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Fiscal Year 2009-2010


Report to the Legislature on the Agency’s Plan


for Implementing Individual Budgeting


“iBudget Florida”


February 1, 2010


Jim DeBeagrine, Charlie Crist,


Director Governor


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Table of Contents


Brief Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Project Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Overview of Individual Budgeting Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Detailed Agency Proposals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Suggested Statutory Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


Appendix I: Questionnaire for Situational Information. . . . . . . . . . . . . . . . . . . . .


Appendix II: Table of State Algorithm Elements. . . . . . . . . . . . . . . . . . . . . . . . .


Appendix III: Options Provided to Stakeholders for Consideration. . . . . . . . . . .


Appendix IV: Technical Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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BRIEF OVERVIEW


Like many other states, Florida faces a variety of challenges in serving


individuals with developmental disabilities. These include difficulties predicting


and managing Medicaid waiver expenditures, a complex service delivery system


that hinders consumer control, and a growing wait list that is difficult to address in


a system that is prone to budget deficits that consume new resources. These


are interrelated issues.


Individual budgets have been proposed as a possible solution to these


challenges. A number of other states use individual budgeting systems. The


federal government is also encouraging states to consider this approach.


With individual budgeting, a mathematical formula (also known as an algorithm)


is developed through statistical analysis to fairly allocate available funds. The


formula considers individual consumer characteristics and generates a budget


amount for each person.


By determining a budget amount for each consumer at the beginning of the


service planning process, various costly and complicated controls can be scaled


back or eliminated.


Budget amounts would be set considering the limits of the appropriation for the


Agency for Persons with Disabilities (APD), thus greatly reducing the likelihood of


deficits.


APD also proposes modifying other system elements such as the prior service


authorization system and the role of the waiver support coordinator to simplify the


system and support greater self-direction.


Consumers and their families will benefit from:


o Greater ability to choose services that matter to them, given their unique


situations.


o Greater flexibility for consumers to respond to changing needs.


o Reduced bureaucracy and “red tape.”


o Support coordinators freed to focus on providing help that makes a real


difference.


o Confidence that their funding is fair compared to other consumers who are


similarly situated.


o Reduced likelihood of policy changes that cause significant disruption due


to budget deficits.


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o Security of a financially stable system that will be there to serve them


down the road.


o Greater control over their lives.


o Greater opportunity for the Agency to use new funds to serve the wait list


rather than resolve deficits.


The Legislature included proviso language in the 2009 General Appropriations


Act requiring the Agency to submit a plan for individual budgets. To develop this


plan, APD involved the public through two rounds of statewide meetings, a


stakeholders’ group which met three times, and a project website. APD also did


extensive research and contracted with a Ph.D.-level statistician to develop the


algorithm.


The formula proposed by APD considers . . .


The formula has been tested and is well within acceptable standards of accuracy.


It is also relatively simple and uses information already gathered during APD’s


assessment process.


The formula can be modified over time to take advantage of research findings


and new data elements which may be of value but not currently available.


Other system changes envisioned under individual budgets include:


o Restructuring the array of services available through the waiver to


increase flexibility.


o Eliminating the prior service authorization process, replacing it with a


scaled-back, more personalized service review process.


o Reframing waiver support coordinators’ role to refocus on person-centered


planning, identifying and using more non-waiver services such as


community services, and coordinating supports.


o Creating a virtually paperless process.


o Providing training, information, and tools for managing budgets and


making smart decisions to consumers and families.


o Monitoring of consumers’ budgets and service patterns to ensure health


and safety and appropriate use of funding.


o Creating a process for consumers with exceptional needs or significantly


changed needs to apply for additional funding.


APD plans to phase individual budgets in over time, with the schedule dependent


upon receipt of required federal approvals for changes in the waiver system.


APD would begin the first phase in Fall 2010, involving a limited number of


consumers in two or three areas. Such a first step would enable the Agency to


explore how the system works in practice and make refinements as needed.


During this time, the Agency would also be enhancing its needs assessment


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instrument, gathering new data, and refining the algorithm. A wider phase-in


would begin in the Summer or Fall of 2011.


In conclusion, an individual budgeting approach has the potential to make the


system simpler, more manageable, financially stable, more equitable, and more


consumer-friendly. The State of Florida and consumers will benefit from a


simpler, more financially stable system.


