Proposed Changes to Rates & Update on the Transition Plan Home & Community Based Services Waiver for...

Proposed Changes to Rates& Update on the Transition Plan

Home & Community Based Services Waiver for People with Intellectual & Developmental

Disabilities September 17, 2015

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Goals for Today

Discuss proposed amendments to rate methodologies for certain services.

Gather your feedback on our proposed waiver amendments. (All comments will be entered into the public record.)

Provide an update on our progress on our Transition Plan.

RATES

• DDS submitted proposed waiver amendments to CMS in February 2015 and received a series of questions about how the rates were developed.

• This resulted in our undertaking a full review of the rate methodology and proposing certain changes.

Updated Indirect Cost CalculationsWaiver Service Current Rate Proposed Rate

(2/2015)New Proposed Rate

Individualized Day Supports (IDS)(1:2 ratio)

$6.11/ 15 min $5.32/ 15 min $5.31/ 15 min

IDS (1:1 ratio) New Service $9.32/15 min $9.40/ 15 min

Respite $5.19/ 15 min $5.19/ 15 min $5.13/ 15 minutes

Supported Employment Paraprofessional

$6.33/ 15 min $7.22/ 15 min $7.14/ 15 min

Supported Employment Professional

$10.67 $11.93/ 15 min $11.86/ 15 min

Hourly Rate Methods Components

IDS Indirect Calculation

Mgr 75 hours $2,478.06

QIDP 30 hours $1,400.95

RN delegation 20 hours $1,089.46

Training 30 hours $1,208.89

Sub-total $6177.362Program transportation staff/person 8 per trip times 125 days $2000

Program supplies and activities $2500

Total $10677.362

Annual Billable cost per DSP $49,318.67

Indirect Percentage 22%

Respite Indirect Calculation

QIDP 5 hours $233.49

RN delegation 7 hours $381.31

Training 20 hours $805.92

Sub-total $2,577.16 Transportation $8 per trip times 47 trips to one location $376.00

Program supplies and activities $300.00

Total $3,253.16

Annual Billable cost per DSP $34,632.00

Indirect Percentage 9%

Supported Employment Para Indirect Calculation

Mgr 52 hours $1,718.12

QIDP 20 hours $933.97


Training 20 hours $805.92 Sub-total $4111.6921.25 trips per day $2500Program supplies job prep $2200total $8811.692

Annual Billable cost per DSP $43,784.00 Indirect Percentage 20%

Supported Employment Prof Indirect Calculation

Mgr 52 hours $1,718.12

QIDP 30 hours $1,400.95


Training 30 hours $1,208.89 Sub-total $4872.69162 trips per day $4000Program supplies job prep $2500Total $11372.6916

Annual Billable cost per DSP $75,924.99 Indirect Percentage 15%

Supported Living with Transportation (Periodic)

• Rate increased to reflect the increases in costs associated with the time spent transporting the person to different locations for day and vocational services.

Waiver Service Current Rate Proposed Rate(2/2015)

New Proposed Rate

Supported Living with Transportation

$6.61/ 15 min $6.61/ 15 min $6.75/ 15 min

Day Services - # Program Days

• Reduces the number of program days to 249/ year to reflect 11 holidays.


New Proposed Rate

Day Habilitation $3.80/ 15 min $5.57/ 15 min $5.43/ 15 min

Day Habilitation 1:1

$6.77/ 15 min $10.45/ 15 min $10.28/ 15 min

Employment Readiness

$3.80/ 15 min $4.90/ 15 min $4.68/ 15 min

Small Group Day Habilitation

New Service $9.22/ 15 min $8.20/ 15 min

Rate Modifier - Meals

• Meal for people who live independently or with family and attend Day Habilitation, Small Group Day Habilitation, or Individualized Day Supports:

– $7.30/ meal, plus– $5.00 for meal delivery to a Day

Habilitation or Small Group Day Habilitation setting.

