Home and Community Based Waiver

1
Home and Community Based Waiver

• Charlie Crist, Governor
• Barney Ray, Interim Agency Director

• Senate Health and Human Services Appropriation
• Thursday, January 25, 2007
• 900 am 1130 am

2
Presentation Topics

• Overview of Program
• Current State of the Agency
• Appropriations Projected Expenditures
• Reasons Why Costs are Increasing
• Cost and Utilization Control Measures Implemented
• Current Appropriation
• Service Recipients and Funding
• Going Forward - Three Variables that effect Cost
• I. Caseload
• II. Price Level
• III. Utilization

3
Overview of Program Agency History

• In October 2004, the Agency for Persons with
  Disabilities (APD) was established specifically
  tasked with serving Floridians with developmental
  disabilities.
• The Agency is responsible for the management of
  the following Home and Community-Based Services
  Waivers
• Developmental Disabilities Waiver (HCBS/DD)
• Family and Supported Living Waiver (FSL)
• Consumer Directed Care Plus (CDC)
• Todays focus will be on the HCBS/DD Waiver.
• During fiscal year 2005-2006, the Agency served
  over 25,000 persons on the HCBS/DD Wavier.

4
Appropriations versus Projected
ExpendituresFiscal Year 2006-07

• First Priority Establish Sound, Credible
  Expenditure Projections. Deployed Agency for
  Health Care Administration Medicaid Fiscal Office
  to Assist.
• Total HCBS/DD Waiver Appropriation 776,837,838
• AHCA Expenditure Projection 881,630,169
• Based on straight-line projection methodology
• of actual paid claims history for July 06
  Sept 06
• Includes utilization growth of 12.08 (equal to
  prior year)
• Plus prior year claims paid from current year
  budget
• Plus new Brown placements
• Plus new enrollment through January 2007
• Plus provider rate increases
• Projected Deficit based on AHCA
  methodology (104,792,331) Total
• ( 46,905,017) GR

5
Reasons Why Costs are Increasing

• Utilization
• The August 8, 2001, settlement agreement
  (Prado-Steinman Lawsuit) established that the
  State is obligated to provide all medically
  necessary services to people enrolled in the
  waiver.
• Since FY 2002-03, the number of services (per
  enrollee) has increased from an average of 6.37
  services per enrollee, per month to 12.89
  services per enrollee, per month (through FY
  2005-06) representing a 102.4 increase.

6
Reasons Why Costs are Increasing

• Aging of caregivers and need for greater support.
• Increase in number of people served through court
  involvement and forensic histories.
• Increased number of children aging out of school
  and Medicaid state plan services are now
  accessing services through the HCBS/DD Medicaid
  Waiver.
• Better informed advocates, parents, stakeholders
  and providers concerning available services.
  Better access to information, state and federal
  legal precedents, and service availability have
  led to more robust care plans and higher costs.

7
Reasons Why Costs are Increasing

• Waiver Support Coordinators (WSCs) acting as
  advocates in accordance with Chapter 393,F.S.
  These same support coordinators also act as case
  managers and care plan developers for individuals
  receiving services.
• Competing and/or conflicting roles and
  responsibilities exist in statute and rule for
  Waiver Support Coordinators.
• The number of service providers has grown
  substantially impacting utilization. Supply
  Demand.

8
Reasons Why Costs are Increasing

• Impact of Recent Triage Policy
• 2005-2006 Proviso for Triage of enrollees into
  the Developmental Disabilities. Individuals with
  more intense needs and higher service costs are
  being enrolled in the Developmental Disabilities
  waiver.
• 2006-2007 Authority to use triage methods
  obtained for Crisis enrollment.
• Individuals in crisis typically have more
  intense, high cost needs.
• Enrollment has remained relatively flat due to
  utilization increases

9
Cost and Utilization Control MeasuresImplemented
by the Agency

• 2001 A contract for Prior Service Authorization
  (PSA) for selected waiver participants was
  initiated with Maximus, Inc. Contracted PSA was
  expanded to all waiver participants July 1, 2005
  through contracts with Maximus and APS
  Healthcare.
• Waiver Support Coordinators (WSC) develop care
  plans with individuals and families receiving
  services. The plans identify needed or desired
  services. These plans are submitted to the
  appropriate PSA contractor for review and service
  approval.
• The PSA contractor provides a review of requested
  services to determine if services are medically
  necessary. Only medically necessary services are
  approved for funding.
• Contracted PSA has provided standardization in
  medical necessity determinations for the state.

