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H C B S P R O V I D E R F E E D E V E L O P M E N T CONSIDERATIONS STATE-SPECIFIC WAGE DATA FROM THE...
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HEALTH WEALTH CAREER HCBS PROVIDER FEE DEVELOPMENT MARKET-BASED APPROACH August 30, 2016 Presenters Deidra Abbott, MPA Misti Beckman Robert Karsten, ASA, MAAA Mercer Government Human Services Consulting Atlanta, Minneapolis, Phoenix and Washington, DC
Transcript of H C B S P R O V I D E R F E E D E V E L O P M E N T CONSIDERATIONS STATE-SPECIFIC WAGE DATA FROM THE...
H E A L T H W E A L T H C A R E E R
H C B S P R O V I D E R F E E D E V E L O P M E N T
M A R K E T - B A S E D A P P R O A C H
August 30, 2016
Presenters
Deidra Abbott, MPA
Misti Beckman
Robert Karsten, ASA, MAAA
Mercer Government Human Services Consulting
Atlanta, Minneapolis, Phoenix and Washington, DC
© 2016 MERCER LLC 2
Describe the fee/rate methodologies used for each service
Describe additional factors considered in arriving at the final rate, such as cost of living, inflation factor, difficulty of care, acuity determination, etc.
Indicate the basis of variation when rates vary for different providers
Describe how geographical fees are developed and what factors are considered to account for wage differences across the state
If there is a schedule for annual cost of living increase for the rates, describe how it is determined and provide it
Describe how comments from providers participating in forums are used in the rate-setting process
1 9 1 5 ( C ) H C B S W A I V E R S U B M I S S I O N A N D R E V I E W
Specific to Appendix I-2a, have you been faced with these questions in response
to your 1915(c) waiver amendment or renewal?
© 2016 MERCER LLC 3
1 9 1 5 ( C ) H C B S W A I V E R S U B M I S S I O N A N D R E V I E W
© 2016 MERCER LLC 4
1915(C) HCBS WAIVER RENEWAL
AND/OR AMENDMENT SUBMISSIONS
ONGOING
MORE RIGOROUS
REVIEW PROCESS
GUIDANCE CONTINUES TO EVOLVE
PRESENTS CHALLENGES FOR STATES
IMPACTS WAIVER
APPROVAL PROCESS
1 9 1 5 ( C ) H C B S W A I V E R S U B M I S S I O N A N D R E V I E W
© 2016 MERCER LLC 5
S E S S I O N O B J E C T I V E S
OVERVIEW MARKET-
BASED HCBS FEE
SCHEDULE
DEVELOPMENT
PROCESS
COVER WHO, WHAT,
WHEN, WHERE, WHY
AND HOW
RECOGNIZE CURRENT ENVIRONMENT
IDENTIFY AND CLARIFY TERMINOLOGY
DISCUSS ALLOWABLE FEE DEVELOPMENT
METHODS
IDENTIFY KEY COMPONENTS OF PROCESS
DISCUSS DATA SOURCES
SHARE LESSONS LEARNED
HOW WE WILL
GET THERE
© 2016 MERCER LLC 6
Y O U R S P E A K E R S
Misti Beckman
Partner
• Misti has been with Mercer for more
than fifteen years, assisting states in
program design and implementation,
fee-for-service and capitated
managed care rate development
processes, administrative design,
program monitoring and stakeholder
engagement.
• Almost 20 years of health care
experience focused on HCBS and
MH/BH initiatives.
• Directs consulting teams on a variety
of state Medicaid programs, working
with the state to develop options and
models that best meets their needs.
Robert Karsten, ASA, MAAA
Senior Associate
• Bob has been with Mercer for
almost five years, assisting states in
program design and implementation,
fee-for-service and capitated
managed care rate development
processes and stakeholder
engagement.
• Provides actuarial consulting for a
variety of state Medicaid programs
and partners with the state in
developing payment solutions that
best meets their needs.
• Specializes in MLTSS and HCBS
initiatives.
Deidra Abbott, MPH
Principal
• Deidra has been with Mercer for
almost five years, working on a
wide range of issues including
program design and
implementation, health plan
readiness reviews, program
monitoring, health plan
contracting and stakeholder
engagement.
