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C olorado L egislative C ouncil S taff

Room 029 State Capitol, (303) 866Denver, CO 3521 FAX: 80203-1784 866-3855 TDD: 8663472

Pursuant to section 24-72-202(6.5)(b),research memorandaandotherfinalproducts ofLegislativeCouncil Staff research that are not related to proposed or pending legislation are consideredpublic inspection. If are think additional research is required and subject to public records and you this memorandum is the Legislative Council Librarian at (303) 866-4011 by product, please call not a final July 19, 2007.

July 12, 2007 TO: Members of the Interim Committee to StudyLongterm Care Services and SupportsDisabilities for Persons with Developmental Elizabeth Burger, Research Associate II, 303-8666272 Shipley, Senior Research Assistant, 303-866Jessika 3528 Stapleton, Senior Research Assistant, 303-866Kelly 4789 Larsen, Senior Fiscal Analyst, 303-866-3488 Amy


SUBJECT: Overview of the System of Long-term Care for Persons with Developmental Disabilities in Colorado This memorandum provides an overview of Colorado's system of long-term carefor persons with developmental disabilities. Specifically, this memorandum discusses thedescribes the services that are provided. In addition, the services and administration of memorandum describes current funding for services in the state and discusses the waiting lists for services. Finally, the memorandum provides estimates of the funding required to eliminate the waiting lists for services,to the restructuring of Medicaid waivers and describes issues related used to provide services to disabilities. persons with developmental

Definition of Developmental Disability State statute defines a developmental disability as a disability that is manifested before the

that is 22 years of age which person reaches manifested before the constitutes a substantial disability to the disabilityindividual. In addition, the affected must be attributable to mental retardation or related conditions which includecerebralpalsy, epilepsy, autism,orother neurological conditions when such conditions result in impairment of general intellectual functioningoradaptivebehavior similar retardation. mental to that ofapersonwith

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Administration of Services The Division of Developmental Disabilities within the overseesDepartment of Human Services theadministration of services forpersons withdevelopmental disabilities. state services for persons with developmental disabilities majority of Becausethevast are funded through the state Department of Health Care Policy and Medicaid program, the state Financing also oversees persons with developmental disabilities. administers services for and Community Centered Boards (CCBs). In Colorado, persons withadevelopmentaldisability access services through a Community Centered Board (CCB). There are 20 CCBsCentered Boards are private entities which, as designated Community in Colorado. by statute: • • • • are authorized to determine the eligibility for services of persons with developmental disabilities who live in a specific geographic region; provide case management services to persons with developmental disabilities; entry for persons to receive serve as the single point of state- and federally-funded services and supports; and provide authorized services and supports to persons with developmentalor by purchasing services and supports either directly disabilities from service agencies.

Eligibility for Services Anyperson mayrequest an evaluation to determine whether that person has for services. CommunityCentered Boards are disability and is eligible adevelopmental responsible for determining for services. If the CCB determines the whether the person is eligible person 30 eligible for services, within is days of the eligibilitydetermination, the CCB must develop an individualized plan for the plan must identify: individual. The individualized the needs of the person or family receiving services; the specific services and supports appropriate to meet those needs; date for initiation of services and supports; the projected and anticipated results to be achieved by receiving the the services and supports. The individualized plan must be reviewed at least annually and appropriate. modified as necessary or • • • •

Services Provided Services for those individuals who qualify are provided through four main programs: • Adult Comprehensive Services (Comp); • Supported Living Services (SLS); • Children's Extensive Support (CES); and • Family Support Services (Family Support).


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Below is a description of each program, who is eligible, and what services are provided. Adult Comprehensive Services (Comp). Comprehensive services are provided to disability who are living outside individuals with a developmentaladult their family home and require 24-hour supervision and residential services. To be eligible, one must bedevelopmental disability, and require extensive support services to a at least 18 years old, have live safely outside the home. program are: Some services included in this • • • • • • • • residential habilitation with 24 hour supervision; day habilitation services including supported employmentlife activities, andto typical community services, access generalized skill development; training and habilitation services in the areas of personal, physical, mental, and social development; transportation; specialized medical equipment and supplies, such as wheelchairs, wheelchair or toys or computers that aid adaptation, van adaptation, in communication; skilled nursing; behavioral services and mental health services; and dental and vision services.

Some services take placewithin the communitysetting, while shelteredothers takeplacein segregated where the majority of people workshops or training centers may have a disability. Supported Living Services (SLS). Supported Living Services are services and supports disabilities to live in the their own assist persons with developmental to home, apartment, familyhome, SLS setting. Supported Living or rental unit that qualifies as an Services are provided as an alternative to institutional placement for individuals with developmental disabilities, but are not like Comp services. To be intended to provide 24-hour supervision eligible, one must either live independentlywith limited supports or alreadyreceive services from other resources such as family members. Services include: • • specialized medical equipment and supplies; counseling and therapeutic services;

• • • •

• • • •

dental, hearing, and vision services; day habilitation services including physical, occupational, or speech therapy; home modification; personalassistanceservicesincluding assistancewithbathing,personalhygiene,eating, dressing, grooming, reliefto familymembers who normallyprovide personal care, and medications; communication services such as speech/language therapy; services including individual, group, counseling behavioral interventions, diagnostic evaluations, occupational, and physical therapy; transportation; and assistance with employment (pre-vocational and supported employment).


