Virginia’s ID/DD Waiver Re-Design Update

vaACCSES Annual Provider Conference

June 8, 2015

Connie Cochran, Assistant Commissioner and

Dawn Traver, Waiver Operations Director Division of Developmental Services Virginia Department of Behavioral

Health and Developmental Services

The Big Picture

Slide 3

CMS Final Rule Is Good For the People We Support

• It is conveys an aspiration for all people.

• It requires working in the ‘gray’ area of what is or isn’t—not a check off.

• It requires us to really understand how to help people have the contacts that lead to opportunities for a broader, richer life.

Slide 4

Virginia Settlement Agreement with US Department of Justice

• Extensive in process and some specific deliverables – 122 reporting elements (example: 2 hour crisis response)

• Is really about establishing systems of services that grow and self-correct over time

• Is really about meeting the needs of all citizens in the community—Olmstead

• Is really about access to a holistic array of services, supports and resources – when needed and aligned.

Slide 5

Waiver Redesign

• Is about aligning service definitions – with a clear method of setting rates for providers to deliver

the best services

– with the Commonwealth coming closer to matching “service packages” to the greatest percentage of members within the waiver

– while bending the curve on costs to be able to sustain and reduce the wait list to a manageable number—whereby natural turnover meets demand in a reasonable amount of time

• Is about shifting expectations – to community supports

– lessening the demand on creating more congregate settings – CMS Final Rule

Slide 6

Magic of 7 Levels – 4 tiers or 2 tiers (Independent Living)

• Why: while 7 is a lucky number that was not the reason—the process of developing updated waivers, worked for the Commonwealth for key services for 7 levels—and the validation study supported this assumption

• Why service packages—allow us to segment the needs into some predictability of what is needed for providers, for funding ,and by individuals served

• Why some & not others: for services not driven by the intensity, no reason to make all services linked and not everyone in each level needs same

• How: staggered in and working with DMAS and their vendor on overlapping

• When: target still July 2016 – and need providers ready and prepared.

The Details

Slide 8

I/DD Waiver Redesign

• Although not required by the Settlement Agreement, amending and restructuring the three waiver for persons with I/DD will result in services and supports that promote the community integration required by the Agreement.

• In his 6th Report to the Court, the Independent Reviewer mentioned no fewer than a dozen times the importance of waiver redesign as a vehicle for complying with the Agreement.

Slide 9

Public Stakeholder Forums

Waiver Design Advisory

Committee (WDAC)

State Employment

Leadership Network

(SELN)

Community Engagement Advisory Workgroup

(CEAG)

16 Forums (September/October 2013)

8 sites across VA 1000 Attendees

Eligibility Case

Management Waiting List Provider

Advisory Services Array

Policy Subgroup Training

Subgroup

Policy Data Training and

Education State

Collaboration

My Life/My Community Public Comment Portal

Waiver Updates Stakeholder

Distribution List

Public Presentations

Residential Services

Workgroup

TACIDD vaACCSES VBPD

SA Stakeholder Advisory Group

Parent Support Groups

CIAC

VARO

CSB SCs DD CMs

The Arc of VA

VNPP

Partnership for People with Disabilities

State Agencies

VACSB

Legislative Updates

Slide 10

Essential Elements of I/DD Waiver Redesign

• The redesigned waivers will utilize a supports budgeting methodology for residential and day services based on the assessed intensity of need of the individual.

• Providers will need to demonstrate the necessary competencies to serve individuals with more complex needs.

• Some services will have tiered reimbursement rates to support individuals with more complex needs and encourage providers to use more intensive staffing patterns for these persons.

Slide 11

Slide 12

Relationship of Individual Levels to Reimbursement Tiers

0

1

2

3

4

5

6

7

8

9

Level 1/Tier1

Level 2/Tier2

Level 3/Tier3

Level 4/Tier3

Level 5/Tier4

Level 6/Tier4

Level 7/Tier4

Level

1

2

3

3

4

4 4

How You Spend Your Day Employment supports or integrated day

services

Building Independence Waiver For adults (18+) able to live independently in the

community. Individuals own, lease, or control their own

living arrangements and supports are complemented by

non-waiver-funded rent subsidies. Supports are

episodic/periodic in nature.

