether these Veterans Should Also care to avoid estate recovery (and for the state Retain Medi-Cal Coverage Depends on to realize savings from their transfer to USDVA their Individual Situations long-term care) is to discontinue their Medi-Cal Veterans in FFS Generally Should Retain coverage entirely. Medi-Cal Coverage. Veterans enrolled in FFS We recognize that some veterans residing in Medi-Cal who transfer to USDVA-operated or SNFs have little possibility of returning to their -contracted facilities would be appropriately home or community. For example, some of these advised not to discontinue their Medi-Cal veterans may be institutionalized due to a terminal coverage, but rather retain it as a safety net in illness or a debilitating condition from which the event that they return to the community and recovery is highly unlikely. Because these veterans require HCBS or other services that may be difficult would not likely require HCBS in the future, to obtain through USDVA. Otherwise, they would maintaining their Medi-Cal coverage may not be have to reenroll in Medi-Cal following discharge necessary once they transfer to USDVA long-term from the USDVA-funded SNF, and may experience care. These veterans may consider discontinuing disruptions to care while waiting to receive HCBS. their Medi-Cal coverage, since they could benefit Moreover, during their stay at the USDVA facility, from avoiding estate recovery of managed care they would still be able to avoid estate recovery for payments while sacrificing little in the way of the cost of most health care and long-term care services they actually require for the foreseeable services while remaining enrolled in FFS Medi-Cal. future. However, veterans who are likely to transition Later in the report, we describe how DHCS back to their home and community would have to could track Medi-Cal savings from veterans who weigh the trade-offs of having continuous Medi-Cal maintain their FFS Medi-Cal coverage following coverage versus avoiding the estate claim when their transfer to USDVA long-term care. deciding whether to remain enrolled in Medi-Cal. 22 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt l aCk Of d ediCated r eSOUrCeS and PARIS Veterans from long-term care clients O ther f aCtOrS C OnStrained P ilOt and discontinuing their Medi-Cal coverage and i tS e valUatiOn relying instead on their USDVA coverage. However, DHCS did not confirm whether We find the implementation of the pilot, discontinued Medi-Cal recipients success- including the evaluation of outcomes from the fully transferred to a USDVA long-term pilot, was constrained by a lack of resources and care facility, thereby failing to confirm a other factors that we describe below. We base basic policy premise of PARIS Veterans. our findings on (1) our discussions with program staff who oversee PARIS Veterans at DHCS and • Certain Outreach and Monetary DVA, (2) our discussions with representatives of Benefit Enhancements Obtained Went CVSOs from the original three pilot counties, and Unmeasured. To our knowledge, there (3) DHCS’ report on the pilot. are no official measures of (1) outreach to individuals who may be eligible for USDVA DHCS Lacked Dedicated Resources to health care but are not yet enrolled, Effectively Implement Pilot and (2) monetary benefit enhancements The DHCS did not receive or request additional obtained by veterans as a result of PARIS resources to implement PARIS Veterans. According outreach. to DHCS, the lack of resources constrained its ability to more effectively implement the pilot in DHCS Does Not track All FFS Cost the following ways. Avoidance Resulting From PARIS • Duplicate Data Obscured Evaluation of Cost avoidance refers to expected payments on Pilot. The DHCS was unable to produce FFS claims that Medi-Cal would otherwise have to an unduplicated count of the number of make over a given period of time if an individual submissions, hits, referrals, and CVSO who discontinued coverage or used alternative contacts over all eight quarters of the pilot. coverage had instead obtained care through This makes it difficult to evaluate the actual Medi-Cal during that same period. Because it is success rate of outreach efforts. impossible to track which services the beneficiary would have used in this alternate scenario, • Non-Updated Referral Lists Hindered cost-avoidance calculations may be based on the Outreach. The DHCS was unable to update beneficiary’s actual prior utilization of services, or referral lists for errors identified by CVSOs the average expenditures for all FFS beneficiaries during previous quarters. As a result, some in the same aid category. In contrast, managed CVSOs complained that they received care savings are only tracked by DHCS when a referral lists