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TransformationChanging the MR System
to Make Every Day Lives a RealityDecember 03, 2001
Dennis W. Felty
ASSUMPTIONS
This is a time of great opportunity for individuals and their families
This is a best effort to describe a rapidly changing system
Much of what we talk about may change This is the biggest change ever
AN EVERY DAY LIFE
a person's basic needs, to reaching a rich quality of life in all aspects of a person's life. It is always changing throughout a person's entire life experience. It is the kind of life we all want and is not unique to people who happen to have disabilities.
An every day life is a life rich in the qualities a person most desires; one that shows how connected we are to each other. It is a life that grows from a person's own choices, desires and dreams and is not controlled by whatkind of services happen to be currently available. It goes beyond just meeting
TRENDS
Waiver entitlement (Olmstead letter #4)
Olmstead/ADA entitlement Federalization of MR funding & policy CMS requirement for equitability CMS requirement for consistency Choice, Individualized Funding and Self Determination Data requirements for legislative initiatives & full funding OMR & DPW Information Technology initiatives Baby boomer demographics & waiting list $1,600,000,000 provided for services in Pennsylvania
POLICY OPTIONS
State fee schedule (EPSTD, partial, outpatient)
Managed care model with MCO (Health Choices)
Limited access & utilization (commercial behavioral health)
Withdraw from Medicaid Continue with current system Comprehensive resource management
system
OLMSTEAD LETTER #4
42 CFR 441.303(f)(6) “The State must indicate the number of unduplicated beneficiaries to which it intends to provide waiver services in each year of its program.This number will constitute a limit on the size of the waiver program unless the State requests and the Secretary approves a greater number of waiver participants in a waiver amendment.
Thus, unlike Medicaid State plan services, the waiver provides an assurance of service only within the limits on the size of the program established by the State and approved by the Secretary. The State does not have an obligation under Medicaid law to serve more people in the HCBS waiver than the number requested by the State and approved by the Secretary. If other laws (e.g.,ADA) require the State to serve more people,the State may do so using non-Medicaid funds or may request an increase in the number of people permitted under the HCBS waiver. Whether the State chooses to avail itself of possible Federal funding is a matter of the State ’s discretion.Failure to seek or secure Federal Medicaid funding does not generally relieve the State of an obligation that might be derived from other legislative sources, such as the ADA.”
OLMSTEAD LETTER #4
“A State is obliged to provide all people enrolled in the waiver with the opportunity for access to all needed services covered by the waiver and the Medicaid State plan. Thus, the State cannot develop separate and distinct service packages for waiver population subgroups within a single waiver. The opportunity for access pertains to all services available under the waiver that an enrollee is determined to need on the basis of an assessment and a written plan of care/support. This does not mean that all waiver participants are entitled to receive all services that theoretically could be available under the waiver. The State may impose reasonable and appropriate limits on utilization.”
OLMSTEAD LETTER #4
“Once in the waiver, an enrolled individual enjoys protection against arbitrary acts or inappropriate restrictions, and the State assumes an obligation to assure the individual’s health and welfare.”
page 6, paragraph 3
OLMSTEAD LETTER #4
“We appreciate that a State’s ability to provide timely access to particular services within the waiver may be constrained by supply of providers, or similar factors. Therefore, the promptness with which a State must provide a needed and covered waiver service must be governed by a test of reasonableness. The urgency of an individual’s need, the health and welfare concerns of the individual, the nature of the services required, the potential need to increase the supply of providers, the availability of similar or alternative services and similar variables merit consideration in such a test of reasonableness.”
page 6, paragraph 4
OLMSTEAD LETTER #4
“The fact that states have the authority to limit the total number of people who may enroll in a waiver provides states with reasonable methods to control the overall spending. This means that states should be able to manage their waiver budgets without undermining the waiver purpose or quality by exceptional restrictions applied to services that will be available within the waiver.”
page7, paragraph 5
MEDICAID WAIVERS
Person/Family Driven Supports Waiver (PFDS) Non entitlement re having all needs met IER $21,125 maximum funding Implemented as pilot in July 2002 then state wide in Jan 2003
Home and Community Based Services Waiver (HCBS)
Entitled to have all needs met IER No cap on maximum funding Includes residential services
PFDS PILOT COUNTIESJuly 1, 2002
Dauphin Delaware Westmoreland Berks
Other counties my choose to begin implementation July 1, 2002
TIME LINE
PFDS Pilot July 2002 PFDS Statewide Jan 2003 ITQ Jan 2003 HCBS July 2003 MAMIS Nov
2003?
