No Wrong Door: Promising Practices for Accessing Long-Term Services and Supports

No Wrong Door: Promising Practices for Accessing Long-Term Services and Supports

Photo courtesy of Sullivan County New Hampshire ServiceLink

Most of us will need long-term services and supports (LTSS), either for ourselves or our family members. However, most of us do not know about our options and how to pay for these services. That is why the LTSS State Scorecard—created by the AARP Public Policy Institute and funded by The Scan Foundation and The Commonwealth Fund—ranks states on their Aging and Disability Resource Centers. These Centers are an important feature of a high performing LTSS system.

Aging and Disability Resource Centers can serve as the gateway for helping individuals and their families find and access LTSS, including light housekeeping, transportation, and respite care to give family caregivers a break, just to name a few. States have these “one-stop-shopping” models to help people receive public and private services regardless of which organization they contact. Therefore, they are sometimes called “no wrong door.” If people contact an organization within this system, they can be connected with information, referrals, and supports, resulting in “no wrong door” to services irrespective of their age, income, or disability. Area Agencies on Aging, Centers for Independent Living, and state agencies such as Medicaid agencies and state units on aging work together to make up this no wrong door system. While the states have these centers, the operations and functions of each center vary greatly, which is why the Scorecard ranks them.

Although the previous two Scorecards included an indicator on these Centers, the upcoming third edition contains an updated indicator to reflect published guidance on key elements of no wrong door systems from the federal government. AARP, in collaboration with the U.S. Administration for Community Living and The Lewin Group, collected information for this indicator from a survey of state administrators. Then, they followed up by interviewing administrators from states that had scored well or demonstrated innovation to produce a newly released promising practices and toolkit paper on person- and family-centered practices.

This first in a series of promising practices and toolkit papers provides concrete examples of how six states—Connecticut, Michigan, New Hampshire, Virginia, Washington, and Wisconsin—plus the District of Columbia promote person- and family-centered practices in their no wrong door systems. These Centers are using an interactive process directed by individuals and family members to support decision making. They also help to develop a plan of support that reflects an individual’s and family’s strengths, preferences, needs, and values. It affirms the core principle that each person is the expert in his or her own life rather than simply plugging people into programs based on their eligibility.

The promising practices are:


  • Ensuring leadership support for these practices (with examples from the District of Columbia’s mayor-led cross-population task force, Michigan’s broad support for change, and Virginia’s state legislation on this practice);
  • Creating standards for these practices (with examples from Washington’s statewide standards of practice, Virginia’s co-employment model between aging and disability organizations, the District of Columbia’s intake to better listen to people and families, and Wisconsin’s follow-up);
  • Training the “no wrong door” workforce (with examples from New Hampshire’s training and certification, the District of Columbia’s training for all, New Hampshire’s peer support model, Virginia’s person-centered advocates, and Connecticut’s essay exam); and
  • Helping people maximize use of private resources (with an example from Wisconsin that has been a leader in serving private pay clients).


This promising practices and toolkit paper includes resources and contacts for state and federal administrators, providers, and advocates to learn about—and even replicate—these practices. This paper also provides a checklist of what is needed to move toward more person- and family-centered practices.

NOTE: The third edition of the Scorecard will be released soon … on June 14th. Promising practices and toolkits are a new feature of the Scorecard project. More papers—such as promising practices in preventing long-term nursing home stays—will be forthcoming. For the new Scorecard, the promising practices and toolkit papers, and more, please go to the LTSS State Scorecard interactive website at


Wendy Fox-Grage is a Senior Strategic Policy Advisor for the AARP Public Policy Institute. She works on state long-term services and supports issues, including Medicaid and home- and community-based services.






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The American Health Care Act Makes Unsustainable Cuts to Medicaid

The American Health Care Act Makes Unsustainable Cuts to Medicaid

Recent policy conversations related to the American Health Care Act (AHCA) have focused on  proposals that would eliminate the Affordable Care Act’s critical protection for people with preexisting conditions. This  controversial proposal has drawn  a lot of attention for good reason. Eliminating this important protection, which keeps insurance companies in the individual (non-group) market from considering health status when making coverage decisions, could hurt millions—especially older adults who tend to develop more health conditions as they age.