• Over 28 years of experience in
MLTSS and HCBS initiatives,
• Former CMS Technical Director
for Home and Community-Based
Services Waivers.
© MERCER 2016 7
M E R C E R G H S C S O L U T I O N S
CLINICAL / BEHAVIORAL
HEALTH
PROGRAM DESIGN, POLICY
PROCUREMENT,
IMPLEMENTATION AND
EVALUATION
PHARMACY
DESIGNING AND
IMPLEMENTING EFFECTIVE
PHARMACY MANAGEMENT
PROGRAMS
ACTUARIAL
DEVELOPING, REVIEWING AND
SETTING RATES, FINANCIAL
AND ACTUARIAL ANALYSES
INFORMATICS
INTERPRETATION AND EVALUATION
CLAIMS AND ENCOUNTER DATA, ANALYSIS
AND ENHANCEMENT
POLICY & OPERATIONS
STRATEGIZE AND NAVIGATE FEDERAL
RULES TO ACCOMPLISH POLICY,
FINANCIAL AND OPERATIONAL GOALS
Our holistic approach provides a unique perspective and creative solutions for our clients
M E R C E R G H S C C L I E N T S
Massachusetts
Connecticut
New Jersey
Delaware
DC
California
Oregon
Washington
Montana
Arizona
Pennsylvania
North Carolina
South Carolina
Georgia
Florida
Puerto Rico Virgin Islands
Colorado Kansas
New Mexico
Texas
Missouri
Wisconsin
Ohio
Louisiana
Idaho
Oklahoma
www.mercer-government.mercer.com
Mississippi
Nebraska
Virginia
Utah
LEGEND
Actuarial/Financial Long-term services and support
Clinical/Behavioral Policy
Pharmacy Other
Informatics Blue States — Current client
HR/Uninsured Green States — Past client
New
York
Minnesota
© 2016 MERCER LLC 9
I N T E R E S T E D I N T H I S T O P I C — W H O ? W H Y ?
STATES LOOKING TO
NAVIGATE 1915(C)
HCBS WAIVER
SUBMISSION PROCESS
STATES LOOKING TO
ALIGN PAYMENT WITH
PROGRAMMATIC
OUTCOMES
PROVIDERS LOOKING
TO GROW, EXPAND,
EVOLVE THEIR
BUSINESS
INDIVIDUALS AND
FAMILIES DESIRING
FLEXIBILITY AND
ACCESS TO NEEDED
SERVICES
© 2016 MERCER LLC 10
“RATE METHODOLOGY IN A
FFS HCBS STRUCTURE,
FEBRUARY 2016”
PRESENTED IN MARCH 2016
“FEE SCHEDULE HCBS
RATE SETTING”
PRESENTED IN JULY 2016
C M S C O M M U N I C A T I O N S A N D T R A I N I N G
ALLOWABLE RATE SETTING
METHODOLOGIES PRESENTED
EXPECTATIONS OUTLINED FOR
1915(C) APPENDIX I-2A
EXPECTATION THAT FEE SCHEDULES
BE UPDATED EACH WAIVER RENEWAL
EXPECTATION THAT CRITERIA BE
DEVELOPED THAT ALLOWS FOR AN
ANNUAL REVIEW OF THE FEES
HCBS RATE SETTING IS
EVOLVING IN 2016
KEY TAKEAWAYS
© 2016 MERCER LLC 11
T E R M I N O L O G Y
FEE SCHEDULE
NEGOTIATED MARKET PRICE
TIERED RATES
BUNDLED RATES
COST RECONCILIATION
OUTCOMES-BASED PAYMENTS
MILESTONE-BASED PAYMENTS
SALARY/WAGES
EMPLOYEE RELATED EXPENSE/BENEFITS
PRODUCT COSTS
GEOGRAPHIC CONSIDERATIONS
FULL-TIME VERSUS PART-TIME STAFF
EFFICIENCY, ECONOMY & QUALITY OF CARE
PROSPECTIVE
RETROSPECTIVE
ACUITY AND LEVEL OF CARE
BASE DATA
DIRECT CARE STAFF, DIRECT CARE HOURS
NON-DIRECT (INDIRECT) CARE STAFF, HOURS
ADMINISTRATIVE, OVERHEAD AND OPERATIONAL
EXPENSES
STAFFING RATIOS