10
Cost and Utilization Control MeasuresImplemented
by the Agency

• July 2003 Implemented Standardized Rate System
  for waiver providers.
• Prior to July 2003 provider rates were negotiated
  by each APD Area with no uniformity or equity in
  price levels.
• July 2004 Introduced Gatekeeper, an improved
  automated system of pre-payment checks for
  billing authorization.
• Gatekeeper assures that payment is made only for
  services authorized in care plans.

11
FY 2006-07 HCBS/DD Family Supported Living
(FSL) Waivers LBR Request Appropriation
12
Service Recipients and Funding History
13
Going Forward Recommendations for Managing Costs

• The Three Key Variables
• Variable I. Caseload
• We can manage enrollment
• Variable II. Price Level
• We can manage what we pay for services (rates)
• Variable III. Utilization
• We can examine our current policies governing
  utilization

14
Going Forward -- Recommendations for Managing
Costs Variable I Caseload

• Current Enrollment HCBS/DD Waiver 25,418
• Once enrolled in the waiver, individuals have
  access to all medically necessary services.
• Current Projected Deficit -- Attributing Factor
• Current Caseload at current utilization rates is
  an attributing factor.
• The Agency must
• Align enrollment with appropriations.
• Challenge
• Just aligning enrollment by itself will not keep
  program costs within appropriation if utilization
  for enrollees continues to increase at current
  rates. No utilization cap.
• Once enrolled, you remain enrolled.
• As of January 1, 2007 Includes CDC Enrollment
  - Data Source ABC Database

15
Going ForwardRecommendations for Managing
CostsVariable II Price Level

• The Agency implemented a Standardized Rate System
  for waiver providers in July 2003.
• A provider rate increase was funded by the
  Legislature and implemented July 1, 2006.
• Current Projected Deficit -- Attributing Factor
• Price Level is not an attributing factor to the
  Agencys deficit.
• We could reduce projected deficit by reducing
  service rates.
• Challenge
• Impact of rate reductions and/or rate roll-backs
  on client services and provider organizations.

16
Going ForwardRecommendations for Managing Costs
Variable III - Utilization

• Utilization is Driven by Medical Necessity
• The Federal government requires every state to
  establish medical necessity conditions for all
  Medicaid-funded services.
• Medical Necessity is defined by AHCA in section
  59G-1.01(166)(a), Florida Administrative Code and
  Included in HCBS/DD Waiver Services Medicaid
  Coverage and Limitations Handbook and section
  59G-8.200, F.A.C.

17
Going ForwardRecommendations for Managing Costs
Variable III - Utilization (Contd)

• Florida had defined Medical Necessity as
  follows
• Necessary to protect life, to prevent significant
  illness or disability, or alleviate severe pain.
• Individualized, specific, and consistent with
  symptoms or confirmed diagnosis, and not in
  excess of individuals needs.
• Consistent with generally accepted professional
  medical standards and not experimental or
  investigational.
• Reflective of the level of service that can be
  safely furnished, and for which no equally
  effective, more conservative, or less costly
  treatment is available statewide.
• Furnished in a manner not primarily intended for
  the convenience of the recipient, caretaker or
  provider.

18
Going ForwardRecommendations for Managing Costs
Variable III - Utilization (Contd)

• Review the accuracy and effectiveness of the
  medical necessity determinations, the Agency will
  take the following steps.
• Attributing Factor
• Utilization increases are the main driver of
  over-spending.
• No cap or limit on utilization other than
  medical necessity
• The Agency Proposes
• A top to bottom program operation review
  including an evaluation of care plan development
  policies.

19
Going ForwardRecommendations for Managing Costs
Variable III - Utilization (Contd)

• Utilization Trends
• Fiscal Year Utilization Change
  from
• (Services Per Enrollee) Prior Year
• 2002-03 6.37
• 2003-04 9.91 55.50
• 2004-05 11.51 16.13
• 2005-06 12.89 12.08
• 2006-07 14.05 8.97
  
• Based on first 3 months actual experience.

20
Going ForwardRecommendations for Managing Cost
Current Challenges Variable III Utilization
(Contd)

• The top to bottom evaluation should consider
• Service utilization. Are services provided
  appropriate to the needs of each individual?
• Establishing incentives for Waiver Support
  Coordinators to align care plans to appropriate
  service needs and create efficiencies in the
  system.
• Review of Prior Service Authorization policies to
  ensure efficiencies and adherence to medical
  necessity guidelines.

21
Going ForwardRecommendations for Managing Cost
Current Challenges Possible Long-Term
Options

• Transition program to capitated service delivery
  model
• Amend existing Medicaid Waiver
• Add a Personal responsibility component (like
  Nursing Home program)
• Impose service (utilization) and/or spending caps

22
Home and Community Based Waiver
QUESTIONS

• Senate Health and Human Services Appropriation
• Thursday, January 25, 2007
• 900 am 1130 am