Virginia s ID/DD Waiver Re-Design Update vaaccses Annual Provider Conference June 8, 2015 Connie Cochran, Assistant Commissioner and Dawn Traver, Waiver Operations Director Division of Developmental Services Virginia Department of Behavioral Health and Developmental Services
The Big Picture
CMS Final Rule Is Good For the People We Support It is conveys an aspiration for all people. It requires working in the gray area of what is or isn t not a check off. It requires us to really understand how to help people have the contacts that lead to opportunities for a broader, richer life. Slide 3
Virginia Settlement Agreement with US Department of Justice Extensive in process and some specific deliverables 122 reporting elements (example: 2 hour crisis response) Is really about establishing systems of services that grow and self-correct over time Is really about meeting the needs of all citizens in the community Olmstead Is really about access to a holistic array of services, supports and resources when needed and aligned. Slide 4
Waiver Redesign Is about aligning service definitions with a clear method of setting rates for providers to deliver the best services with the Commonwealth coming closer to matching service packages to the greatest percentage of members within the waiver while bending the curve on costs to be able to sustain and reduce the wait list to a manageable number whereby natural turnover meets demand in a reasonable amount of time Is about shifting expectations to community supports lessening the demand on creating more congregate settings CMS Final Rule Slide 5
Magic of 7 Levels 4 tiers or 2 tiers (Independent Living) Why: while 7 is a lucky number that was not the reason the process of developing updated waivers, worked for the Commonwealth for key services for 7 levels and the validation study supported this assumption Why service packages allow us to segment the needs into some predictability of what is needed for providers, for funding,and by individuals served Why some & not others: for services not driven by the intensity, no reason to make all services linked and not everyone in each level needs same How: staggered in and working with DMAS and their vendor on overlapping When: target still July 2016 and need providers ready and prepared. Slide 6
The Details
I/DD Waiver Redesign Although not required by the Settlement Agreement, amending and restructuring the three waiver for persons with I/DD will result in services and supports that promote the community integration required by the Agreement. In his 6 th Report to the Court, the Independent Reviewer mentioned no fewer than a dozen times the importance of waiver redesign as a vehicle for complying with the Agreement. Slide 8
The Arc of VA CIAC VACSB TACIDD vaaccses Public VBPD Presentations My Life/My Community Public Comment Portal SA Stakeholder Advisory Group CSB SCs 16 Forums (September/October 2013) 8 sites across VA 1000 Attendees Policy Subgroup Training Subgroup State Agencies Public Stakeholder Forums Community Engagement Advisory Workgroup (CEAG) Residential Services Workgroup Waiver Design Advisory Committee (WDAC) State Employment Leadership Network (SELN) Eligibility Case Management Waiting List Provider Advisory Services Array Policy Data Training and Education State Collaboration Partnership for People with Disabilities Parent Support Groups VNPP Legislative Updates Waiver Updates Stakeholder Distribution List VARO DD CMs Slide 9
Essential Elements of I/DD Waiver Redesign The redesigned waivers will utilize a supports budgeting methodology for residential and day services based on the assessed intensity of need of the individual. Providers will need to demonstrate the necessary competencies to serve individuals with more complex needs. Some services will have tiered reimbursement rates to support individuals with more complex needs and encourage providers to use more intensive staffing patterns for these persons. Slide 10
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Relationship of Individual Levels to Reimbursement Tiers 9 8 4 4 7 4 6 5 4 3 3 Level 3 2 2 1 1 0 Level 1/Tier 1 Level 2/Tier 2 Level 3/Tier 3 Level 4/Tier 3 Level 5/Tier 4 Level 6/Tier 4 Level 7/Tier 4 Slide 12