Companion

• Match the rate for Personal Care Services

• Add a group rate for 1:2 or 1:3Waiver Service Current Rate Proposed Rate

(2/2015)New Proposed Rate

Companion 1:1 New Service $4.72/ 15 min $4.72/ 15 min

Companion group

New Service New Service $2.91/ 15 min

Creative Arts Therapies

• Change in group rate (not to exceed 1:4) by $.01


New Proposed Rate

Creative Arts Therapy Group

New Service $25.00/45 min $24.99/ 45 min

Group Supported Employment

• Add a rate for Group Supported Employment Paraprofessional Individual Services: $2.85 / 15 minutes.

Comparison of ICF and Waiver Rate Components

ICF/IDD FY 16

StaffingFY 15

MBILW Rate

DSP -1 $13.87 $14.07 $14.08DSP -2 $13.87 $14.07 $14.08DSP-3 $13.87 $14.07 $14.08CNA $17.39 $17.63 $17.65LPN $21.70 $22.00 $22.02RN $34.77 $35.26 $35.28

QMRP $29.81 $30.22 $30.24Hse Manager $22.35 $22.67 $22.68

current 1.47% New/2015

DSP 13.60 13.80

LPN 22.850.336029 23.19

RN 36.610.538382 37.15

QIDP 31.380.461471 31.84

Hse Manager 23.530.346029 23.88

DD Waiver Originally Proposed

HCBS IDD Waiver Transition Plan

• Review of the HCBS Settings Rule• Update on Self-Assessments• Initial Remediation• Submissions for Heightened Scrutiny• Next Steps

HCBS Settings Rule• Title: Medicaid Program; State Plan Home

and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act) or “The Settings Rule”

• Published in the Federal Register on 01/16/2014

• Effective March 17, 2014• www.hcbsadvocacy.org 18

http://www.hcbsadvocacy.org/

HCBS Settings RequirementsThe Home and Community-Based setting:

• Is integrated in and supports access to the greater community

• Provides opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources

• Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid home and community-based services


• Is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting

– Person-centered service plans document the options based on the individual’s needs, preferences; and for residential settings, the individual’s resources


• Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint

• Optimizes individual initiative, autonomy, and independence in making life choices

• Facilitates individual choice regarding services and supports, and who provides them

HCBS Settings RequirementsProvider Owned and Controlled Settings – Additional Requirements • Specific unit/dwelling is owned, rented, or occupied under legally enforceable agreement • Same responsibilities/protections from eviction as all tenants under landlord tenant law of state, county, city or other designated entity • If tenant laws do not apply, state ensures lease, residency agreement or other written agreement is in place providing protections to address eviction processes and appeals comparable to those provided under the jurisdiction’s landlord tenant law

HCBS Settings RequirementsProvider Owned and Controlled Settings – Additional Requirements

• Each person has privacy in their sleeping or living unit • Units have lockable entrance doors, with appropriate staff having keys to doors as needed • People sharing units have a choice of roommates • People have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement


• People have freedom and support to control their schedules and activities and have access to food any time • People may have visitors at any time • Setting is physically accessible to the person


• Modifications of the additional requirements must be:

– Supported by specific assessed need – Justified in the person-centered service plan – Documented in the person-centered service plan

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Settings That Are PresumedNot HCBS

• Settings in a publicly or privately-owned facility providing inpatient treatment.

• Settings on grounds of, or adjacent to, a public institution.

• Settings with the effect of isolating individuals from the broader community of individuals not receiving Medicaid HCBS.

Settings That Tend to Isolate

CMS Examples:

• The setting is designed specifically for people with disabilities, and often even for people with a certain type of disability.

• The people in the setting are primarily or exclusively people with disabilities and on-site staff provides many services to them.

Settings That Tend to Isolate

• The setting is designed to provide people with disabilities multiple types of services and activities on-site, including housing, day services, medical, behavioral and therapeutic services, and/or social and recreational activities.

• People in the setting have limited, if any, interaction with the broader community.

To Overcome the PresumptionThe State must submit the settings to CMS for Heightened Scrutiny review and present evidence that:• The setting is integrated in the community to the extent

that a person or persons without disabilities in the same community would consider it a part of their community and would not associate the setting with the provision of services to persons with disabilities.