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Executive Summary


Background


Like many other states, Florida faces a number of challenges in serving


individuals with developmental disabilities. These include difficulties predicting


and managing Medicaid waiver expenditures leading to budget deficits, a


complex service delivery system that is costly to taxpayers and hinders


consumer control, and a growing wait list. These are interrelated issues.


In addition, the recent deficits in the Medicaid waiver program have consumed


virtually all new funding available for the program. This prevents enrolling


individuals from the wait list, which has grown to more than 19,000. The deficits


have also prompted Legislatively-imposed cost controls. These controls have


had a very uneven impact, substantially affecting some individuals while having


very limited impact on others. They also added new layers of complexity to the


system and eliminated certain services upon which individuals relied. These cost


controls have demonstrated limited success in actually bringing down costs.


Financial stability is an absolute prerequisite to both addressing the wait list and


ensuring a stable system for enrollees that is not subject to almost constantly


changing requirements and limitations. For this reason, the Agency for Persons


with Disabilities (APD or Agency) recommends the development and


implementation of individual budgets (iBudgets).


Individual budgets have been used by a number of other states to address the


challenges noted above. Over the past several years, there have been


discussions that Florida should explore this approach as well. In response, the


2009 Legislature directed the Agency to develop a plan to implement individual


budgets in Florida. Subsequent to the 2009 session, a consultant engaged by


the Florida Developmental Disabilities Council recommended individual


budgeting in a strategic plan for serving consumers with developmental


disabilities in Florida.


To develop the required plan, APD started by conducting extensive research on


individual budget systems in other states. APD staff conducted an extensive


literature review and received Florida-specific advice from several consultants.


Additionally, APD engaged the services of a Ph.D.-level statistician, Dr. Xu-Feng


Niu, a statistics professor at Florida State University.


APD also involved the public in developing the plan through two (2) rounds of


open meetings held throughout the state. A more focused stakeholders’ group


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was assembled which met three (3) times and provided ongoing advice in the


preparation of this report. APD also developed a project website to keep the


public informed of developments.


Overview of Individual Budgeting


Individual budgeting is based on a simple concept: it is the use of objective data


on personal needs and characteristics to equitably allocate available funds


among eligible recipients. The first step is to develop a mathematical formula


(also known as an algorithm) through statistical analysis. The goal is to identify


key individual characteristics that best predict an individual’s service needs.


Although formal assessment results are typically included in the model, they are


never the only variables considered. The formula then generates a budget


amount for the individual, who then directs the development of a support plan


within the limits of the budget. Thus, development of the individual’s budget is


the first step of the support planning process in a system utilizing individual


budgets.


This contrasts with the current process where the budget is developed after the


support planning process. Today, the process begins with conversations


between the consumer and the waiver support coordinator. These discussions


result in a support plan that the support coordinator develops. The plan lists


needed and desired services. The plan is then reviewed by a third party prior


service authorization (PSA) contractor for compliance with applicable regulations


and to verify medical necessity. The portion of the support plan approved by the


PSA contractor becomes the person’s cost plan which, in essence, is their


budget. Services can be added, or the mix of services can be altered, subject to


PSA approval.


Because of the subjective level of human judgment involved, some have


expressed concerns that this system has some inequities. The system is also


complex, requiring the involvement of many persons and much paperwork. In


addition, the PSA system has proven ineffective in its primary goal of cost


containment. Finally, the current system provides very few direct financial


incentives to creatively engage community resources or voluntarily reduce


services that are no longer needed.


Individual budgeting, on the other hand, uses a formula that objectively utilizes


individual characteristics, enhancing equity. Since cost control is achieved by the


limits of the established budget, the need to review every single service choice


an individual makes for the purpose of cost containment is not necessary. This


will allow for elimination of the prior service authorization process as it exists


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today. It will also allow the state to ease current service limitations and


restrictions while actually enhancing the ability to manage expenditures.


By reducing current government oversight of highly personal decisions, the state


further empowers consumers and families and relieves the public of the burden


of financing expensive regulatory activities. Because consumers can use


savings they may identify in their support plans to fill more urgent self-directed


needs, they have a direct financial incentive to make wise decisions and


effectively leverage community resources.


Achieving financial stability will allow policymakers to use new funds to address


the wait list. It will also provide the foundation for a system that can be sustained


over the long term without the need for periodic and disruptive changes to the


overall system.