Proposed Integrated I/DD Waiver Redesign Amend Day Support Waiver to Amend DD Waiver to Amend ID Waiver to Building Independence Waiver For adults (18+) able to live independently in the community. Individuals own, lease, or control their own living arrangements and supports are complemented by non-waiver-funded rent subsidies. Supports are episodic/periodic in nature. Changing needs Changing needs Family/Individual Supports Waiver For individuals living with their families, friends, or in their own homes, including supports for those with some medical or behavioral needs. Designed to meet individual support needs and preferences. Available to both children and adults. Changing needs Changing needs Community Living Waiver 24/7 services and supports for individuals with complex medical and/or behavioral support needs through licensed services. Includes residential supports and a full array of medical, behavioral, and non-medical supports. Available to adults and children. Supports Budget is Based on: Supports Budget is Based on: Supports Budget is Based on: Where You Live Intermittent, low overall cost residential supports in individual s own apartment Where You Live Supports in family home or apartment setting Where You Live Higher cost congregate residential supports available How You Spend Your Day Employment supports or integrated day services How You Spend Your Day Employment supports or integrated day services How You Spend Your Day Employment supports, integrated day services and group employment/day services Supplemental Supports/Services: One or more services based on individual assessed needs Supplemental Supports/Services: One or more services based on individual assessed needs Supplemental Supports/Services: One or more services based on individual assessed needs
Process Developing Rate Models Changes to billing conventions Establishing four rate tiers (based on the seven levels) for residential services and day supports Splitting congregate residential into distinct models group home, supported living, and sponsored placement billed on daily basis Varying group home rates by home size, with higher rates for smaller homes Billing day supports and group supported employment on an hourly basis rather than for partial-days Establishing higher rates for day supports delivered in the community compared to at a center Slide 14
Process Developing Rate Models (cont d) Major assumptions Direct Support Professional wages o Based on median wage for comparable position(s) published by the Bureau of Labor Statistics, which is a cross-industry survey of Virginia employers Direct Support Professional benefits o In addition to mandatory benefits, provides for 30 days of paid leave, $375 per month for health insurance, and $100 per month for other benefits assuming an 85 percent take-up rate Agency overhead included at an average of 21 percent Day Supports staffing ratios o Range from 1:7 to 1:2 at a center and from 1:3 to 2:3 in the community based on a member s level of need (additionally, there is a 1:1 community rate that any member may access) Slide 15
Process Public Comment Process Draft rate models and related materials posted online for public review and comment Notification emailed to providers and other stakeholders Comment period open for one month (all late comments were considered) Comments received from approximately 250 individuals Several changes made in response to comments, including: Increased Tier 4 rates (the highest tier) for residential services Additionally increased sponsored placement rates across all tiers Reduced assumed attendance for day supports and group supported employment (increasing these rates) Revised (lowered) wage assumptions for rest of State rates Slide 16
Implementation and Cost Impact Average change in rate varies by service Group Home + 4.9 percent ($13.5 million) Sponsored Placement - 0.4 percent ( - $0.3 million) Supported Living + 0.8 percent ($0.1 million) In-Home Residential Support + 30.5 percent ($15.0 million) Day Support + 11.3 percent ($9.9 million) Pre-Vocational Services + 8.0 percent ($0.9 million) Group Supported Employment - 3.7 percent ( - $0.4 million) Skilled Nursing + 109.7 percent ($16.5 million) Therapeutic Consultation + 58.2 percent ($0.5 million) Slide 17
Issues of Interest Northern Virginia Rates Rate models for Northern Virginia and the rest of the State were set independently rather than using a fixed premium For most rates, this approach resulted in Northern Virginia variances comparable to the current 15 percent premium For some rate model factors there are significant cost differences (e.g., wages) while others have less significant differences (e.g., staff benefits, transportation) Rest of State wage assumptions were reduced from the draft rate models, which increased the rate differences For most services, rate increases are slightly higher in Northern Virginia compared to the rest of the State Slide 18
Issues of Interest Sponsored Residential Proposed rate models would have reduced Sponsored Residential rates by 11 percent on average After revisions made in response to comments, average rate would be nearly unchanged (anticipated reduction of 0.4 percent) Individual rates will change by varying amounts, with some increasing and others decreasing Overall, the average sponsored residential rate is expected to be greater than the average group home rate Rate model built based on a stipend rather than a wage Annual stipend paid to the sponsored home assumed in the rate models varies by level of need and ranges from $30,000 to $81,000 per member Slide 19
