Waiver Slot Enrollment

Progress Report

As Required By

2016-17 General Appropriations Act, H.B. 1, 84th Legislature,

Regular Session, 2015 (Article II, Department of Aging and

Disability Services, Rider 31)

Health and Human Services Commission

March 2017

i

Table of Contents

1. Executive Summary ...................................................................................................................1

2. Introduction ................................................................................................................................1

3. Background ................................................................................................................................2

4. Individuals Enrolled in Each Type of Slot and Purpose ........................................................2

5. Planned Enrollment for the Remainder of the 2016-17 Biennium ........................................3

6. Identified enrollment systems delays or barriers by the agency and plan to address

identified issues to achieve targets by the end of fiscal year 2017 .........................................4

HCS PI Initiative Slots for Persons Moving Out of Large and Medium ICFs/IID ......................4

HCS PASRR Slots for Persons with IDD Moving from Nursing Facilities ................................5

HCS PASRR Slots for Persons with IDD Diverted from Nursing Facility Admission ...............5

Updates to the System Reporting Process- MDCP Enrollment Data Post November 1, 2017 ....6

7. Conclusion ..................................................................................................................................6

List of Acronyms ............................................................................................................................7

Appendix A: Graphs .....................................................................................................................1

1

1. Executive Summary

The 2016-17 General Appropriations Act, H.B. 1, 84th Legislature, Regular Session, 2015

(Article II, Department of Aging and Disability Services, Rider 31) directs the Department of

Aging and Disability Services (DADS) to submit a plan for waiver slot enrollment to the

Legislative Budget Board, the Governor, the Senate Finance Committee, and the House

Appropriations Committee. As of September 1, 2016, the DADS waiver slot enrollment function

transferred to the Texas Health and Human Services Commission (HHSC). Therefore, HHSC is

now providing the report.

In accordance with the rider, the progress report identifies:

The number of individuals enrolled in each type of slot and for each purpose identified in the

rider;

The planned enrollment for the remainder of the 2016-17 biennium;

Any systems delays or barriers with enrollment, as identified by the agency; and

A plan to address those issues to achieve targets by the end of fiscal year 2017.

As required by the rider, the report describes identified enrollment delays and barriers with

enrollment in specific waiver programs, such as individuals transitioning from a state

supported living center (SSLC) having more complex medical and behavioral needs, which

make finding appropriate community placement more challenging. The report also includes

information regarding agency plans to address those issues, such as training and technical

assistance with Local Intellectual and Developmental Disability Authorities (LIDDAs).

2. Introduction

As required by Rider 31, the plan should include waiver slot enrollments appropriated for the

following programs and purposes:

Promoting Independence (PI) Initiative for the Home and Community-based Services waiver

program:

o For persons moving out of large and medium Intermediate Care Facilities for Individuals

with Intellectual Disabilities or Related Conditions (ICF/IID);

o For children aging out of foster care;

o To prevent institutionalization/crisis;

o For persons moving out of state hospitals; and

o For children moving out of Department of Family and Protective Services (DFPS)

general residential operations (GRO).

Reduction of the interest lists (IL) for the following waiver programs:

o Medically Dependent Children Program (MDCP);

o Community Living Assistance and Support Services (CLASS);

o Home and Community-based Services (HCS); and

o Deaf Blind with Multiple Disabilities (DBMD).

2

Compliance with federal Preadmission Screening and Resident Review (PASRR)

requirements for the HCS waiver program:

o For persons with intellectual and developmental disabilities (IDD) moving from nursing

facilities; and

o For persons with IDD diverted from nursing facility admission.

The plan will also discuss planned enrollment for the remainder of the biennium and any systems

delays or barriers that may impede the agency's ability to enroll clients into waivers in a timely

manner.

3. Background

The previous report submitted in conjunction with Rider 31 was developed by DADS and

published in March 2016.