PFDS WAIVER SERVICES
Day service (licensed 2380 and unlicensed) Pre - Employment and Supportive Employment Community Habilitation Physical Therapy Occupational Therapy Visiting Nurses Behavior Therapy Visual Mobility Therapy Transportation Speech and Language Therapy Respite Personal Support for Community Integration Vendor
SERVICE DESCRIPTIONS
“Services Descriptions” define the services that are available under the PFDS Waiver. People enrolled in the Waiver can only receive services described and approved in the Waiver. Similarly, providers can only bill for service activities described in the service descriptions of the Waiver. The provider will be responsible to assure that all services billed meet the specifications of the service descriptions.
SYSTEM ELEMENTS
Choice & Self Determination Entitlement & equity driven Geographic choice Individual Service Plan (ISP) Individual Estimated Resources (IER) Target Budget
Individualized funding Invitation to Qualify (ITQ) Prospective Fee based State wide waivers with consistent benefits Comprehensive web based data system
Waiver1000 enrollees $20,000,000
Provider ProviderProvider
County Contingency
Fund$400,000
EmergencyServices & Waiting
List Funding100/year
$2,000,000To meet increased needs
of people enrolled in the waiver
ISP 1001 $100,000
WAIVER FUNDING
HCBS Waiver1000 enrollees $20,000,000
County Contingency
Fund$400,000
EmergencyServices & Waiting
List Funding100/year
$2,000,000To meet increased needs
of people enrolled in the waiver
ISP 1001 $100,000
ISP1 + ISP2 + ISP3 …. ISP1000 = $20,000,000
ISP1 + ISP2 + ISP3 …. ISP1001 = $20,100,000
ISP1 + ISP2 + ISP3a ….ISP1000 = $20,000,000
ISP1 + ISP2 + ISP3 …..ISP1100 = $22,000,000
ISP1 + ISP2 + ISP3 …. ISP999 = $20,000,000
ISP1 + ISP2 + ISP3 …. ISP1000 = County Allocation
COUNTY CONTINGENCY FUND
County Contingency
Fund$400,000
To meet increased needsof people enrolled in the waiver
Year 1 - ISP1 + ISP2 + ISP3 …. ISP1000 = $20,000,000
Year 2 - ISP1 + ISP2 + ISP3 …. ISP1000 = $20,800,000
COUNTY CONTINGENCY FUND
HCBS Waiver1000 enrollees $20,000,000
ISP/PAYMENT PROCESS 2003
Need Assessment
IER TargetBudget
IndividualService Plan
Selection of Provider
MAMIS FeeSchedule
Service Contract
ServiceEncounter
InvoiceMAMIS
MAMISClaims Payment
PaymentAuthorization
to County
County paysInvoice
CountyApproves Rate
ITQInvitation to
Qualify
RateNegotiation &
Contract
OMR Allocation
HCSIS DATA SYSTEMHome & Community Services Information System
State wide Web based Invitation to Qualify Incident Management Needs assessment data Individual’s Estimated Resources (IER) Individual Service Plan (ISP) Individualized budget Claims payment (MAMIS) Provider performance data Longitudinal Statistical analysis of needs assessment & cost
MCO
Provider Provider
Provider
OMR/County
ConsumerFamily
ProviderProvider
Provider
SYSTEM STRUCTURE
ConsumerFamily
ConsumerFamily
ConsumerFamily
ISO
FEE OPTIONS
County set fee Provider County negotiated
fee Vendor fees
PFDS RATE SETTING
The provider will propose a rate for each service in each county they designate in their ITQ declaration. Each rate proposal will be negotiated by each county and the provider. When the county and provider reach agreement, the county will issue a contract on the rate and when the contract is signed the rate will be entered into the HCSIS county fee schedule. The provider may propose different rates for the same service provided in different locations. The 4300 fiscal regulations will not apply to PFDS Waiver services, however the provider will disclosure profits by contracted rate in their audit.