Issues of Interest 344-Day Billing Policy Rate models for residential services are constructed assuming a 344-day billing year Estimated cost of service for a full 365-day year is calculated, $36,500 for example Rather than calculating a daily rate of $100 ($36,500 divided by 365 days), the cost is divided by 344, producing a rate of $106.10. This approach allows providers to be fully compensated (paid $36,500) even if the member is occasionally absent Since a provider is fully compensated after 344 billing days, they cannot bill more, even if the member is present for more days (because they have been paid for 365 days of service over the 344 billing days) Slide 20
New Services: Integrated Day The Settlement Agreement requires the Commonwealth to provide integrated day opportunities vs. the current day system that is characterized by very large congregate facilities. Proposed new services: Community Engagement Community Coaching Community Guide Individuals will be encouraged to take advantage of the above instead of group day support services. Slide 21
Community Engagement Provides a wide variety of opportunities to facilitate and build relationships and natural supports in the community Uses the community as the learning environment Emphasizes the person actively interacting with others without disabilities Ratio of no more than 1 staff per 3 individuals Slide 22
Community Coaching 1:1 service that takes place in the community Designed for those who need intensive support to build a specific skill set Addresses one particular barrier that prevents a person from engaging in their community Typically a time-limited service Slide 23
Community Guide Direct, 1:1 assistance to individuals to help them identify and access community resources that will meet their needs and interests Information and assistance to help the individual problem solve and make decisions about ways to develop supportive community relationships Time limited Slide 24
New Services: Employment Waiver redesign will provide the necessary underpinnings for a more robust set of employment services and supports that provides incentives for employment. Proposed new services: Workplace Assistance Services ongoing support to a competitively employed individual who requires more than sporadic support to maintain stable employment Benefits Planning Services assistance to individuals and their families to coordinate their Social Security benefits with employment to make informed choices about work Slide 25
New Services: Integrated Array of Residential Options The Settlement Agreement requires the Commonwealth to facilitate individuals receiving Waiver services to live in their own home, leased apartment, or family's home, when such a placement is their informed choice and the most integrated setting appropriate to their needs. Currently Virginia s I/DD Waivers provide more congregate residential supports than integrated options. New services: Shared Living Supported Living Independent Living Individuals will be encouraged to move from congregate settings to these services when appropriate to their needs. Slide 26
Shared Living Medicaid payment for a portion of the total cost of room and board for an unrelated live-in support person of the waiver recipient. In exchange, the live-in support person provides extra eyes on and assists the individual with some needed supports in the home and community; helps the individual make natural community connections. Slide 27
Supported Living Residential supports provided to individuals in a DBHDS licensed apartment setting More of a terminology change, as individuals are already supported in these settings under a different waiver service Will typically have round the clock access to staff Slide 28
Independent Living Supports to secure a self-sustaining, independent living situation for individuals living in their own apartments, alone or with a roommate Limited to no more than 21 hours per month To be coupled with rental assistance Slide 29
New Services: Medically Oriented To enable those with the most complex medical needs to successfully live in integrated community settings. Proposed new services: Private Duty Nursing a correction to the system as currently providing continuous nursing care inappropriately under Skilled Nursing Adult Dental Services preventive or basic care up to a capped amount per year Slide 30
New Services: Behaviorally Oriented To enable those with the most complex behavioral needs to successfully live in integrated community settings. Proposed new services: Center-based Crisis Supports to ensure appropriate funding for the REACH Crisis Therapeutic Homes which are designed for individuals who are experiencing an identified behavioral health need or behavioral challenge preventing them from being stable in their home setting Crisis Support Services comprised of crisis prevention, crisis intervention and crisis stabilization Slide 31