The enrollment data presented in this current report for HHSC waiver programs is a snapshot

in time. The number of individuals who are in various stages of enrollment, enrolled in a

waiver program, or whose providers have submitted claims fluctuates. Following a waiver slot

offer, several factors may impact an individual’s progress through the enrollment process to

successful enrollment or closure of the slot offer, including:

Functional and diagnostic eligibility;

Provider selection;

Medicaid eligibility;

Availability of a preferred residential setting;

Transition planning from an institution to the community; and/or

Plan of care development.

4. Individuals Enrolled in Each Type of Slot and Purpose

Table 1: Individuals Enrolled in Each Type of Slot and Purpose summarizes the data regarding

the waiver programs, type of slot, and enrollment figures. To ensure the Commission does not

exceed its appropriation, waiver slot releases may be slowed or paused. Once additional capacity

is realized, slots will be released again.

Table 1: Individuals Enrolled in Each Type of Slot and Purpose

Program Type of Slot Purpose Net Change

In Enrollment

as of December

2016

End of FY

2017 Target*

(Cumulative)

MDCP IL Reduction To offer waiver services to

applicants registered as

waiting on the programs

interest list.

50 ** 244

CLASS IL Reduction 591 853

DBMD IL Reduction 90 76

HCS IL Reduction 563 1692

3

Program Type of Slot Purpose Net Change

In Enrollment

as of December

2016

End of FY

2017 Target*

(Cumulative)

HCS PI Initiative For persons moving out of

large and medium ICF/IID 208 500

For children aging out of

foster care 142 216

To prevent

institutionalization/crisis 268 400

For persons moving out of

state hospitals 107 120

For children moving out of

DFPS GRO 14 25

HCS Compliance

with federal

PASRR

requirements

For persons with IDD moving

from nursing facilities 288 700

For persons with IDD diverted

from nursing facility

admission

201 600

* DADS adjusted end-of-fiscal-year targets to account for any under- or overfilled slots as of

the end of August 2015. In August 2015, there were 140 unfilled slots in MDCP, 494 unfilled

slots in CLASS, and 26 unfilled slots in DBMD. The HCS waiver was overfilled by 442 slots.

HCS slots were overfilled in response to feedback DADS received during fiscal year 2014-

2015 about not filling slots quickly enough. The impacts of over-releasing names from the

interest list resulted in exceeding the end-of the year target. In addition, the CLASS slot target

was adjusted to account for higher per person costs than were assumed in the General

Appropriations Act.

** The MDCP waiver population was transferred to STAR Kids managed care on November 1,

2016. The net change in enrollment count for MDCP shown in the table above, is as of the end

of October 2016. HHSC staff are currently updating system reporting processes to calculate

this metric starting November 1, 2016.

5. Planned Enrollment for the Remainder of the 2016-17 Biennium

HHSC calculates the affordable average number of slots for each waiver based upon projected

service costs, and if needed, adjusts the enrollment targets in order to remain within appropriated

funding levels. For example, for the 2016-17 biennium, HHSC estimates the monthly cost for

CLASS to be $3,900 compared to $3,724.61 assumed in the General Appropriations Act.

The appropriation assumes HHSC will roll out slots for the purpose of reducing the HCS interest

list equally throughout the 2016-17 biennium. HHSC is further directed by Rider 31(b)(3) to

enroll 711 persons by the end of fiscal year 2016 and the remaining persons in fiscal year 2017.

4

Historically, to achieve a gradual rollout of slots, HHSC prospectively releases names from the

interest list on a monthly basis.

In determining the number of names to release each month, HHSC takes into account the

historical “take-up-rate”1, as well as the historical number of waiver slots expected to come

open each month as the result of attrition.

Because the enrollment process can be lengthy, HHSC releases more names from the interest

lists at the beginning of the fiscal year to ramp up enrollment.

HHSC staff meet monthly to:

Review the number of individuals enrolled in each waiver program2;

Identify the number of individuals whose eligibility is in the process of being determined;

Discuss the waiver slot take-up-rate;

Discuss available funding levels to support waiver slot releases; and

Review the number of remaining slots available.

