Committee on Long-Term Care Services and Supports for Persons with Developmental Disabilities I.

Introductory Remarks: Over the past two years, the developmental disabilities services system, which is a very complex system, has undergone major changes that are unprecedented. And, more changes will be forthcoming. The purpose of this presentation is to share with you: A. B. C. II. Why systems change is necessary? What are the basic components of systems change? and The relevance of these changes to the HJR 1043 Committee.

Why is systems change necessary? A. Stated succinctly, to be in compliance with Medicaid regulations. In November 2005, the Centers for Medicare and Medicaid Services (CMS) conveyed in writing to Colorado’s Single State Medicaid Agency, the Colorado Department of Health Care Policy and Financing (CDHCP&F) that the following changes were needed for the Home and Community Based Services – Developmental Disabilities waiver (HCBS-DD) to be in compliance with Medicaid Regulations: 1. Break out the previously single bundled comprehensive services and corresponding rate. This evolved into the uniform rate setting methodology being developed; Account for all waiver expenditures via an Audit Trail for each individual enrolled and receiving services; Provide evidence that the Single State Medicaid Agency: a. b. Maintains administrative authority over its waivers; Has an effective quality management system to address incidents and other health and welfare issues; and Is knowledgeable of and accountable for all waiver expenditures.

2.

3.

c.

4.

Provide evidence that: a. Medicaid payments were for waiver services

1

actually provided to an eligible waiver recipient; b. A written Service Plan has been developed and delineates waiver and non-waiver services to be provided; The waiver cost per person must be broken out into unit cost and utilization components, both of which must be fully explained and documented; The cost component must include a cost per unit of service for each service rendered. The cost per unit must be reasonably estimated; and Ensure that there is an audit trail for all state and federal funds.

c.

d.

e.

B.

The CMS waiver review outcomes were consistent with and predicated upon CMS waiver protocols1. More specifically, as a condition of waiver approval, Colorado’s Single State Medicaid Agency is required to provide the following assurances: 1. 2. 3. 4. The health and welfare of waiver participants; Service Plans are responsive to waiver participant needs; Only qualified providers serve waiver participants; The state conducts level of care determinations consistent with the need for institutionalization; The Single State Medicaid Agency retains administrative authority over the waiver program; and The state provides fiscal accountability for the waiver.

5.

6. C.

In the spring of 2006, the CMS Waiver Steering Committee was created to develop a work plan to bring Colorado into compliance with Medicaid Regulations. Segue Consulting, The Human Services Research Institute and Navigant were retained by DDD to assist the state. The committee is also comprised of DDD’s constituency.

1

“HCFA Regional Office Protocol for Conducting Full Reviews of State Medicaid Home and CommunityBased Services Waiver Programs” (Version 1.2) December 20, 2000 (pp. 1-38). CMS now conducts HCBS waiver reviews in accordance with new procedures entitled: “CMS Interim Procedural Guidance for Conducting Quality Reviews of Home and Community-Based Services (HCBS) Waiver Programs, February 2007 revised.

2

III.

What are the basic components of systems change? A. Informed Choice: Providing information to consumers and their families that enables them to make informed choices about: 1. Whether they want to receive institutional services (i.e. ICF/MR) or HCBS services in the community; and Qualified Medicaid providers available within the state of Colorado who provide services and supports consistent with the needs of the individual as identified within his/her Service Plan.

2.

B.

Audit Trail: Provision of a clear audit trail that will be reviewed by CMS, CDHCP&F and DDD during field audits. The audit trail includes: 1. Eligibility Documentation: a. b. c. d. DD Eligibility Medicaid Eligibility Level Of Care: ULTC 100.2 Decision of the individual/guardian to choose waiver rather than institutional services (ICF/MR) and Notification of an individual’s right to a fair hearing.2

e. 2.

The Service Plan: a. The amount, scope and duration of services are to be based upon a comprehensive assessment of needs, services and supports (i.e. Supports Intensity Scale) of the individual; A uniform rate setting methodology is in place to justify rates for services to be provided; Documentation exists that information was provided to the individual and/or guardian identifying all qualified providers available from whom the individual/guardian can choose to provide services and supports, consistent with the Service Plan; and

b.

c.

2

CMS: “HCBS Waiver Application: Instructions, Technical Guide and Review Criteria” Version 3.4 (p. 203).

3

d.

The Service Plan must reflect the full range of a participant’s service needs and include both Medicaid and non-Medicaid services along with informal supports that are necessary to address those needs.3

3.