New Services: Community Access Settlement Agreement requires the Commonwealth to provide transportation in accordance with its approved HCBS Waivers Proposed new service: Non-medical transportation transportation to employment or other community sites Slide 32
New Services: Community Access (cont d) Settlement Agreement requires the Commonwealth to develop peer programs to facilitate individuals to meet and converse with other individuals currently living in the community Proposed new service: Peer Mentor Supports specially trained individuals with DD assisting others with DD to become aware of and advocate for the least restrictive community services in their own lives Slide 33
New Services: Community Access (cont d) Proposed new service: Electronic Based Home Supports goods and services based on Smart Home technology to support greater independence and safety. Would be used in lieu of some hours of paid staff support. Slide 34
Planned New Services by Waiver Community Living Family & Individual Support Building Independence Shared Living Shared Living Shared Living Workplace Assistance Supported Living Independent Living Support Community Engagement Workplace Assistance Community Engagement Community Coaching Community Engagement Community Coaching Community Guide Community Coaching Community Guide Non-medical Transportation Community Guide Non-medical Transportation Benefits Planning Non-medical Transportation Benefits Planning Electronic-based Home Supports Peer Mentor Supports Benefits Planning Electronic-based Home Supports Electronic-based Home Supports Peer Mentor Supports Adult Dental Peer Mentor Supports Adult Dental Private Duty Nursing Adult Dental Private Duty Nursing Slide 35
Redesigned Waiver Possible Timeline July 2016 October 2016 January 2017 Building Independence, Family & Individual Supports and Community Living Waivers commence New group home rate structure (daily billing vs. current hourly billing) in effect. Other services effective by individual plan year. Transition of In-home & nonresidential individuals (e.g. living with family) in effect. New sponsored residential rate structure transition in effect. Other services effective by individual plan year. Slide 36
Strategies to Gain Federal Financial Participation DBHDS and DMAS participate in bi-weekly conference calls with the Centers for Medicare and Medicaid Services (CMS) to identify any necessary revisions to the Commonwealth s draft waiver redesign plans and gain CMS approval for innovative strategies. A fall of 2016 submission of the waiver amendments would enable CMS to fully consider all desired changes and give approval conditional on VA approved funding. Slide 37
VA s HCBS Settings Rule Transition Plan Transition Plan for ID waiver submitted with 2/11/15 amendment requesting 2014 GA approved slots Approved on May 7, 2015 with waiver amendment approval Statewide Transition Plan submitted on March 17, 2015 Received CMS communication on June 3, 2015 that plan is being reviewed Slide 38
Elements of the Transition Plan Provider Self Assessments ID/DD waiver providers: Survey Monkey 321 received High percentage of providers viewed agency as in compliance Summary Report to be placed on DBHDS s website Follow-up by DMAS & DBHDS DMAS: QMR DBHDS: Office of Licensing & DDS Community Resource Consultants Recommended completion of HCBS Setting Assessment Tool to be distributed as a means of developing own plan toward compliance Slide 39
Elements of the Transition Plan (cont d) Compliance and Monitoring Team To include: individuals, family members, state agency reps, private providers, advocacy organizations, CSB reps and other stakeholders Initial meeting: recorded web-ex to be made available 6/25/15 Develop cross agency SME on the Settings Rule and Transition Plan Ensure a collective understanding of requirements Advise & support the education and training of professionals, providers & stakeholders Ensure a cohesive, broadly represented approach toward compliance, monitoring and capacity issues Ensure successful achievement of full compliance by March 2019 Slide 40
Elements of the Transition Plan (cont d) Other Elements: Developing letter regarding Settings Rule for SCs/CMs to give individuals/family member to educate Dedicated DBHDS toll-free phone line for stakeholders to provide input regarding providers compliance: 844-419-1575 DBHDS Licensing regulations being revised to comport CRCs providing consultation and technical assistance to SCs/CMs and ID providers Individuals receiving supports from providers not in compliance by June 2018 will be offered opportunity to transition to another provider to keep waiver services Slide 41
More Information About the Settings Rule http://www.medicaid.gov/medicaid-chip-program- Information/By-Topics/Long-Term-Services-and- Supports/Home-and-Community-Based-Services/Homeand-Community-Based-Services.html Now includes guidance for NON-RESIDENTIAL SETTINGS Slide 42