For individuals living with their families, friends, or in their own homes, including supports for those with

some medical or behavioral needs. Designed to meet individual support needs and preferences. Available to

both children and adults.

Community Living Waiver 24/7 services and supports for individuals with complex

medical and/or behavioral support needs through licensed services. Includes residential supports and a full array of medical, behavioral, and non-medical supports.

Available to adults and children.

Where You Live

Where You Live Supports in family home or apartment

setting

How You Spend Your Day Employment supports or integrated day

services

How You Spend Your Day Employment supports, integrated day services and group employment/day

services

Amend DD Waiver to Amend ID Waiver to

Proposed Integrated I/DD Waiver Redesign

Supports Budget is Based on: Supports Budget is Based on:

Family/Individual Supports Waiver

Supports Budget is Based on:

Higher cost congregate residential supports available

Amend Day Support Waiver to

Changing needs

Changing needs

Changing needs

Changing needs

Supplemental Supports/Services: One or more services based on individual assessed needs

Supplemental Supports/Services: One or more services based on individual assessed needs Supplemental Supports/Services:

One or more services based on individual assessed needs

Where You Live Intermittent, low overall cost residential supports in individual’s own apartment

Slide 14

Changes to billing conventions

• Establishing four rate tiers (based on the seven levels) for residential services and day supports

• Splitting congregate residential into distinct models – group home, supported living, and sponsored placement – billed on daily basis

• Varying group home rates by home size, with higher rates for smaller homes

• Billing day supports and group supported employment on an hourly basis rather than for partial-days

• Establishing higher rates for day supports delivered in the community compared to at a center

Process – Developing Rate Models

Slide 15

Process – Developing Rate Models (cont’d)

Major assumptions • Direct Support Professional wages

o Based on median wage for comparable position(s) published by the Bureau of Labor Statistics, which is a cross-industry survey of Virginia employers

• Direct Support Professional benefits

o In addition to mandatory benefits, provides for 30 days of paid

leave, $375 per month for health insurance, and $100 per month

for other benefits assuming an 85 percent take-up rate

• Agency overhead included at an average of 21 percent • Day Supports staffing ratios

o Range from 1:7 to 1:2 at a center and from 1:3 to 2:3 in the community based on a member’s level of need (additionally, there is a 1:1 community rate that any member may access)

Slide 16

Process – Public Comment Process

Draft rate models and related materials posted online for public review and comment • Notification emailed to providers and other stakeholders

• Comment period open for one month (all late comments were considered)

• Comments received from approximately 250 individuals

Several changes made in response to comments, including: • Increased Tier 4 rates (the highest tier) for residential services

• Additionally increased sponsored placement rates across all tiers

• Reduced assumed attendance for day supports and group supported employment (increasing these rates)

• Revised (lowered) wage assumptions for rest of State rates

Slide 17

Implementation and Cost Impact

Average change in rate varies by service • Group Home + 4.9 percent ($13.5 million)

• Sponsored Placement - 0.4 percent ( - $0.3 million) • Supported Living + 0.8 percent ($0.1 million) • In-Home Residential Support + 30.5 percent ($15.0 million)

• Day Support + 11.3 percent ($9.9 million) • Pre-Vocational Services + 8.0 percent ($0.9 million) • Group Supported Employment - 3.7 percent ( - $0.4 million)

• Skilled Nursing + 109.7 percent ($16.5 million) • Therapeutic Consultation + 58.2 percent ($0.5 million)

Slide 18

Issues of Interest – Northern Virginia Rates

Rate models for Northern Virginia and the rest of the State were set independently rather than using a fixed ‘premium’

• For most rates, this approach resulted in Northern Virginia variances comparable to the current 15 percent premium

• For some rate model factors there are significant cost differences (e.g., wages) while others have less significant differences (e.g., staff benefits, transportation)

• Rest of State wage assumptions were reduced from the draft rate models, which increased the rate differences

For most services, rate increases are slightly higher in Northern Virginia compared to the rest of the State

Slide 19

Issues of Interest – Sponsored Residential

Proposed rate models would have reduced Sponsored Residential rates by 11 percent on average

• After revisions made in response to comments, average rate would be nearly unchanged (anticipated reduction of 0.4 percent)

• Individual rates will change by varying amounts, with some increasing and others decreasing

• Overall, the average sponsored residential rate is expected to be greater than the average group home rate

Rate model built based on a ‘stipend’ rather than a wage • Annual stipend paid to the sponsored home assumed in the

rate models varies by level of need and ranges from $30,000 to $81,000 per member

Slide 20

Issues of Interest – 344-Day Billing Policy

Rate models for residential services are constructed assuming a 344-day billing year

• Estimated cost of service for a full 365-day year is calculated, $36,500 for example

• Rather than calculating a daily rate of $100 ($36,500 divided by 365 days), the cost is divided by 344, producing a rate of $106.10.