that contained the same errors beneficiary disenrolls from the managed care over multiple quarters, including deceased plan and the department ceases to make known recipients, incorrect contact information, monthly capitated payments for that beneficiary. and individuals who are not veterans or According to our conversations with program dependents. staff, DHCS does not regularly track such cost • Transfers to USDVA Went Unconfirmed. avoidance to include as official savings within the The DHCS assumes state savings from Medi-Cal budget in cases when individuals remain www.lao.ca.gov Legislative Analyst’s Office 23 An LAO RepORt in FFS Medi-Cal but use alternative coverage. DHCS and CVSos Did Not Share Same Therefore, DHCS was unable to provide an estimate Policy Priorities for PARIS Veterans of potential fiscal benefits from individuals The DHCS report to the Legislature regarding who shift to USDVA long-term care but do not the PARIS Veterans pilot indicates that the primary discontinue their FFS Medi-Cal coverage. focus of DHCS during the pilot was to use the Veterans match to identify clients who would CVSo outreach Was Constrained by voluntarily supplant their Medi-Cal coverage Lack of Resources with USDVA health care, yielding Medi-Cal Through conversations with CVSO savings. However, the primary focus of CVSOs is representatives, it is our understanding that they to advocate and assist veterans and their family faced several challenges in performing outreach members to obtain benefits, such as monetary activities related to PARIS Veterans. The CVSOs benefits. The CVSOs were expected to make reported that they were only able to conduct PARIS the case to veterans to discontinue Medi-Cal Veterans outreach to the extent that staff had coverage on the basis that (1) USDVA health care time available after they completed their routine is superior to Medi-Cal and (2) the veteran could duties. Further, the need for a veterans service potentially avoid the Medi-Cal estate claim. In representative to have some level of knowledge our conversations with CVSO representatives, about Medi-Cal eligibility in order to conduct they expressed a belief that counseling veterans the requisite outreach meant that only certain to discontinue Medi-Cal coverage generally went individuals were qualified to do so. The one-on-one against their mission to help veterans. Accordingly, nature of the outreach also made it labor-intensive. CVSO outreach may not have been as robust as DHCS intended. RECoMMENDAtIoNS r eexaMine h Ow tPl and e State r eCOvery effect, the IHSS recipient receiving A&A is provided P OliCieS a PPly tO ihSS r eCiPientS more services (in the form of the A&A award and IHSS hours) than the assessed need may warrant. Require DHCS and DSS to Jointly If the Legislature passed legislation to change Report to the Legislature the state’s current TPL policy and require DHCS to begin counting A&A as TPL for IHSS, then the In this report, we describe the legal basis for state would realize Medi-Cal savings. (The amount counting A&A as TPL in the IHSS program and of savings would depend upon the number of IHSS note that it appears to be inconsistent for the state recipients currently receiving A&A and the average to count A&A as TPL in SNF settings but not for award amount received by these individuals.) IHSS since both SNF care and the IHSS program However, we recognize that such a change in are Medi-Cal LTSS. In addition, the rationale for state policy has implications—for example, IHSS why certain IHSS recipients receive an A&A award recipients who receive the A&A award would now, intended for IHSS-like services that the state does in effect, be contributing to a greater share of cost not count toward IHSS costs is unclear to us. In for their IHSS benefits. 24 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt Aside from the state’s current treatment of Fund savings for changing the current A&A for IHSS, there is a second policy issue that approach to (1) count A&A as TPL for IHSS we identify as preventing the state from realizing and (2) include the IHSS costs of PCSP Medi-Cal savings from PARIS Veterans on the recipients in the Medi-Cal estate claim. order of those achieved by Washington’s Medicaid Upon receiving this information prepared program. In California, since 2000, IHSS costs jointly by DHCS and DSS, we believe the incurred by PCSP recipients—approximately Legislature would then have sufficient information one-half of the caseload today—have been exempt to determine whether changes to current state from the state’s Medi-Cal estate recovery claim. policies are appropriate in order to facilitate greater Even if the state changed its policy to count A&A as Medi-Cal savings from PARIS Veterans. TPL for