Consumers and their families will benefit from:


o Greater ability to choose services that matter to them, given their unique


situations.


o Greater flexibility for consumers to respond to changing needs.


o Reduced bureaucracy and “red tape.”


o Support coordinators freed to focus on providing help that makes a real


difference.


o Confidence that their funding is fair compared to other consumers who are


similarly situated.


o Reduced likelihood of policy changes that cause significant disruption due


to budget deficits.


o Security of a financially stable system that will be there to serve them


down the road.


o Greater control over their lives.


o Greater opportunity for the Agency to use new funds to serve the wait list


rather than resolve deficits.


The Plan


APD engaged the services of a Ph.D.-level statistician, Dr. Xu-Feng Niu, a


statistics professor at Florida State University, to assist in developing a formula.


The recommended formula considers. . . . This algorithm has relatively high


predictability using FY 2007-08 expenditures.


Because there were other variables of interest to stakeholders for which APD


lacked reliable and data for testing, APD proposes using this algorithm in the


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initial phase-in of individual budgets while the Agency works with stakeholders to


define new variables to test, collect necessary data, evaluate the variables’


predictiveness, and refine the algorithm.


Other system changes envisioned include:


o Revising the service array to increase flexibility for consumers and


families.


o Eliminating the prior service authorization process, replacing it with a


scaled-back, more personalized service review process.


o Reframing waiver support coordinators’ role to refocus on person-centered


planning, locating community resources, and coordinating supports.


o Creating a virtually paperless process.


o Providing consumers and families training, information, and tools for


managing budgets and making good decisions.


o Increasing behind-the-scenes monitoring of services to ensure health and


safety and appropriate use of funding.


o Creating a process for consumers with exceptional needs or significantly


changed needs to apply for additional funding.


Limitations and Caveats


Individual budgeting can be extremely useful in promoting equity, efficiency,


stability and self-determination. It is important, however, to recognize that it is


not a magic solution for all challenges that Florida faces now or in the future. In


addition, the transition to a new system will bring implementation challenges that


must be considered.


Individual budgets will not guarantee that each consumer will have funding for all


waiver services they want or believe they need. Individual budgets will instead


distribute the available funding equitably according to the variables in the


algorithm. This funding will be responsive to individual needs, so that consumers


requiring more support will receive more funding than consumers with fewer


support needs. While the approach will certainly provide more clarity as to the


level of unmet need, policymakers ultimately make the decision within the budget


process. Thus, advocates will have better information but must remain engaged


as budget decisions are made.


Individual budgets will not guarantee that people make wise choices or that


families and communities become more engaged. The process simply provides


opportunities and incentives. Quality assurance and other measures designed to


detect and neutralize abusive behavior will continue to be necessary.


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Transitional issues will arise as the system is implemented. Some consumers


may experience increases in their iBudgets compared to current cost plan


amounts, while others may experience decreases. APD has performed initial


reviews to assess health and safety under this initial iBudget, as is described in


the report. APD is proposing a phase-in of the new budgets, as many other


states have done. This will allow consumers time to adjust to new budget


amounts. It will also allow APD to study the way the system works and make


adjustments as needed.


Some system changes would require federal government approval. Based on


initial discussions with the federal government and other states’ waivers


approved by the federal government, APD believes these have a good likelihood


of being approved, but such approval is not guaranteed.


Additionally, some changes would require resources to be provided to the


Agency or redirected from existing funding for implementation. If resources were


not provided, these proposals would need to be modified. For example, the tools


for helping consumer manage their iBudgets and for the Agency to monitor


health and safety rely on an enhanced information technology system. If such an


IT system could not be implemented, the Agency may have to scale back some


of the consumer flexibility contemplated under the iBudget system in order to


better protect health and safety.


While these are important issues, APD believes that they can be mitigated and


that the overall outcomes of greater system simplicity, greater sustainability,


more equitable funding, and increased self-direction make iBudgets a worthwhile


endeavor.


Implementation


APD plans to phase individual budgets in over time, with the schedule dependent


upon receipt of required federal approvals for changes in the waiver system.


APD would like to begin the first phase in Fall 2010, involving a limited number of


consumers in two or three areas. Such a first step would enable the Agency to


explore how the system works in practice and make refinements as needed.


During this time, the Agency would also be enhancing its needs assessment


instrument, gathering new data, and refining the algorithm. A wider phase-in


would begin in the Summer or Fall of 2011.


