Thank you for this opportunity to testify on behalf of the Senior Agenda Coalition. The Senior Agenda Coalition is an organization of thirty consumer groups, agencies and providers dedicated to improving the lives of Rhode Island seniors and to promote "Aging in Community".

We offer our comments based on the language of the May 6 th amendments to Article 17 and also in context of the Global Consumer Choice Compact Proposed Waiver submitted to CMS on March 26th .

The rebalancing of long term care as outlined in the new Article 17 and discussed in the Global Waiver concept paper is appealing and we commend the innovative ideas included. Article 17 also starts to address much needed rate reform for home and community services. This is essential for reform to be successful. The Senior Agenda Coalition supports the proposals' goals to increase access to home and community-based services and to shift funding towards a 50-50 split between institutional and home and community services. These reform concepts formed the basis of the 2006 Long Term Care Service and Finance Reform Act (a.k.a. Sullivan-Perry law) which we strongly supported.

These desired long term care reforms are part of a much larger all-encompassing reform which "caps" the entire Medicaid program at an agreed upon amount over a five-year period. In return the state gets great flexibility in running its Medicaid program. However, the provision to cap the entire Medicaid program raises a number of unanswered questions. In particular, what data on funding and caseload projections will be used to set the cap. A global cap presents risks to the state. It also puts elders at risk for service denials. This is a risk we do not support.

The reform proposals set new stricter eligibility criteria for skilled nursing home care. Persons meeting these more restrictive criteria and eligible for Medicaid would be entitled to either nursing home care or home and community services. We support this. A second new group of persons with lower care needs, who under today's standards would be eligible for nursing home care, would now be limited to home and community care services, BUT THEY WOULD ONLY GET SERVICES IF FUNDING IS AVAILABLE. The Senior Agenda Coalition has fought to give elders greater choices in choosing long term care. Under the present design of the Global Waiver, only those meeting the highest level of need will have choice and access. Those in the next level will be eligible for home and community-based care, but they will have no guarantee of access. It alarms us to think of frail eighty and ninety year olds in need of assistance with activities of daily living on waiting lists for care. We think this aspect of the proposal exposes our elders to an unacceptable risk. We hope you would agree and consider changing this.

We believe that long term care reform could proceed without the Global Waiver. The Sullivan-Perry Law (RIGL 40-8.9-5) authorized DHS to submit waiver and/or state plan amendment requests needed for systemic long term care reform. We think substantial savings can be achieved with less risk by proceeding with long term care reform under a distinct Section 1115 waiver without a cap and ask you to consider that alternative.

We pose a number of questions about specific language in Article 17 which we list at the end of our testimony and respectfully ask you to consider them as you deliberate on these important proposals. We also are concerned with two sections of Article 17 that amend Department of Elderly affairs (DEA) statute. Section 13 (page 31, lines 17-24) decouples eligibility for the co-pay program from RIPAE eligibility and gives the department authority to set eligibility by regulation. The co-pay program is highly efficient and eligibility is streamlined by tying it to RIPAE. With all the changes taking place, it seems unnecessary to make this change which would incur additional administrative costs and delegate to DEA what we believe should be set in statute. We respectfully ask you to defer making this change.

We are also concerned with the provision for a new passenger cost share for the RIDE program with DEA setting the cost share by regulation (Section 12 - page 25). The Senior Agenda opposes such an open-ended provision for cost-sharing. The trips provided under the DEA are essential trips that allow persons to remain living at home and in the community (medical appointments, adult day services, nutrition programs) and are not used for incidental purposes. The provision conflicts with Rep. Lewiss bill to prohibit such cost-sharing and is inconsistent with the goal to maintain elders in the community. We believe it deserves further study.

Respectfully, we ask the Committee to consider the following questions in reviewing Article 17.

• Will the legislature review the projections used to set the Global cap? Under the Global cap, how will the annual Medicaid allotment be allocated among populations in the event of a projected shortfall? Will the customary role of the legislature in the budget process be diminished with the waiver or under provisions of Article 17? Will there be a legislative oversight role in implementation of the proposed waiver?
• Section 6 (page 13) of the article mandates all Medicaid beneficiaries to be enrolled in managed care delivery systems and authorizes DHS to redesign the Medicaid benefit package through the regulatory process under emergency filing.
  What benefit changes are being considered by the department under benefit redesign and how will benefits change from the current scheme?
• In Section 2 (page 3) there is language to protect state in event of national emergency.
  Why is not a state emergency included in the lists of protections?
• Section 2 (page 5, Line 16) would allow waiting lists for "certain non-traditional optional Medicaid services". What are these services? Are they any of the "core" services described in the Global Compact document submitted to CMS?
• Section 2 (page 5, line 16) authorizes creation of new Assessment and Coordination Unit.
• Are existing staff resources sufficient given the limits on FTEs? Will staff be adequately trained especially for assessing persons with dementias and others with
  special needs? Is there an intent to outsource any of these functions?
• Line 21. Mandates the new Assessment and Coordination Unit provide "education and choice counseling". What is meant by this? How would this coordinate with existing duty of DEA to provide information and screening for long term care (42-66-4(b)(2))?
• A new program of "Shared Living" is anticipated for elders and adults with disabilities. Will regulations be developed for this and how will this program be monitored?