PFDS RATE SETTING COMPONENTS
Rates will be prospective. There will be no cost settlement. The 4300 regulations will not apply to PFDS services. Rates will be effective on the date they are approved by the
county and are entered into the HCSIS Fee Schedule. Rates may not be applied retroactively. With the agreement of the county and the provider, rates may
be changed mid year. OMR may publish guidelines on rate setting and appropriate
cost components of proposed rates. Providers may be required to report profit levels in their audit.
Such information may by used in subsequent rate setting. There may be multiple rates for different provider sites.
RATE SETTING COMPONENTS
Cost per hour of work Hours available that are
scheduled Travel time per visit Phone time per visit Case coordination per visit Cost of marketing Cost of capital Service Descriptions HIPAA compliance costs
Cost of compliance No shows Administration Training Rejected invoices Profit/retention Cost of infrastructure Direct travel cost per visit Incident management Unit rounding
A rate setting model is available at:http://www.keystonehumanservices.org/links.html#rate
THE IMPORTANCE OF A CAPITAL BASE
Working capital A more dynamic commercial market Choice Compliance risk Increased loss exposure Infrastructure investment Business development
DOWNSIDE LOSS EXPOSURE
Choice Unfunded ISP Components High transaction costs Infrastructure costs Utilization loss Marketing costs Compliance & audit risk Rates No retroactive contract adjustments Claims payment loss Cost of capital Start up & business development
CLAIMS PAYMENT
MAMIS, the state Medicaid Claims Payment system will be utilized. Providers will submit invoices for each encounter (hour, 1/4 hour or day of service). MAMIS will validate the invoice against: the ISP, the IER, the individualized budget (frequency) and the county fee schedule. If all screens pass, MAMIS will authorize the county to make payment.
Note: The MAMIS system will not be available until 2003.
CLAIMS PAYMENT
Prior to MAMIS being available for claims payment processing, providers will submit invoices to the county.
SERVICE AUTHORIZATIONS
When the ISP is completed and is within the IER, the county will authorize the services. The provider may continue to provide the services and bill for services as long as the county service authorization is in effect.
MAMIS - CLAIMS PAYMENT
MAMIS, the state Medicaid Claims Payment system will be utilized in 2003. Providers will submit invoices for each encounter (hour, 1/4 hour or day of service). MAMIS will validate the invoice against: the ISP, the IER, the individualized budget (frequency) and the county fee schedule. If all screens pass, MAMIS will authorize the county to make payment.
Note: The MAMIS system will not be available until 2003.
COMPLIANCE
In a Medicaid fee for service environment, a provider has a very significant responsibility to assure that invoices submitted are valid and that all services billed were fully delivered. Incorrect invoices, regardless of intent, may be defined as Medicaid fraud with very serious penalties including criminal liability for both individuals and corporations. Providers may want to give very serious consideration to establishing a Corporate Compliance Program.
COMPLIANCE
In a Medicaid fee for service, anyone, who has knowledge of incorrect bills has an obligation to disclose that information to the office of Medical Assistance. Consistent with direction from the Office of Medical Assistance the provider may be required to do a self audit (outside independent auditors) to review all bills for the defined period. The provider may be required to make restitution plus penalties for all incorrect payments. The Office of Medical Assistance provides for an informant to be eligible for a cash reward of up to 25% of the recovered funds.
HIPAA COMPLIANCE
Under the Health Insurance Portability and Accountability Act - provider agencies are responsible for full compliance with HIPAA regulations relevant to the confidentiality and safe keeping of health care information under Transformation and HICSIS.
“The doctor’s lawyer will see you now.”
New Yorker Book of Doctor Cartoons
Rigorous compliance environments, within systems that require increasing precision, risk compliance and infrastructure costs that will not be cost effective and may have an adverse effect on viability.
INDIVIDUALIZED SERVICE PLAN
The team, comprised of the individual, family, friends and other persons who care about the individual, will develop an ISP (Individual Service Plan). The ISP is designed to meet the person’s needs, service and support preferences. The ISP will be developed within the context of an individual Estimated Resource budget (IER). The IER is a threshold number that sets an estimate of resources available to the individual.