Prior Authorization of Waiver Services and Supports: Documentation is available to demonstrate that the need for Medicaid funded services and supports, as identified within the Service Plan, have been reviewed and approved by DDD prior to services being rendered.

4.

Service Billings: Documentation can be provided to show that service rendered by a qualified provider is consistent with dates and types of services delineated within the Service Plan.

C.

Portability of Waiver Resources: Individuals receiving waiver services can relocate within the state with his/her state/federal funded waiver resource. Transparency: Individuals/guardians are to be informed about and provided: (1) information about the type of Medicaid funded resource they have; (2) a listing of qualified Medicaid providers within the state; (3) a copy of their Supports Intensity Scale (SIS) evaluation; (4) an explanation, of how rates are determined and associated with support service needs identified; (5) an explanation about those services and supports identified within the Service Plan; (6) a copy of their Service Plan; and (7) a copy of the dispute resolution process. In addition, DDD’s constituency will have access to information posted on its website regarding the developmental disabilities services system as a result of the CMS Systems Change grant entitled: “Quality Assurance and Quality Improvement in Home and Community-Based Services for Colorado's Citizens with Developmental Disabilities”.

D.

E.

Mitigating Conflicts of Interest: The development and implementation of adequate firewalls to mitigate conflicts of interest of the CCB as the Single Entry Point, or the state as a provider of services (Regional Centers). Presently, DDD is awaiting a report with recommendations from the University of Southern Maine.

3

CMS: “HCBS Waiver Application: Instructions, Technical Guide and Review Criteria” Version 3.4. (p. 203).

4

F.

Uniform Rate Setting Methodology: The methodology for determining rates for services to be provided shall be uniform among all Medicaid providers within the state. Dispute Resolution Process: Providing individuals/guardians information about their rights to dispute resolution. Administrative Authority: Documentation that administrative authority of waiver services rests with the Single State Medicaid Agency (CDHCP&F).

G.

H.

IV.

The Relevance of Systems Change to the Mission of the HJR 1043 Committee: A. Transparency: The developmental disabilities services system is becoming more transparent as a result of: 1. 2. 3. The implementation of a uniform rate setting methodology; The implementation of an audit trail; Access to CCB/provider information on DDD’s website (e.g. listing of Medicaid providers; Quality Assurance reviews, annual financial audits); and Provision of information to individuals and families as profiled in section III-D (Items 1 through 7).

4.

B.

Reliability: Consistency among the twenty Community Centered Boards will be enhanced as a result of: 1. A uniform Service Plan being used throughout the system for all waiver services, effective August 1, 2007; Uniform rate setting methodology; Incorporating the components of systems change into QA/QI reviews of the provider community; and Implementation of a three-way contract that reflects the components of systems change.

2. 3.

4.

C.

Efficiency: The developmental disabilities services system has been operating its programs of services and supports in an efficient manner when you consider the following:

5

1.

For FY 2005-06, 8% of CCBs expenditures, on average, is for administrative overhead; Some CCBs are utilizing local funds to serve more individuals because of the lack of sufficient Medicaid/state funded resources; CCBs have used bonds to cover their capital improvement expenditures; and Colorado’s per capita expenditure for services and supports is 44th among the fifty states.4

2.

3.

4.

D.

Accountability: Systemic/provider accountability has been one of the strengths of Colorado’s developmental disabilities services system considering that: 1. Annual, independent fiscal audits of each of the twenty CCBs are conducted; Quality Assurance reviews by DDD of all CCBs and providers are conducted; Annual, confidential satisfaction surveys are conducted by the CCBs. Some of the CCBs contract this responsibility out to qualified, uninvolved entities to enhance responses from individuals/families as well as to ensure confidentiality; Program and fiscal audit reviews are conducted at least every five years by Region 8 of the Centers for Medicare and Medicaid Services; The Department of Health Care Policy & Financing provides oversight of DDD program administration; Program audits are conducted by the Colorado Department of Public Health and Environment of all ICFs and Group Homes; The establishment and utilization of Human Rights Committees are required of every CCB; and Audit reviews of DDD are conducted by Colorado’s State Auditor’s Office.

2.

3.

4.

5.

6.

7.

8.

4

Rizzolo, M.C.,Hemp, R., Braddock, D., & Pomeranz-Essley, A. (2004). The state of the states in developmental disabilities: 2004. Boulder, CO: University of Colorado, Coleman Institute for Cognitive Disabilities and Department of Psychiatry (Table 17/p. 52).