But the preexisting condition protection is not the only serious concern. The proposed legislation would also make huge cuts to Medicaid by taking almost $1 trillion (or 25 percent of all Medicaid dollars in 2016) out of the program by 2026. How?  By fundamentally changing the way the program is funded. Under the AHCA, Medicaid funding would move from a federal guarantee to match all legitimate state expenditures on health care and long-term services and supports (LTSS) for eligible beneficiaries, to a capped payment system that would give states a fixed dollar amount per enrolled beneficiary [i]. Although per enrollee caps respond to changes in enrollment, they do not respond to increases in health care costs attributable to medical or pharmaceutical innovation, nor do they respond to other changes in the health care environment that could affect per enrollee spending. Health care costs, we all know, are notorious for their rapid rise. The result: an ever-widening gap between cost and funding.

The impact of such a huge loss of federal Medicaid funds on people with disabilities and poor seniors will be devastating—especially for 11 million Medicare beneficiaries who are also eligible for Medicaid. These individuals—called dual eligibles, or duals—are the poorest and sickest of all Medicare beneficiaries and rely on Medicaid for critical LTSS services, like help with toileting, bathing, and eating.

Faced with major losses of federal funding for their Medicaid programs,  states would have limited options. They could plug the funding hole with state revenues, which is unlikely given competing demands on state budgets. States could also cut provider rates, which could lead to significant access problems for beneficiaires because many providers may choose not to serve the Medicaid population. States could also eliminate optional eligibility categories, including some that provide access to LTSS. Finally, states could reduce or eliminate access to optional services, including home and community-based LTSS. Limiting access to needed LTSS for dual eligibles will most surely result in increased use of emergency room and hospital services, ultimately shifting costs to the Medicare program—creating a “pay me now or pay me later” situation for the federal government.

Rather than take millions  of dollars out of Medicaid and shift significant costs to Medicare, it is time to have a reasoned conversation about how to improve the program in ways that don’t leave gaping holes in the health care safety net that millions of people  and their family caregivers rely on.


[i] States have the option of receiving block grant funding for children and non-elderly, non-disabled adults. Block grants are fixed amounts of money that do not respond to changes in enrollment or program costs.



Lynda Flowers is a Senior Strategic Policy Adviser with the AARP Public Policy Institute, specializing in Medicaid issues, health disparities and public health.



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The Fierce Urgency of Now: How $880 Billion in Cuts to Medicaid Could Hurt Us All

The Fierce Urgency of Now: How $880 Billion in Cuts to Medicaid Could Hurt Us All

If you have protection against future catastrophic out-of-pocket costs for basic life functions, consider yourself lucky. The vast majority of people in the United States don’t.

Yet the reality is that there’s a 52 percent chance that someone turning 65 today might develop a severe disability requiring long-term services and supports (LTSS)—that is, help with such functions as eating, bathing, dressing, and toileting.

For more extensive care, the cost can surpass $250,000 for those over the age of 65—a figure that could easily decimate even some middle-class families, never mind lower-income earners. As a result, many people deplete their resources, become impoverished, and wind up needing relief from Medicaid as a last resort. Thus, millions of Americans, many of whom you might never have guessed would need Medicaid, find themselves having to turn to the half century-old program for this vital support. But at least that safety net is there.

However, if some in Congress get their way, that safety net may disappear, a position AARP firmly opposes. Provisions in the most recent House health reform proposal threaten to roll back the federal promise of coverage and services for millions of Americans, including at least 17 million children and adults with disabilities and low-income older adults who rely on Medicaid. Meanwhile, the proposal would instead shift more costs to states and their taxpayers. In short, hanging in the balance of a debate raging in Washington is $880 billion in federal funding for crucial health care and LTSS.

Responsive Medicaid Would Turn Rigid

For more than 50 years, Medicaid has served as a critical safety net for millions of people with limited income and resources. Current law guarantees access to health care and LTSS to all eligible individuals. States and the federal government share the risk, responsibility, and cost of financing Medicaid. The federal government guarantees states financial support, based on the relative wealth of the state, of between 50 and 75 percent of the program’s cost, even if cost goes up.

The program responds to changes in the economy, public health outbreaks, natural disasters, and medical cost growth. During the Great Recession when millions lost their jobs—and their employer-based health insurance—Medicaid served as a critical safety net. And as the Zika virus spread throughout the U.S. recently, Medicaid responded with the necessary funding.

In its current form, the House health legislation would fundamentally alter the program by changing the financing structure to a per capita cap. Under such a system, the federal government would set a maximum limit on how much to reimburse states on a per-enrollee basis for children, adults, individuals with disabilities, and seniors. While payments to states would reflect changes in enrollment, the cap would shift the risk to states for higher-than-expected cost growth due to epidemics, blockbuster drugs, and natural disasters. In addition, the cap would not account for the changing mix of an aging population. As we get older the needs for LTSS will go up, but budgets will not. Setting the caps at a time when per-beneficiary spending for low-income seniors is much lower would result in an underfunded safety net for this population.