PERSONAL SUPPORTS BROKER
One of the exciting services available is a Personal Supports Coordinator. This option would permit an individual or their family
to select a consultant or advocate to support and/or participate in the ISP and provider selection process. This person could assist in planning, advocacy, identifying natural supports, preferences, service model options, costs, innovative alternatives, evaluating and selecting providers. The cost of this service can be funded through the person's ISP.
INVITATION TO QUALIFY
In order to maximize choice and competition, an ITQ (Invitation To Qualify) process will be used where all provider agencies that meet state qualifications will be entitled to be on the County’s approved provider list. After completing the ISP, an individual or family may then select any provider or combination of providers on the list to carry out the ISP. Providers will then be reimbursed at their approved rate for the contracted service. Families will have the option of using existing providers, starting a new provider agency, or use of informal supports including friends, family and neighbors.
“I’m sorry. The doctor no longer makes phone calls.”
New Yorker Book of Doctor Cartoons
INVITATION TO QUALIFY
Single qualification at state level Provider determines which county(s) they want to
provide services in Provider determines which services they will provide in
each county Provider submits rate proposal for each service in each
county Provider county(s) negotiate a rate for each service the rate is entered into county HCSIS rate schedule ISP costs are developed against provider rate schedule Provider agrees to provide service
GEOGRAPHIC CHOICE
The Waivers are state wide waivers and, as such, a family or consumer has the right to receive services to which they are entitled anywhere in the state. If a family wants to receive services in an adjoining county, they may do so. The provider they select will have to be placed on their home county ITQ list and the provider will be paid by the family’s home county at the rate approved in the county where the services are delivered.
CHOICE
Choice is a foundation principle in Transformation. It provides the person using services and their family with greater control over resources and the selection of the people and providers that will be providing their supports. Choice operates within the parameters of the ISP, the IER, ITQ, service descriptions and providers’ willingness and ability to provide services. The ISP is the central document that ultimately defines decisions around Choice and provides the formal authorization for services to be funded by the county.
CHOICE ISSUES
Who speaks for the person being served CMS requirement that a person’s needs be met Competency and informed consent The individuals Needs Assessment Individual Service Plan (ISP) Individual Estimated Resources (IER) # of Providers on Invitation to Qualify List (ITQ) Provider and county capacity Waiver Service Descriptions Enrollment in PFDS or HCBS Waiver Number of providers willing and able to provide services County authorization for services
CHOICE & SYSTEM CAPACITY
An essential element of Choice is that there are
several, perhaps three or more providers willing and able to provide the services
described in the ISP.
INTERMEDIARY SERVICE ORGANIZATION
Each county will have an Intermediary Service Organization or ISO. The role of the ISO is to serve as an agent that will pay bills for services that are not offered by provider agencies through the County ITQ process.
These include services that tend to be informal and offered on an hourly basis. The ISO may also serve as the employer for these persons and can also arrange for the purchase of adaptive equipment and accessibility modifications.
SERVICE COORDINATOR
The Service Coordinator will have extensive influence on the ISP process including the integrity of the process and family and consumer satisfaction and confidence. They will carry significant responsibility for presenting options including creative solutions specific to the needs and preferences of the consumer.
INDIVIDUAL ESTIMATED RESOURCES
The IER will be a statistical calculation based on a correlation between the 63 questions on the needs assessment and historical costs of care for the individuals assessed. Needs assessment questions that have a statistically significant correlation with cost will be used to calculate individual IERs. IERs will be based on state wide data adjusted for cost of living differences.
The Individual Estimated Resources
The IER is an estimated funding amount intended to meet each person’s needs.
The funding amount is portable and moves with the person.
The IER is a threshold that will require review and approval for funding at levels above the IER.
Is intended to provide equity and consistency. Is an important tool to better plan and budget
for future needs.
The Individual Estimated Resources
People currently receiving services will have their funding level grandfathered so they will not experience any reduction in service.
The IER will be piloted in PFDS services. The IER must be adequate to meet peoples
needs who are enrolled in the HCBS Waiver. The IER must be adequate to assure choice.