IHSS, this exclusion means that only some IHSS recipients would have a financial incentive to e StaBliSh n ew P ilOt Of PariS seek A&A to reduce the amount of their Medi-Cal v eteranS w ith M Odified O UtreaCh estate claim. There does not appear to be a policy a PPrOaCh and a dditiOnal r eSOUrCeS basis for this inconsistent treatment of IHSS Earlier, we indicated that modest General recipients for the purpose of estate recovery. Fund savings may be attainable from statewide To assist the Legislature in re-evaluating the implementation of PARIS Veterans to transfer state’s current TPL and estate recovery policies, we certain veterans from Medi-Cal-funded SNFs to recommend that the Legislature require DHCS and USDVA long-term care. We also noted the potential DSS to jointly report to the Legislature by hearings financial benefits to certain veterans from such on the 2014-15 budget on the following three issues. transfers, as well as from linking veterans with • Policy and Legal Rationale for Current USDVA monetary benefits for which they are Approach. The DHCS and DSS should eligible. However, our savings estimates are highly provide a policy and legal rationale for the uncertain and assume that (1) around 500 veterans current approach in which (1) A&A is not in the state meet eligibility requirements for such counted as TPL for IHSS and (2) the IHSS transfers and (2) a combination of effective CVSO costs of PCSP recipients are exempted from outreach and other factors result in half of these estate recovery while the IHSS costs of veterans successfully transferring to USDVA recipients of other subprograms are not. long-term care. In our view, the PARIS Veterans pilot did not demonstrate the level of outreach • Assessment of Policy Implications of necessary for maximizing such transfers, due to Changing Approach. The DHCS and resource constraints, a problematic approach, and DSS should provide an assessment of the other issues. Moreover, because CVSOs only acted policy implications of changing the current on 25 percent of the referrals from DHCS, the pilot approach to (1) count A&A as TPL for IHSS yielded little information about the potential size and (2) include the IHSS costs of PCSP of the veteran population that may be suitable for recipients in the Medi-Cal estate claim. transfer. • Assessment of Fiscal Implications of We have not seen evidence to suggest that Changing Approach. The DHCS and DSS ongoing implementation of PARIS Veterans in should provide an estimate of General 11 counties—which continues to operate without additional resources—has improved significantly www.lao.ca.gov Legislative Analyst’s Office 25 An LAO RepORt from the pilot. Thus, we believe that any expansion report’s updated assessment of the level of savings of PARIS Veterans beyond these 11 counties— available, the Legislature could consider whether to which increases workload for the involved expand PARIS Veterans statewide and/or whether departments and CVSOs and may not generate to maintain or augment these additional resources. much fiscal or policy benefit due to the current Besides Pursuing Transfers to USDVA problems we highlighted above—is premature. Long-Term Care, Positions Would Also Connect However, we think that there is enough potential Veterans to Monetary Benefits. Besides pursuing for fiscal and policy benefits to justify a second long-term care transfers that fiscally benefit pilot, if the pilot is refocused with a better outreach the state, these positions would also support approach and provided with additional resources activities that yield mainly policy benefits to the as we recommend below. If the Legislature provides state: facilitating USDVA monetary awards for modest resources to support the operation and veterans, dependents, and survivors identified in evaluation of this second pilot, we believe there is a the Veterans match. Increasing veterans’ access reasonable chance for it to accomplish the following to their entitled compensation and pension objectives. benefits has been a consistent priority for the Legislature. However, the DHCS report suggests • Demonstrate how much (1) a refined that monetary benefit enhancement may have been approach to outreach and (2) dedicated underemphasized during the original pilot due to resources will actually improve lack of resources. The VBE setup in Washington— implementation and outcomes. on which we model many aspects of our • Provide more data to inform estimates of the recommendation—demonstrates how the Veterans potential level of savings from expanding match may help the state reach aging, disabled, PARIS Veterans—under improved and/or housebound veterans and survivors who implementation—to other counties. may not be able to regularly access CVSO