• This approach allows providers to be fully compensated (paid $36,500) even if the member is occasionally absent

• Since a provider is fully compensated after 344 billing days, they cannot bill more, even if the member is present for more days (because they have been paid for 365 days of service over the 344 billing days)

Slide 21

New Services: Integrated Day

• The Settlement Agreement requires the Commonwealth to provide integrated day opportunities vs. the current day system that is characterized by very large congregate facilities.

• Proposed new services:

– Community Engagement

– Community Coaching

– Community Guide

• Individuals will be encouraged to take advantage of the above instead of group day support services.

Slide 22

Community Engagement

• Provides a wide variety of opportunities to facilitate and build relationships and natural supports in the community

• Uses the community as the learning environment

• Emphasizes the person actively interacting with others without disabilities

• Ratio of no more than 1 staff per 3 individuals

Slide 23

Community Coaching

• 1:1 service that takes place in the community

• Designed for those who need intensive support to build a specific skill set

• Addresses one particular barrier that prevents a person from engaging in their community

• Typically a time-limited service

Slide 24

Community Guide

• Direct, 1:1 assistance to individuals to help them identify and access community resources that will meet their needs and interests

• Information and assistance to help the individual problem solve and make decisions about ways to develop supportive community relationships

• Time limited

Slide 25

New Services: Employment

• Waiver redesign will provide the necessary underpinnings for a more robust set of employment services and supports that provides incentives for employment.

• Proposed new services:

– Workplace Assistance Services – ongoing support to a competitively employed individual who requires more than sporadic support to maintain stable employment

– Benefits Planning Services – assistance to individuals and their families to coordinate their Social Security benefits with employment to make informed choices about work

Slide 26

New Services: Integrated Array of Residential Options

• The Settlement Agreement requires the Commonwealth to facilitate individuals receiving Waiver services “to live in their own home, leased apartment, or family's home, when such a placement is their informed choice and the most integrated setting appropriate to their needs.”

• Currently Virginia’s I/DD Waivers provide more congregate residential supports than integrated options.

• New services:

– Shared Living

– Supported Living

– Independent Living

Individuals will be encouraged to move from congregate settings to these services when appropriate to their needs.

Slide 27

Shared Living

• Medicaid payment for a portion of the total cost of room and board for an unrelated live-in support person of the waiver recipient.

• In exchange, the live-in support person provides extra “eyes on” and assists the individual with some needed supports in the home and community; helps the individual make natural community connections.

Slide 28

Supported Living

• Residential supports provided to individuals in a DBHDS licensed apartment setting

• More of a terminology change, as individuals are already supported in these settings under a different waiver service

• Will typically have round the clock access to staff

Slide 29

Independent Living

• Supports to secure a self-sustaining, independent living situation for individuals living in their own apartments, alone or with a roommate

• Limited to no more than 21 hours per month

• To be coupled with rental assistance

Slide 30

New Services: Medically Oriented

• To enable those with the most complex medical needs to successfully live in integrated community settings.

• Proposed new services:

– Private Duty Nursing – a correction to the system as currently providing continuous nursing care inappropriately under Skilled Nursing

– Adult Dental Services – preventive or basic care up to a capped amount per year

Slide 31

New Services: Behaviorally Oriented

• To enable those with the most complex behavioral needs to successfully live in integrated community settings.