• The individual participates regularly in typical community life activities outside of the setting to the extent the individual desires. Such activities do not include only those organized by the provider agency specifically for a group of individuals with disabilities and/or involving only paid staff; community activities should foster relationships with community members unaffiliated with the setting.

• Services to the individual, and activities in which the individual participates, are engaged with the broader community.

HCBS Waiver Transition Plan

• All states were required to develop an HCBS transition plan, that provides a comprehensive assessment of potential gaps in compliance with the new regulation, as well as strategies, timelines, and milestones for becoming compliant with the rule’s requirements by March 2019.

• DDS submitted its Statewide Transition Plan on March 17, 2015 and worked with stakeholders on our state self-assessment.

• Providers conducted self-assessments and are writing transition plans for their own organizations.

• Transition Plans are due September 21, 2015

• Service coordinators are be talking to people who receives HCBS services about their experiences to inform our assessment.

• Ongoing

State Self-Assessment

• Work with HCBS Settings Advisory Group to review and make recommendations for remediation, where needed, on:

• All HCBS waiver service definitions and provider requirements.

• All regulations governing HCBS. • DDS/DDA Provider Certification Review (PCR)

process. • DOH licensing requirements and regulations. • All relevant DDS/DDA policies, procedures, and

protocols, including Quality Management practices and tools.

• Provider training requirements. • Human Care Agreements and rate methodologies. • Information systems.

Draft Changes to General Provisions • 1938 HOME AND COMMUNITY BASED SETTING

REQUIREMENTS

1938.1 All Supported Living, Supported Living with Transportation, Host Home, Respite Daily, Residential Habilitation, Day Habilitation, Small Group Day Habilitation, Individualized Day Supports, Supported Employment, Small Group Supported Employment and Employment Readiness settings must: • be chosen by the person;• ensure people’s right to privacy, dignity, and respect, and freedom

from coercion and restraint;• be physically accessible to the person and allow the person access

to all common areas; • support the person’s community integration and inclusion,

including relationship-building and maintenance, support for self-determination and self-advocacy, and opportunities for employment and meaningful non-work activities in the community;

• provide information on individual rights; and• allow visitors at any time, with any exception based on the

person’s assessed need and justified in his or her person-centered plan.

Draft Changes to General Provisions

1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS

1938.2 All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must:

• Be integrated in the community and support access to the greater community;

• Provide opportunities for the person to engage in community life;

• Allow full access to the greater community;

• Be leased in the names of the people who are being supported. If this is not possible, then the provider must ensure that each person has a legally enforceable residency agreement or other written agreement that, at a minimum, provides the same responsibilities and protections from eviction that tenants have under relevant landlord/tenant law. This applies equally to leased and provider owned properties.

Draft Changes to General Provisions1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS

1938.2(e) All Supported Living, Supported Living with Transportation, Host Home, Residential Habilitation, and Respite Daily, settings must:

• Develop and adhere to policies which ensure that each person receiving services has the right to the following:

• Privacy in his or her personal space, including entrances that are lockable by the person (with staff having keys as needed);

• Freedom to furnish and decorate his or her personal space (with the exception of Respite Daily);

• Control over his or her personal funds and bank accounts;

• Privacy for telephone calls, texts and/or emails; and

• Access to food at any time.


1938 HOME AND COMMUNITY BASED SETTING REQUIREMENTS

1938.3 Any deviations from the requirements in § 1938.2(e) must be supported by a specific assessed need, justified in the person’s person-centered Individualized Support Plan, and reviewed and approved as a restriction by the Provider’s Human Rights Committee.

Draft Changes to General Provisions 1911 INDIVIDUAL RIGHTS (New Additions)

Each Waiver provider shall develop and adhere to policies which ensure that each person receiving services has the right to the following: • Be informed orally and in writing of the following:

• Complaint and referral procedures including how to file an anonymous complaint;

• How to report an allegation of abuse, neglect and

exploitation;

• For people receiving residential supports, the person’s rights as a tenant, and information about how to relocate and request new housing.


Provider Requirements (1904.4)

• Complete mandatory training in Person-Centered Thinking, Supported Decision-Making, Supporting Community Integration, and any other topics as determined by DDS.