services. • Improve the financial situation of aging and Modified outreach Approach disabled veterans by helping them avoid (or Continue to Pursue Transfers to USDVA reduce) a Medi-Cal estate claim and access Long-Term Care When Appropriate . . . We their entitlements to USDVA monetary explained earlier that Medi-Cal savings may be benefits. realized—when appropriate—from transferring • Generate sufficient savings within the pilot eligible veterans to USDVA-funded SNF care. to cover the cost of additional resources. Furthermore, if a USDVA-funded SNF bed is available and a veteran is willing and able to Accordingly, we recommend the state (1) pilot make this transfer, then such an individual would for two years what we believe to be an improved potentially experience the financial benefits of approach to PARIS Veterans outreach, and (1) no longer making a Medi-Cal share-of-cost (2) provide dedicated two-year limited-term staff payment for SNF care and (2) avoiding a higher resources at DHCS, DVA, and CVSOs to conduct Medi-Cal estate claim amount. Therefore, we and evaluate this second pilot. The DHCS would believe that facilitating these transfers continues again be required to produce a report of the pilot’s to be an appropriate state objective for the second findings and recommendations. Based on the pilot. 26 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt . . . But Modify Outreach Approach to Address to veterans enrolled in FFS Medi-Cal, there are CVSO Concerns About Veterans’ Best Interests. certain instances in which veterans enrolled in The previous pilot’s outreach may have been Medi-Cal managed care may benefit financially hindered by CVSOs’ reluctance or unwillingness to from discontinuing their Medi-Cal coverage. This counsel veterans in long-term care to discontinue is because Medi-Cal managed care payments, their Medi-Cal coverage altogether. In our findings, which are relatively high for SPDs, may be included we argued that discontinuing Medi-Cal is usually in the Medi-Cal estate claim if the veteran remains not appropriate for veterans with FFS coverage, but enrolled in Medi-Cal after switching to a USDVA- may be appropriate for certain veterans enrolled funded SNF bed. This financial benefit, however, in Medi-Cal managed care. Under CCI, 6 of the comes with a potential trade-off—discontinuing 11 counties that currently participate in PARIS Medi-Cal coverage may restrict a veteran’s access Veterans are scheduled to shift LTSS—including to certain HCBS if the veteran eventually returns SNF care—from FFS to managed care benefits for to the community. In counties where LTSS become most SPDs. In these six counties, CVSOs may alter managed care benefits under CCI, CVSOs would their views about whether veterans in long-term inform veterans and their family members about care should always keep their Medi-Cal coverage. the trade-offs between keeping and discontinuing We recommend a modified approach to CVSO their Medi-Cal coverage so that they can make outreach that differs depending on whether the informed decisions. veteran receives SNF care under FFS or managed Additional Staffing Positions care. We believe this approach will ease the tension between the state’s fiscal interest and CVSOs’ We recommend the addition of the following current reservations about advising veterans dedicated two-year limited-term positions at to discontinue their Medi-Cal coverage, and DHCS, DVA, and three CVSOs to continue thereby foster greater cooperation from CVSOs in outreach to transfer veterans to USDVA long-term performing PARIS outreach and follow-up. care—using the modified approach that we In FFS Counties, CVSOs Should Not Advise outlined above. Veterans to Discontinue Medi-Cal Coverage. One Position at DHCS to Support Under this approach, CVSOs would continue to Department’s Role as Lead Agency for PARIS contact veterans who may be willing and able Veterans. We recommend one staff position at to transfer to USDVA long-term care. However, DHCS dedicated solely to supporting operations in counties where LTSS remain FFS benefits, and oversight of the second PARIS Veterans CVSOs would not ask these veterans to consider pilot. This additional position would consistently discontinuing their Medi-Cal coverage. As we track cost-avoidance associated with veterans in explain later, DHCS would receive additional staff FFS counties who transfer to USDVA long-term resources to track FFS cost-avoidance for any care but retain their Medi-Cal coverage. The veterans who transfer to USDVA long-term care additional position would also work on improving while maintaining their Medi-Cal coverage. the collection and reporting of outcomes from In Managed Care Counties, CVSOs PARIS Veterans. In particular, the position would Should