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Children's Extensive Support Services (CES). Children's providedExtensive Support Services are to children who have a developmental disability, or to children under the age of five who are at risk of a developmental disability or developmental delay. To be eligible, one mustor medical needs. Children's Extensive Support intensive behavioral have Services are provided as an alternative to institutional placement for children with developmental disabilities. Services include: • personal assistanceservicesincluding assistancewithbathing,personalhygiene,eating, dressing, grooming, and medications; • child care assistance; • professional services such as counseling and therapeutic services; services such as housekeeping tasks; • household • home modification services such as adaptation of showers or toilets andramps orthe home accessible with making railings; • community connection services such as providing for recreational medical equipment and supplies including • specialized equipment; and wheelchairs, wheelchair or toys or computers that aid adaptation, van adaptation, in communication. FamilySupport Services. FamilySupport Services are children intended to with developmental allow and adults provide services to disabilities to remain in their family home and toas the primary care givers. Referrals to the Family support to families provide Support CCBs. Thoseeligiblearerequired tohaveafamilymember through program are made withadevelopmental disability living in the household. Eligibility for the Family Support Services program does not necessarily The Family Support program is not guarantee services or support. funded through a Medicaidstate dollars. waiver, but is funded with A family support plan is developed in conjunction with an individual's Individual Plan in order to avoid duplicative services. Services may include: • • family support grants; support service coordination and educational materials;

• • • • • • • •

emergency and outreach services; reimbursement for medical and dental expenses not covered by health insurance programs; child care; mobility aids and adaptive equipment; therapy and family counseling; recreation and leisure needs; transportation; and special dieting foods, clothing, and homemaker services.

Current Funding and Waiting Lists The vastmajorityof services for personswithdevelopmental disabilitiesare fundedthrough federal Medicaid waiversfor home- andcommunity-based services. TheseMedicaid waiversenable persons with developmental the state to support services for disabilities using Medicaid funds that –4–

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originate as 50 percent General Fund and 50 percent federal funds. However, waiverof the state Medicaid program in that the state may from other parts services differ limit the total number As a result, there are waiting lists for services. program participants. of Table I reflects FY 2007-08 funding and waiting list information. Adult Comprehensive Services, Adult Supported Living Services, and the Children's Extensive Support programs by Medicaid with a 50 percent state funded primarily or entirely are contribution. For budgetary are the number of individuals who are purposes, program resources expected toand may services for actual number of clients served. a full year receive vary from the Some oflists are anticipated to be removed during FY 2007-08 due to waiting the persons on the the funding ofclientresources and changing new needs. Family Support Services are primarily funded with state General Fund moneys, and current funding serves about 4,000 families.
Table I FY 2007-08 Funding and Waiting Lists

Total Community Program Adult Comprehensive Services (Comp) Adult Supported Living Services (SLS) Children's Extensive Support (CES) Family Support Services Funding $257,604,990 $61,106,767 $8,184,233 $7,269,644

Resources Funded 3,872 3,584 395 1,176

Avg. Cost Full per Year Resource $66,530 $17,050 $20,720 $6,182

Waiting List as of April 2007 1,368 2,324 157 4,178

a) Reflects funding in the Developmental Disability Services, Community Services, Program Costs line item of the FYBill. It does not include 403 adult residential resources at the regional centers or 2007-08 Long services funded local dollars. with

b) Of the resources shown, 78 adult comprehensive resources and 24 adult supported living services are funded for of six months in FY 2007-08. These resources are counted as 0.5. an average

Eliminating the Waiting Lists The waiting lists for developmental disability services are a fundamental problem. While manypeople anticipated a judicial resolution from a lawsuit alleging that the state's waiting lists for were illegal, the courts ruled in the developmental disability services 1 state's favor allowing the The ruling leaves the state with broad waiting lists to continue. flexibility to set funding levels for services to the developmentally disabled.


Mandy R. v. Owens. In February 2005, Judge Richard P. Matsch, the trial court judge for the federal district September in 2006, the 10th Circuit Court of Appeals upheld the ruling. state's favor. On court, ruled 21,the


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Services foradults. The projected cost to the state of entirelyeliminating the current waiting lists for adult services is estimated at $46.6 million annually. Costs are shared between comprehensive services and supported living services as shown in Table II.
Table II Cost of Eliminating the Current Medicaid Waiting Lists for Services for Adults with Developmental Disabilities
Net State Cost Program Adult Comprehensive Services (Comp) Adult Supported Living Services (SLS) Total per Client* $29,688 $9,320 $39,008 Resources Required** 1,094 1,515 Total State Cost $32,478,672 $14,119,800 $46,598,472

*Costs are based on FY 2007-08 average net state costs including case management. **Resources required are based on the waiting list as of April 2007, reduced by 20 percent to account for individuals not in a timely fashion and assuming 344 SLS slots would be opened up by removed from the wait list individuals moving to comprehensive services from SLS.