HHSC management staff uses the information described above and determines the number of

names to release from the interest lists in the following month. When HHSC identifies

individuals whose Medicaid eligibility is not progressing in a timely manner, the agency works

with:

Access & Eligibility Services staff within HHSC to prioritize these cases; and

Service providers to offer technical assistance.

6. Systems delays or barriers identified by the agency and plan to address those issues to achieve targets by the end of fiscal year 2017

HHSC identified enrollments concerns for three HCS slot types/purposes. HHSC has made slot

offers to the targeted population; however, we are experiencing a higher level of clients

declining slots for the following slot types and purposes:

HCS PI initiative slots for persons moving out of large and medium ICFs/IID;

HCS PASRR slots for persons with IDD moving from nursing facilities; and

HCS PASRR slots for persons with IDD diverted from nursing facility admission.

HCS PI Initiative Slots for Persons Moving Out of Large and Medium ICFs/IID

HHSC releases slots monthly to individuals residing in SSLCs and large and medium

ICFs/IID. For SSLCs, SSLC staff request a slot when an individual has been recommended for

community placement. Following SSLC census reduction efforts in the previous biennium,

individuals transitioning from an SSLC during the 2016-17 biennium have more complex

medical and behavioral needs, which make finding appropriate community placement more

challenging. As a result, the number of monthly community transitions has decreased.

1 A formula that takes into account the number of successful enrollments in proportion to the number of names

released in the past. 2 The number of individuals enrolled in a waiver program is based on paid claims.

5

HHSC releases slots to individuals in large ICFs/IID based on the date the individuals are

placed on the HCS interest list. For medium ICF/IID, slots are released to individuals age 22 or

younger based on the date the individuals are placed on the HCS interest list. The number of

individuals in ICFs/IID who are also on the HCS interest list has decreased. Many individuals

who remain in large ICFs/IID and individuals age 22 or younger in medium ICFs/IID received,

but ultimately declined, HCS slot offers.

HHSC will continue to offer slots to individuals who are on the HCS interest list and residing

in ICFs/IID.

HCS PASRR Slots for Persons with IDD Moving from Nursing Facilities

HHSC releases slots monthly to adults who are admitted into nursing facilities and approves

requested slots for individuals to transition from nursing facilities to the community; however,

the number of individuals accepting the HCS slot offer has been lower than anticipated.

Individuals may have high medical needs or may require nursing facility services to stabilize

health conditions before being able to transition to the community. Many individuals and/or

their authorized representatives decline the slot until their medical issues are addressed and are

ready to transition to the community.

LIDDAs will continue to provide community living options through educational activities,

discuss community living options every six months, conduct service planning team meetings

quarterly and provide service coordination to individuals residing in nursing facilities monthly.

HHSC will offer additional technical assistance to LIDDAs when individuals decline an offer

to identify barriers and work through issues to reach a solution representative of the

individuals’ choice.

HCS PASRR Slots for Persons with IDD Diverted from Nursing Facility Admission

Due to the low number of enrollments of adult individuals diverted from nursing facility

admissions and in response to recommendations made by the Promoting Independence

Advisory Committee and EveryChild, Inc., DADS expanded the slot offer criteria in June 2016

to include individuals of all ages. We expect this change will positively affect the utilization of

nursing facility diversion slots. HHSC will continue to review all requests to determine if

diversion from nursing facility admission is appropriate due to medical needs of individuals

who may also fall into this targeted population.

HHSC will conduct further analysis on actions taken to resolve enrollment system delays and

barriers to achieve enrollment targets by the end of fiscal year 2017.

Based on implementation of the enrollment plan, HHSC expects to meet the targets for

appropriated waiver slot enrollment and identified no additional system delays or barriers from

achieving this goal for all other slot types and purposes.