• Develop and implement a continuous quality assurance and improvement system, that includes person-centered thinking, community integration, and compliance with the HCBS Settings Rule, to evaluate the effectiveness of services provided.


1907 INDIVIDUAL SUPPORT PLAN (ISP) (Changes)

• The ISP is the plan that identifies the supports and services to be provided to the person and the evaluation of the person’s progress on an on-going basis to assure that the person’s needs and desired outcomes are being met, based on what is important to and for the person, specifically including identifying the person’s interest in employment, identifying goals for community integration and inclusion, and determining the most integrated setting available to meet the person’s needs.

• The ISP shall be developed by the person and his or her support team using Person-Centered Thinking and Discovery tools and skills.

Draft Changes to Day/ Voc Regs

• Ban payment of stipends for attendance or participation at day or vocational programs.

• Require development of PPP & JS/CPPP.

• Emphasis on community integration.

• Day Habilitation must include activities to support community integration and inclusion. These must occur in the community in groups not to exceed 4 participants and must be based on people’s interests and preferences as reflected in their Individualized Support Plan and Person-Centered Thinking and Discovery tools.

• Employment Readiness must include community-based employment preparation experiences that are related to the person’s employment goals.

Provider Self-Assessments

CMS Recommended Assessment Question

# Indicator Prevalence in Provider Setting (Select 1-6, above )

Provide name and hyperlink, if available, for specific evidence of compliance. If no specific evidence is available, please indicate that.

Comments & Feedback: Please use this section to help us identify systemic support and barriers to achieving compliance with the HCBS Settings Rule; areas in which training, technical assistance and capacity building would be helpful; explanations, if needed, of your self-assessment score; etc.

(a) The home ensures a person’s rights of privacy, dignity, respect and freedom from coercion and restraint.

The following PCR question(s) may be helpful in responding to this section: CQ.2- Is the person’s right to privacy acknowledged and practiced? (for 1 & 4 below) CQ.3 – Is the person and/or their representative aware of actions they can take if they feel they have been treated unfairly, have concerns or are

displeased with the services being provided? (for 2 below) CQ.25 – Is the person and/or their representative able to communicate and/or demonstrate their rights as a consumer of waiver services? ( for 2 below) OO.CQ.20- Does the provider ensure proper handling of all consumer records including security, confidentiality, and retention in accordance with DDS

and federal policies (for 3 below)

1 People are provided personal care assistance in private, as appropriate.

2 Information is provided to people on how to make an anonymous complaint.

3 People’s health and other personal information (e.g., mealtime protocols, therapy schedules) are kept private.

Personal Experience Assessments

Provider Transition Plans

• Any issues identified during the self assessment; and

• Continuous quality improvement plan to: – advance rights and choice; – support people to build and maintain

relationships with and without people with disabilities;

– fully engage in self-determination and supported decision-making;

– work in competitive, integrated employment or engage in community-based, integrated retirement activities;

– participate in a variety of community activities based upon their interests; etc.

Provider Transition Plans

Type of Setting

Issue # of Sites Remedial Strategy

Lead Unit Target Date

Ongoing Monitoring

Residential Habilitation

Access to Visitors

10 Issue policy

Operations 11/1/2015 Quarterly review of visitor logs and interviews with people who receive supports.

Train staff Training 12/1/2015

Inform and educate people we support and their families

Operations 12/1/2015

What’s Next?

PPR & PCR•Validation of Provider Transition Plans•Update Provider Performance Review to include monitoring of Provider Transition Plans, by 10/2015•Revise Provider Certification Review by 12/2015

Transition Plan•Update Transition Plan with timelines and milestones for compliance•Submit providers for heightened scrutiny review•Submit to CMS by 3/2016

Moving Forward•Revise DDS additional policies, procedures and regulations by 4/2016•Training and support capacity building for providers, with a focus on employment•Continued community engagement

For More Information

Erin LevetonState Office of Disability AdministrationDC Department on Disability Services(202) [email protected]://dds.dc.gov/page/waiver-amendment-information

mailto:[email protected]

http://dds.dc.gov/page/waiver-amendment-information



Proposed Changes to Rates & Update on the Transition Plan Home & Community Based Services Waiver for...

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