INDIVIDUAL ESTIMATED RESOURCES
Each question in the needs assessment that is determined to be statistically significant in relation to historical costs will be assigned a specific dollar value determined by the correlation. ie
Residential yes $30,000Medication yes $5,000Behavioral yes $10,000
INDIVIDUAL ESTIMATED RESOURCES
IER = x1 + x2 + x3 + x4 + ……. X
64
IER = $450 + $3,000 + $32,000 …..
IER = $75,210
STATISTICAL & VALIDITY ISSUES
Normal statistical variation Individual needs assessment’s validity Model effectiveness impact Direct care compensation impact Variation in costs driven by model ISP costs based on historical data Reliability, validity and complexity issues around
“total life” needs assessments Provision for synergistic cost efficiencies Correlation between need assessment & IER
Individualization
IER
RATES
CHOICE
ISP
“You'll be coughing up money for some time.”New Yorker Book of Doctor Cartoons
RESOURCE CONTROL POINTS
Consumer choice Needs Assessment IER ISP Process Service Coordinator Fee Schedule Legislative Allocation IER Formula
“You don’t know how lucky you are! A quarter of an inch either way, and it would have been outside the area of reimbursable coverage!”
New Yorker Book of Doctor Cartoons
“Competitive industry forces will ultimately be as powerful as public policy forces.”
OPPORTUNITY
Choice & Self Determination Individualized Budget Invitation to qualify More consistent policy Secure Medicaid funding Entitlement Potential for full funding Valid and reliable data More equitable allocation of resources
“The ringing in your ears - I think I can help.”
New Yorker Book of Doctor Cartoons
RESOURCES
Overview of the Transformation Process http://www.keystonehumanservices.org/transformationoverview.html
Links on human services, transformation, family resources and self determination.http://www.keystonehumanservices.org/links
Dauphin County Self Determination Web Sitehttp://www.dauphinselfdetermination.org/
Pennsylvania Office of Mental Retardation Web Sitehttp://www.dpw.state.pa.us/omr/dpwmr.asp
Rate setting modelhttp://www.keystonehumanservices.org/links#rate
This presentationhttp://www.keystonehumanservices.org/links#dctrans
P/FDS Waiver Services-Definitions Required for Rate SettingSummary: Bucket Approach with Modifiers
ITQ ServiceCategory Service Name
ServiceDescription Unit
StaffRequirement
1. Services to peopleoutside of where they live(Day Services
1.1.0 Day Services (2380)1.1.1 Day Services (2380)-Health Supports1.1.2 Day Services (2380)-Behavioral Supports Level 11.1.3 Day Services (2380)-Behavioral Supports Level 21.2.0 Day Services (Unlicensed)1.2.1 Day Services (Unlicensed)-Health Supports1.2.2 Day Services (Unlicensed)-Behavioral Supports Level 11.2.1 Day Services (Unlicensed)-Behavioral Supports Level 21.3.0 Pre-Employment Services (2390)1.3.1 Pre-Employment Services (Licensed)-Health Supports1.3.2 Pre-Employment Services (Licensed)-Behavioral Supports Level 11.3.3 Pre-Employment Services (Licensed)-Behavioral Supports Level 2
Licensed in for 4 ormore.
Hour
Hour
Hour
Licensurerequirements(e.g. LPN)
2.Employment services 2.1.0 Supported Employment Support to maintaincompetitiveemployment
15min.
3. Services to peoplewhere they live (Homeand Lifestyle Services)
3.1.0 Community Habilitation3.1.1 Community Habilitation-Health Supports
15min.
4. Specialized Supports 4.1.0 Physical Therapy4.2.0 Occupational Therapy4.3.0 Speech and Language Therapy4.4.0 Visiting Nurse4.5.0 Visual/Mobility Therapy4.6.0 Behavioral Therapy
15min.
5. Respite Services 5.1.0 Respite – In Home5.1.1 Respite – Out-of-Home5.1.2 Respite – Camp
Hour
ITQ ServiceCategory Service Name
ServiceDescription Unit
Staff Requirement
6. TransportationServices
6.1 Transportation Trip Mileage
7. Personal Supports 7.1 Personal Supports for Community Integration 15 min.8. Vendor Services (Non-ITQ Services
8.1 Environmental Adaptations8.2 Adaptive Appliances/Equipment8.3 Homemaker/Chore
EachEachEach