Present Veterans With Trade-Offs of support activities to (1) provide an accurate count Discontinuing Medi-Cal Coverage. In contrast of unduplicated hits over the entire pilot period www.lao.ca.gov Legislative Analyst’s Office 27 An LAO RepORt and (2) confirm and document the actual transfers This information would likely include whether the to USDVA long-term care that result from CVSO PARIS Veterans client is currently in SNF care and outreach. whether the individual has a service-connected Similar to the Washington VBE model, the disability rating from USDVA. Such screening by DHCS position would also coordinate regularly DVA staff of PARIS Veterans clients would allow with the two DVA positions that we describe below. CVSOs to focus their outreach on veterans who The DHCS position would help refine the initial have a high likelihood of receiving USDVA benefits. filtering of the match file results and update the One Position at Each of Three CVSOs to referral lists to remove previously detected errors Conduct Follow-Up Outreach to PARIS Veterans so that DVA and CVSOs have more opportunity Clients. In this report, we explained how the to establish successful contacts with veterans. previous pilot sought to realize Medi-Cal savings To further the policy goal of facilitating USDVA by tasking CVSO representatives with outreaching monetary benefits, we also recommend that to clients to discontinue Medi-Cal coverage. Our DHCS—prior to submitting Medi-Cal enrollment findings reveal that this objective was problematic data to DMDC for PARIS matching—direct this on two fronts. First, in many cases, it may not be position to merge the data with information appropriate for a veteran to discontinue his or her from DSS about the number of IHSS hours that a Medi-Cal coverage altogether and rely solely on Medi-Cal beneficiary receives. This would allow USDVA health care because the veteran may not DHCS to identify recipients who may easily qualify be eligible for certain needed services through for A&A benefits due to overlapping criteria for USDVA. Second, helping the state realize Medi-Cal IHSS. savings is not the primary mission of CVSOs. Two Positions at DVA to Conduct Initial We therefore recommend that the three CVSOs Outreach to PARIS Veterans Clients. We describe that conducted the greatest amount of outreach in this report that WDVA conducts initial outreach to PARIS Veterans clients during the first pilot— to PARIS Veterans clients by (1) outreaching to Fresno, San Bernardino, and San Diego—each clients who appear to be eligible but not enrolled receive one position on a two-year limited-term in CHAMPVA and (2) conducting initial outreach basis to enhance PARIS Veterans outreach using to clients who appear to be eligible for USDVA our modified approach, which we believe aligns monetary benefits. We recommend that DVA with their core mission. The PARIS Veterans staff receive two additional staff resources to conduct position in each of these three CVSOs would activities similar to WDVA staff. This initial (1) assist clients by filing USDVA claims for outreach to PARIS Veterans clients would involve monetary benefits and (2) outreach to clients in making phone calls to ascertain basic information SNF care who may be able to successfully transfer about clients, such as whether they are alive and to USDVA-funded SNF care. whether they are interested in seeking USDVA Positions May Pay for Themselves Through monetary enhancements. Modest Improvements in Outcomes. We estimate We further recommend that DVA staff the combined General Fund cost for these positions ascertain key information about the potential for at around $340,000 annually. This estimate an individual to transfer from a SNF bed funded assumes that federal matching funds are available by Medi-Cal to a SNF bed funded by USDVA. for about two-thirds of the cost for DVA and CVSO 28 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt positions. (In order to receive these matching cost-avoidance.) Furthermore, to cover their funds, the state would have to demonstrate that collective cost, these positions need only facilitate a portion of the workload for the non-DHCS 12 additional transfers of veterans to USDVA positions is reasonably related to Medi-Cal long-term care each year. www.lao.ca.gov Legislative Analyst’s Office 29 An LAO RepORt 30 Legislative Analyst’s Office www.lao.ca.gov An LAO RepORt www.lao.ca.gov Legislative Analyst’s Office 31 An LAO R e p O R t LAO Publications This report was prepared by Rashi Kesarwani and Felix Su, and reviewed by Shawn Martin and Mark C. Newton. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This brief and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 32 Legislative Analyst’s Office www.lao.ca.gov