COST OF LIVING
ASSESSMENT TOOLS
© 2016 MERCER LLC 12
C M S R A T E - S E T T I N G M E T H O D S
• Fee Schedule
• Tiered Rates
• Cost Reconciliation
• Negotiated Market Price
• Bundled Rates
• Outcomes/Milestone – Based Payments
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F E E S C H E D U L E D E V E L O P M E N T
M A R K E T - B A S E D M E T H O D O L O G Y
FEES ARE BUILT USING
ASSUMPTIONS THAT ARE REASONABLE AND NECESSARY
TO DELIVER A SERVICE
FEES VARY BY INDIVIDUAL
CHARACTERISTICS SUCH AS
GEOGRAPHY
FEE SCHEDULE MUST SUPPORT
AND ALIGN MULTIPLE GOALS
ACROSS ALL STAKEHOLDERS
FEES UNDER A TIERED METHOD
MAY ALSO VARY BY A PERSON’S
SUPPORT NEEDS
AN INTRODUCTION
© 2016 MERCER LLC 14
F E E S C H E D U L E D E V E L O P M E N T
M A R K E T - B A S E D M E T H O D O L O G Y
Service
Specification
Applicable
Cost
Components
Data
Collection and
Cost
Assumption
Development
Fee Structure & Modeling
© 2016 MERCER LLC 15
F E E S C H E D U L E D E V E L O P M E N T
M A R K E T - B A S E D M E T H O D O L O G Y
SCOPE OF SERVICE
UNIT OF SERVICE
PROVIDER QUALIFICATIONS
LICENSING REQUIREMENTS
REGULATORY REQUIREMENTS
PROVIDER TYPES
STAFFING REQUIREMENTS
SITE-BASED OR MOBILE
OCCUPANCY REQUIREMENTS
SERVICE SPECIFICATION
© 2016 MERCER LLC 16
F E E S C H E D U L E D E V E L O P M E N T
M A R K E T - B A S E D M E T H O D O L O G Y
© 2016 MERCER LLC 17
F E E S C H E D U L E D E V E L O P M E N T
M A R K E T - B A S E D M E T H O D O L O G Y
© 2016 MERCER LLC 18
F E E S C H E D U L E D E V E L O P M E N T
M A R K E T - B A S E D M E T H O D O L O G Y
COSTS NEED TO BE
REASONABLE, NECESSARY
AND RELATED TO THE
DELIVERY OF THE SERVICE,
AS DEFINED IN THE
WAIVERS AND
REGULATIONS
COST COMPONENTS SHOULD
REFLECT THE VISION FOR
SERVICE DELIVERY AND
DESIRED OUTCOMES FOR
INDIVIDUALS IN THE
PROGRAM APPLICABLE COST
COMPONENTS
PRODUCTIVITY
NON-DIRECT EXPENSES
NON-BENEFIT EXPENSES
DIRECT EXPENSES
© 2016 MERCER LLC 19
A P P L I C A B L E C O S T C O M P O N E N T S
D I R E C T E X P E N S E S
DIRECT EXPENSES
WHO WILL WORK DIRECTLY WITH THE
WAIVER PARTICIPANT
DELIVERING THE SERVICE?
WHAT SKILLS, QUALIFICATIONS
ARE REQUIRED OF THE DIRECT CARE
WORKER(S)?
WHAT BENEFITS WILL BE AVAILABLE
TO THE DIRECT CARE WORKER AND
PAID BY THE PROVIDER?
WHAT WILL DIRECT CARE WORKERS BE
PAID BY THE PROVIDER?
© 2016 MERCER LLC 20
A P P L I C A B L E C O S T C O M P O N E N T S
N O N - D I R E C T E X P E N S E S & P R O D U C T I V I T Y
NON-DIRECT
EXPENSES
WHAT PROGRAM SUPPLIES, IF ANY, ARE NEEDED TO
PROVIDE THE SERVICE?
WHO WILL SUPPORT THE DIRECT CARE
WORKERS?
WHAT SKILLS ARE REQUIRED?
WHAT TRAINING IS REQUIRED TO PROVIDE THE
SERVICE?
WHAT PORTION OF THE STAFF ARE
FULL-TIME VERSUS PART-TIME?