Just in the event this was not drastic enough, House leaders are now willing to modify the health legislation and provide states with the option to accept Medicaid block grants—which is a fixed amount of Medicaid funding annually, regardless of actual need or program costs. Under a block grant, people are not guaranteed coverage for services, and funding would not necessarily keep up with health care costs, nor would it be adjusted based on the number of persons served.

The Real Face of Any Savings: State Taxpayers and America’s Most Vulnerable

While block grants and per capita caps on the surface appear to be a mere change in how funds are allocated for Medicaid, thereby saving federal dollars, and allowing greater state flexibility in program implementation, such a shift would result in a program that would be in many ways unrecognizable, both philosophically as well as “on the ground,” where Americans rely on the program every day.

Analyses from the Congressional Budget Office estimates federal spending in Medicaid would decrease by $880 billion by 2026. These cuts could have major implications for state budgets and the ability of states to provide adequate health care and LTSS for low-income seniors and people with disabilities. States and their taxpayers will either have to fill this gap themselves, or fewer people will receive less support for services like LTSS.

Faced with some difficult choices, states may limit optional benefits like home- and community-based services (HCBS), which is generally more cost-effective than long-term care facilities.

The bottom line: Members of Congress will vote on the health legislation later this week.

The Medicaid piece of the new health legislation means that access to services for some of the most vulnerable populations in our society, guaranteed for over a half-century, would be in jeopardy. It would also shift costs to taxpayers at the state level, which is one reason some governors feel the need to oppose it, regardless of their political affiliation. Now is the time to act and voice your concerns. There is just too much at stake.

Debra Whitman is AARP’s chief public policy officer and leads policy development, analysis and research, as well as global thought leadership that supports and advances the interests of individuals age 50-plus and their families. Follow Deb on Twitter: @policydeb

Jean Accius is a nationally recognized expert on aging policy, livable communities and long-term services and supports (LTSS).  He currently serves as the vice president of the long-term services & supports and livable communities group within the AARP Public Policy Institute. Follow Jean on Twitter: @JeanAccius 


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Capping Medicaid Funding Could Hurt Millions of People With Disabilities and Poor Seniors

Capping Medicaid Funding Could Hurt Millions of People With Disabilities and Poor Seniors

Medicaid is the country’s largest public health insurance program, providing access to needed health care and long-term services and supports  (LTSS) to millions of low-income Americans, including more than 17 million children with disabilities, adults with disabilities, and poor seniors.

Right now, states and the federal government share the cost of Medicaid in a way that guarantees services to all who are eligible. Under this arrangement, federal funding increases (or decreases) in response to changes in enrollment, service costs and service use.

That could change, and the implications are significant. Recent proposals would limit federal Medicaid funding by giving states a lump sum of money to cover the cost of their entire program (a block grant), or by giving them a specified amount of money for each enrolled person (a per capita cap). Because both approaches aim to save federal Medicaid dollars, it is likely that neither will adjust over time to reflect increases in cost. This means that the funds will pay for less and less over time and states will need to find ways to deal with the significant loss of federal dollars.

Under these proposals, states would have several choices. They could allocate more tax dollars to Medicaid, which is unlikely, given competing pressures on state budgets for education, law enforcement and other essential functions. They could cut back on the amount of money they pay health care providers, which could cause providers to stop serving the Medicaid population and thus create access problems. They could also stop covering certain groups of people.

Finally, states could limit or eliminate services they are not legally required to provide (also known as optional services) — like home- and community-based services (HCBS). The result would mean that millions of poor seniors and people of all ages living in community settings could lose access to HCBS — like help with dressing, bathing, toileting and eating — to meet their daily needs. These individuals would end up with unmet needs or be forced to rely on costly institutional care (e.g., nursing homes).

The result would be a bad deal for these vulnerable individuals, the vast majority of whom prefer to remain in their homes and communities as long as possible. It would also be a bad deal for states. States pay nearly three times as much per person in institutional settings than they do for each individual receiving LTSS in the community.

Under the current shared financing structure, many states have elected to provide optional services (e.g., HCBS) because they recognize that providing such options best meets the needs and preferences of their residents, including those who require LTSS — not to mention that it can even save them money by keeping people out of institutions. Shifting costs to states through block grants or per capita caps could lead states to cut the critical services and supports that millions of people count on.


Lynda Flowers is a senior strategic policy adviser with the AARP Public Policy Institute, specializing in Medicaid issues, health disparities and public health.




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