• Proposed new services:

– Center-based Crisis Supports – to ensure appropriate funding for the REACH Crisis Therapeutic Homes which are designed for individuals who are experiencing an identified behavioral health need or behavioral challenge preventing them from being stable in their home setting

– Crisis Support Services – comprised of crisis prevention, crisis intervention and crisis stabilization

Slide 32

New Services: Community Access

• Settlement Agreement requires the Commonwealth to provide transportation in accordance with its approved HCBS Waivers

• Proposed new service:

– Non-medical transportation – transportation to employment or other community sites

Slide 33

New Services: Community Access (cont’d)

• Settlement Agreement requires the Commonwealth to develop peer programs to facilitate individuals to meet and converse with other individuals currently living in the community

• Proposed new service:

– Peer Mentor Supports – specially trained individuals with DD assisting others with DD to become aware of and advocate for the least restrictive community services in their own lives

Slide 34

New Services: Community Access (cont’d)

• Proposed new service:

– Electronic Based Home Supports – goods and services based on Smart Home © technology to support greater independence and safety. Would be used in lieu of some hours of paid staff support.

Slide 35

Planned New Services by Waiver

Community Living Family & Individual Support Building Independence

Shared Living Shared Living Shared Living

Workplace Assistance Supported Living Independent Living Support

Community Engagement Workplace Assistance Community Engagement

Community Coaching Community Engagement Community Coaching

Community Guide Community Coaching Community Guide

Non-medical Transportation Community Guide Non-medical Transportation

Benefits Planning Non-medical Transportation Benefits Planning

Electronic-based Home Supports

Benefits Planning Electronic-based Home Supports

Peer Mentor Supports Electronic-based Home Supports

Peer Mentor Supports

Adult Dental Peer Mentor Supports Adult Dental

Private Duty Nursing Adult Dental

Private Duty Nursing

Slide 36

Redesigned Waiver Possible Timeline

•New group home rate structure (daily billing vs. current hourly billing) in effect. •Other services effective by individual plan year.

•New sponsored residential rate structure transition in effect. •Other services effective by individual plan year.

Transition of In-home & non-residential individuals (e.g. living with family) in effect.

Building Independence, Family & Individual Supports and Community Living Waivers commence

July 2016

October 2016

January 2017

Slide 37

Strategies to Gain Federal Financial Participation

• DBHDS and DMAS participate in bi-weekly conference calls with the Centers for Medicare and Medicaid Services (CMS) to identify any necessary revisions to the Commonwealth’s draft waiver redesign plans and gain CMS approval for innovative strategies.

• A fall of 2016 submission of the waiver amendments would enable CMS to fully consider all desired changes and give approval conditional on VA approved funding.

Slide 38

VA’s HCBS Settings Rule Transition Plan

• Transition Plan for ID waiver submitted with 2/11/15 amendment requesting 2014 GA approved slots

– Approved on May 7, 2015 with waiver amendment approval

• Statewide Transition Plan submitted on March 17, 2015

– Received CMS communication on June 3, 2015 that plan is being reviewed

Slide 39

Elements of the Transition Plan

• Provider Self Assessments

– ID/DD waiver providers: Survey Monkey

– 321 received

– High percentage of providers viewed agency as in compliance

– Summary Report to be placed on DBHDS’s website

• Follow-up by DMAS & DBHDS

– DMAS: QMR

– DBHDS: Office of Licensing & DDS Community Resource Consultants

• Recommended completion of “HCBS Setting Assessment Tool” to be distributed as a means of developing own plan toward compliance

Slide 40

Elements of the Transition Plan (cont’d)

• Compliance and Monitoring Team – To include: individuals, family members, state agency

reps, private providers, advocacy organizations, CSB reps and other stakeholders

– Initial “meeting:” recorded web-ex to be made available 6/25/15 • Develop cross agency SME on the Settings Rule and Transition

Plan

• Ensure a collective understanding of requirements

• Advise & support the education and training of professionals, providers & stakeholders

• Ensure a cohesive, broadly represented approach toward compliance, monitoring and capacity issues

• Ensure successful achievement of full compliance by March 2019

Slide 41

Elements of the Transition Plan (cont’d)

Other Elements:

• Developing letter regarding Settings Rule for SCs/CMs to give individuals/family member to educate

• Dedicated DBHDS toll-free phone line for stakeholders to provide input regarding providers’ compliance: 844-419-1575

• DBHDS Licensing regulations being revised to comport

• CRCs providing consultation and technical assistance to SCs/CMs and ID providers

• Individuals receiving supports from providers not in compliance by June 2018 will be offered opportunity to transition to another provider to keep waiver services

Slide 42

More Information About the Settings Rule

• http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-Based-Services.html

– Now includes guidance for NON-RESIDENTIAL SETTINGS