© 2016 MERCER LLC 21
A P P L I C A B L E C O S T C O M P O N E N T S
N O N - B E N E F I T E X P E N S E S
NON-BENEFIT
EXPENSES
WILL A COLA BE APPLIED?
WHAT LEVEL OF ADMINISTRATIVE STAFF COSTS AND OVERHEAD ALLOCATIONS SHOULD
BE INCLUDED?
IS TRANSPORTATION REQUIRED?
ARE THERE GEOGRAPHICAL
DIFFERENCES TO CONSIDER?
ARE THERE ANY OCCUPANCY COSTS
RELATED TO THIS SERVICE?
© 2016 MERCER LLC 22
ASSUMPTIONS NEED TO BE
DEVELOPED TO “PRICE” EACH COST
COMPONENT
MARKET-BASED RESEARCH IS
COMPILED AND DATA ANALYSIS
PERFORMED TO DETERMINE
REASONABLE EXPENSES FOR EACH
COST COMPONENT
MARKET-BASED RESEARCH AND
ANALYSIS MAY ALSO BE USED TO
DEVELOP ASSUMPTIONS FOR
OTHER COST COMPONENTS SUCH
AS STAFF TRAINING AND COST OF
LIVING CONSIDERATIONS
STATE-SPECIFIC WAGE DATA FROM
THE US BUREAU OF LABOR
STATISTICS MAY BE USED TO
DEVELOP WAGE RANGES FOR
DIRECT CARE AND OTHER
PROGRAM STAFF BY SERVICE
MARKET RESEARCH DATA, ALONG
WITH STATE AND FEDERAL
REQUIREMENTS, MAY BE USED TO
ESTABLISH ASSUMPTIONS FOR
EMPLOYER-PAID BENEFITS AND
TAXES
D A T A C O L L E C T I O N A N D C O S T A S S U M P T I O N
D E V E L O P M E N T
EXAMPLES
© 2016 MERCER LLC 23
D A T A C O L L E C T I O N A N D C O S T A S S U M P T I O N
D E V E L O P M E N T
• State experience may be utilized to establish assumptions in these instances
• Provider surveys may be conducted to inform cost assumptions
Market data may not be available for other
components
• DOL ruling on application of FLSA to domestic care workers
• DOL proposed Threshold rule regarding exempt employee salary requirements
• Recent CMS guidance and training regarding the fee development process
Federal considerations of
regulatory and policy changes on the
development of the fees may be necessary
© 2016 MERCER LLC 24
F E E S T R U C T U R E & M O D E L I N G
Fee Structure Considerations
Provider Type
Staffing Ratio
Other Participant’s
Assessed Needs
Size of Home
© 2016 MERCER LLC 25
S E R V I C E C O M P O N E N T C O M P A R I S O N
Service
Where is it delivered?
What is the unit(s) of service?
Who delivers the service?
When is it available?
Occupancy costs
Companion
In-home or community
15 min., hour
Direct care worker (DC) (1:1)
8 hours/day or weekly limit
None/limited
Day Activity
Facility or community
15 min., half day
DC (staffing ratios) and non-DC
4–8 hours/day or weekly limit
Facility-based/ licensure requirements
Res Hab
Provider-owned setting
Per diem (24 hours)
DC and non-DC (staff time and staffing ratios
24 hours, on call
Licensing requirements, but room and board must be excluded
DAY ACTIV IT Y RE S IDE NTI AL
HABIL ITATI ON COM PANION S E RV ICE
© 2016 MERCER LLC 26
L E S S O N S L E A R N E D
Fee schedule development is more than a financial exercise; involves state program, policy and fiscal staff
Fee schedule development may lead to service specification revisions
The state will select the assumptions they believe are most reflective of service delivery expectations
A fee schedule should reflect a reasonable total cost of service delivery. Every assumption used to develop the fee will not align exactly for any one provider
States will need to consider engagement with CMS and other stakeholders throughout the process
© MERCER 2016 27
(C) MERCER 2015 27
QUESTIONS
© 2016 MERCER LLC 28
C O N T A C T S
• Deidra Abbott, Principal
• Misti Beckman, Partner
• Bob Karsten, Senior Associate
Services provided by Mercer Health & Benefits LLC.
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