6

Note: This aspect of the service delivery system will be further enhanced as a result of implementing an audit trail as described in section III-B; E. Innovation: DDD is reviewing the following enhancements to services and supports for individuals enrolled or eligible and awaiting services: 1. Expanding the utilization of families as a viable resource within the developmental disabilities services system: a. Amending waiver services to allow individuals to remain in the same household with their families when receiving HCBS-DD waiver services; and Paying qualified family members for the delivery of specifically defined waiver services.

b.

2.

Fulfilling the recommendations of the Self-Advocate Advisory Committee that would enable self-advocates to direct their own services consistent with the provisions of Consumer Directed Attendant Support Services. Exploring the development of a Public/Private Trust; and Exploring and determining a threshold level in which the attrition rate of resources can equal the annual number of new referrals.

3. 4.

F.

Waiting List Elimination and Funding Options:5 1. The total appropriation for Developmental Disabilities Programs in FY 2007-08 is over $400 million.6 From FY 2004-05 to FY 2005-06, the appropriation for Developmental Disabilities increased by $20 million or 6 percent. From FY 2005-06 to FY 2006-07, the appropriation for Developmental Disabilities increased by $34 million or 9.5 percent.

2.

3.

5

Quarterly Management Report for March 2007, Division for Developmental Disabilities; cost per person is a simple average derived from the total number of persons to be served with state and waiver funds, divided by the total funds requested per program, Senate Bill 07-239, Page 97. The waiting list refers to As Soon As Available (ASAA) and does not reflect total need for those on the safety net. Sentate Bill 07-239 (p. 97).

6

7

4.

Despite these increases in funding the waiting list and demand for services continues to grow. a. From June 1, 2003 to December 1, 2006 DDD received a 2.9% increase in appropriated resources for adults whereas the waiting list for these services increased by 61.1%; and During this same period, DDD received a 37.7% increase in appropriated resources for children and family support services whereas the waiting list for these services increased by 51.4%. 7

b.

5.

The following chart profiles the current waiting for waiver services and their associated costs. The waiting list refers to As Soon As Available (ASAA) and does not reflect total need for those on the safety net.8
Number of Persons on Wait List Cost per service per person Total Medicaid Cash Funds needed to eliminate the current wait list Total General Funds needed to eliminate current wait list $38,657,952 $15,029,231 $ 1,482,485 $55,169,668

Program

HCBS-DD Comprehensive HCBS-SLS HCBS-CES TOTAL

1,212 2,038 163

$63,792 $14,749 $18,190

$77,315,904 $30,058,462 $2,964,970 $110,339,336

V.

Concluding Remarks: A. The CMS audit reviews resulted in each of the three waivers being renewed for the maximum period of five years. 1. Had there been a concern relating to the health and safety, quality of care and services/supports provided to individuals enrolled and receiving services, one or more of the following would have occurred: a. b. Recovery of reimbursements; The waivers would not have been renewed, or the approval period would have been less than five years; or

7 8

CDHS Strategic Plan for FY 08-09 Draft (p. 72). 2008 Long Bill (p. 97).

8

c.

The waivers would have been frozen. That is, Colorado would have been prevented from expanding its waivers up to the cap amount.

2.

None of the above occurred, which is a credit to Colorado and its CCB/provider community. The CMS survey of April 26, 2004 stated the following: “During the on-site portion of the review, we met many individuals whose lives have been enhanced by services and care provided by a number of dedicated and qualified caregivers.” In addition, CMS noted “there has been a marked commitment to the quality of services and needs of the constituency of Colorado’s developmental disabilities service system”.

B.

The number of complaints received and substantiated, compared to the total number of individuals enrolled and receiving services, is extremely small. As a result of systems change, the real issue to be addressed is less about accountability, efficiency or transparency. Rather, it’s about addressing the proverbial “elephant in the room”. It’s my understanding that: 1. 2. Colorado is among the least taxed among the fifty states; Colorado is among the wealthiest of states in terms of per capita income of its citizenry; Colorado is among the top ten states in formal degrees attained by its citizenry; and Yet, in spite of all these wonderful accolades, the reality is that Colorado ranks 44th in per capita expenditures for its most vulnerable citizens!

C.

3.

4.

Unless the 1043 Committee can develop a strategy that will generate needed resources while at the same time meet the provisions of TABOR, I’m concerned that your good work will fall short of its mission. Thank you. Respectfully,

Fred L. DeCrescentis, Director Division for Developmental Disabilities July 18, 2007

9

10