Eliminatingthecurrent waitinglist would onlytakecareoftheproblem foroneyear because the demand for services continues to grow much faster than population growth. Joint Budget Committee staff estimates that growth in demand for comprehensive residential per year, about 4.1 percentservices iswhile growth in the state's population is between 1 and growth is tied,year. The the baby boom generation cohort of rapid 2 percent per in part, to

persons with developmental disabilities. This group increasingly requires state-funded services as their parents age and are no longer able to care for them. Joint Budget Committee staff estimates that 180 new resources would avoid ongoing waiting year in the near future to need to beadded each list growth. After eliminating the waiting list, an annual increase of about $6 million in state funds is required to avoid recreating it. Services for children. At this time, staff is unable to accurately estimate funding requirements to eliminate the waiting list for the Children's Extensive Support program. Placement program's abilityto spend funds while delays and problems with the children in large under-expenditures going back to FY 2005-06. In FY resulted areawaiting placement 2006-07, thirty new Support resourceswere added, but underChildren's Extensive expenditures toppedstaffpercent. Joint an FY 2007-08 budget Budget Committee 30 anticipates that adjustment, children who maybe served or to reducethe budget, is numbers of either to increase likely. While state $1.6 million (157 children x $10,000), at this time, may be as high as funding needs it is unknown how many a waiting list after current funding is children would remain on utilized. Services for families. State funding for Family Support Services is CCBs receive a set amount of money and that a block grant in thatadministered much like funding is used to provide as possible. Thus, anyadditional services to as manyfamilies fundingwould be State funding as high as $24.6 million may be expand services. used to enhanceand required to provide full services to x 4,178 families). However, it is all families on the waitinglist ($5,900 important to note that waiting list are receiving some services. Local of the families on the many funds may also be made available for this program. –6–

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Restructuring of Payments for Services Funded through Medicaid Waivers As noted earlier, the vast majority of state services for persons with through the Medicaid program through various disabilities are fundeddevelopmental waivers.FY 2005-06, the developmentaldisabilitysystemwa through From thelate 1990s smanagedpursuanttoa systemschange Committee and the Department agreement between the Joint Budget of Human Services. Underthe systems change agreement, CCBs received payments based on an average service rate forpersons served, and the CCBs negotiated individual regions and their agreements with upon the specific needs of the persons served. This providers based individual quasi-managed care system wasthe federal Centers for Medicare and eliminated in FY 2006-07 after Medicaid Services (CMS) notified the state that the payment methodology would no longer be permitted. In Februaryof 2006, the state began a process to revamp its and SLSbilling system forAs directed byCMS, Colorado must waiver services. comprehensive establish clearguidelines for determining client levels of need, and rates, develop a process for provider implement a payment system thatan individual for all waiver allows specific costs to be tied to programs. The billing system change has driven a substantial workload for the Department of In addition, the transition initially Services, CCBs, and providers.Human resulted in significant paymentsystem developed to "hold harmless" delays to providers. Finally, a

anyprovider who of the financial losses as a result faced billing system change had technical difficulties and hold to providers until the spring of 2007. were not distributed harmless payments The state is currentlyin the process of developing uniform and day tiered rates for residential services all clients to determine habilitation services and evaluating their level of need and the tier for their services. An interim rate appropriate reimbursement structure for comprehensive into SLS waiver services was putand place in August of 2006. The final rate structure for comprehensive services was expected to be implemented July1, 2007, but delays in back the start date for the new rate structure to sometime have pushed implementation in 2008. The SLS waiver services is anticipated to be implemented in structure for final rate FY 2008-09. The change from a quasi-managed care to a fee-for-service services payment system and waiver will have short- for long-term fiscal implications forthe state. Forbudgeted over $1.8 million for one-time costs associated the state instance, in FY 2006-07, with the billing system implementation. In addition, in FY 2006-07, a General Fund expenditure of approximately $7.6 million was incurred to replace local funds that could no longer be accessed under the newFY 2006-07, the new billing system billing system. Finally, in resulted in a of funds for services for individuals with developmental expenditure one-time underdisabilities of approximately $29.8 million. This under-expenditure was due to decreased flexibilitywell as theto administercash system of accounting for funds, as of CCBs switch to a the Medicaid-funded waiver services. Accordingto the Joint Budget Committee staff, although thefiscal implicationsfor thestatearestill the state's control on overall waiver uncertain, under the new system, costsunder the former limited than will be far more quasi-managed care system.


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