6

Updates to the System Reporting Process - MDCP Enrollment Data Post November 1, 2017

Due to the transfer of the MDCP population from fee-for-service to managed care as part of the

November 1, 2016, STAR Kids implementation, HHSC staff are updating current system process

reporting from a legacy agency system at DADS to an updated agency process involving both

agency staff and the administrative services contractor, Accenture (Texas Medicaid & Healthcare

Partnership [TMHP]).

Because the STAR Kids program is now operational, the next step is to develop and implement

the new reporting system that will capture and report accurate data for this population. HHSC is

working diligently to implement this new system with input from various HHSC program areas

and the contractor. The reporting data for MDCP will reflect updated enrollment and interest list

metrics and methodologies necessary to track the attrition of MDCP slot allocations. HHSC

plans to complete the development of the updated MDCP report in fall 2017.

7. Conclusion

For planned enrollment for the remainder of the 2016-17 biennium, the appropriation assumes

HHSC will roll out slots for the purpose of reducing the HCS interest list equally throughout the

2016-17 biennium. HHSC was further directed by Rider 31, Subsection (b)(3), to enroll 711

persons by the end of fiscal year 2016 and the remaining persons in fiscal year 2017. HHSC will

continue to review the interest list on a monthly basis to ensure there is sufficient funding

available to release additional waiver slots.

HHSC will work to address the noted barriers to enrollment into waivers by continuing to offer

slots to individuals who are on the HCS interest list and residing in ICFs/IID and will provide

technical assistance to LIDDAs when individuals decline an offer to identify barriers and work

through issues to reach a solution representative of the individuals’ choice.

For HCS PASRR slots for persons with IDD Diverted from Nursing Facility Admission,

HHSC will continue to review all requests to determine if diversion from nursing facility

admission is appropriate due to the medical needs of individuals who may be in this targeted

population. HHSC will also conduct further analysis on actions taken to resolve enrollment

system delays and barriers identified to achieve enrollment targets by the end of fiscal year

2017.

Finally, for enrollment data on MDCP waiver slots, HHSC staff will continue to work on

updating current system process reporting from a legacy agency system at DADS to an updated

agency process involving both agency staff and Accenture. HHSC plans to complete the

development of the updated MDCP report in fall 2017.

7

List of Acronyms

Acronym Full Name

IL

PI

HHSC

ICF/IID

DFPS Services

GRO

MDCP

IDD

SSLCs

LIDDA

TMHP

DBMD

CLASS

HCS

PASRR

Interest Lists

Promoting Independence

Health and Human Services Commission

Intermediate Care Facilities for Individuals with Intellectual

Disabilities or Related Conditions

Department of Family and Protective

General residential operations

Medically Dependent Children Program

Intellectual and developmental disabilities

State supported living centers

Local Intellectual and Developmental Disability Authorities

Texas Medicaid & Healthcare Partnership

Deaf Blind with Multiple Disabilities

Community Living Assistance and Support Services

Home and Community-based Services

Pre-Admission Screening and Resident Review

A-1

Appendix A: Graphs

The following graphs compare actual enrollment to targeted enrollment on a month-by month

basis. The targeted trend line is based on a straight-line ramp-up of the number of additional

enrollments added during the year to achieve the year-end enrollment targets for each waiver

program.

2,412

2,434

2528

25892628

2,000

2,100

2,200

2,300

2,400

2,500

2,600

2,700

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MDCP Enrollments

Enrolled Target

A-2

5,484

4960

5623

5726

5,301

6,119

4,500

5,000

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6,000

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CLASS Enrollments

Enrolled

Affordable Target

Appropriated Target

Affordable target has been reduced from appropriated level based upon Projected monthly cost of $3900 vs $3724 assumed in GAA

A-3

236

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100

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DBMD Enrollments

Enrolled Target

24,098

25,629

23,562

26,064

28,091

20,000

25,000

30,000

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HCS Enrollments

Enrolled Target