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Summary


In conclusion, an individual budgeting approach could be an improvement over


the current system, making the system simpler, more sustainable, more


equitable, and more supportive of self-direction. While there may be transitional


issues to address, they can be mitigated through a careful phase-in. Consumers


and families would benefit from having greater ability to choose services that fit


their unique needs, stronger support from support coordinators, less frustration


from excessive “red tape,” and greater ability to control their own lives. By


enhancing system sustainability, they will also benefit from a stronger system


that can serve them now and into the future.


About the Agency for Persons with Disabilities (APD)


The Agency for Persons with Disabilities (APD) works in partnership with local


communities to support people with developmental disabilities in living, learning,


and working in their communities. APD provides critical services and supports


for its consumers to reach their full potential. The Agency serves individuals with


spina bifida, autism, cerebral palsy, Prader-Willi syndrome, and mental


retardation, as well as children at risk of a developmental disability. Examples of


services provided include day activities, therapies, behavior analysis, supported


employment coaching, durable medical equipment, consumable medical


supplies, in-home support services, personal care assistance, and residential


habilitation.


As of January 15, 2010, APD served _______ consumers. Of these,


_____________ were enrolled on one of the Agency’s four Medicaid Home- and


Community-Based Services waivers, and _______________ were on a wait list


for waiver services.


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Full Report


Introduction


The Agency for Persons with Disabilities (APD) works in partnership with local


communities to support people with developmental disabilities in living, learning,


and working in their communities. APD provides critical services and supports


for its consumers to reach their full potential. The Agency serves individuals with


spina bifida, autism, cerebral palsy, Prader-Willi syndrome, and mental


retardation, as well as children at risk of a developmental disability. Examples of


services provided include supported employment coaching, day activities,


therapies, behavior analysis, durable medical equipment, consumable medical


supplies, in-home support services, personal care assistance, and residential


habilitation.


As of January 15, 2010, APD served _______ consumers. Of these,


_____________ were enrolled on one of the Agency’s four Medicaid Home- and


Community-Based Services waivers, and _______________ were on a wait list


for waiver services.


Like many other states, Florida faces a variety of challenges in serving its


consumers. These include difficulties managing its funding, a complex approval


and delivery system that hinders consumer control, and a growing wait list.


These are interrelated issues. Consistently running deficits means new funding


has not been available to serve those waiting for services but must be used


essentially to pay the Agency’s debts. To seek to control deficits, new cost


control measures have been mandated by the Legislature, making the system


more complex and less able to respond to consumers’ changing needs.


Individual budgets have been proposed as a possible solution to the challenges


cited above. Individual budgeting is an approach to allocating funding within


existing Agency resources for those services used by an consumer with a


developmental disability that are funded by the Home and Community Based


Services waiver. A mathematical formula (also known as an algorithm) is


developed through statistical analysis to fairly distribute available funds based on


historical funding patterns. This formula considers individual consumer


characteristics and generates a budget amount for each person. These budget


amounts are identical for consumers in identical situations and different for


consumers in different situations, as measured by the variables in the algorithm.


This approach also allows for changes in budgets as individual needs change.


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This contrasts with the current method of determining individual funding, where


budget development begins with conversations between the consumer, his or her


family, and his or her waiver support coordinator. The consumer, his or her


family, and his or her waiver support coordinator develop a support plan and cost


plan listing the consumer’s needs, identifying resources, and choosing waiver


services. This cost plan must comply with a variety of laws and rules, including


limits on service availability for consumers enrolled in certain tier waivers. The


cost plan is reviewed and approved by the Agency’s prior service authorization


contractor. Because of the level of human judgment involved, some have


expressed concerns that this system is inequitable. The system is also complex,


requiring the involvement of many persons and the submission of much


paperwork to function.


While stakeholders should not expect that individual budgets will result in a


perfectly functioning system, APD believes individual budgets would be an


improvement over the current system. By determining an individualized budget


amount that sets a maximum for the each person’s expenditures at the beginning


of the service planning process, the prior service authorization process can be


greatly minimized, simplifying the system. These budget amounts would be


predetermined to comply with APD’s appropriation, thus greatly reducing the


likelihood of deficits. APD also proposes that the prior service authorization


system be dramatically scaled back to dovetail with a more self-directed system


of planning and selecting supports. Between a new minimized and streamlined


service review process and a virtually paperless electronic system, waiver


support coordinators should be freed from much of the paperwork burdens they


have shouldered. Instead, they will be able to focus on person-centered


planning, problem-solving with consumers, developing natural and community


supports to enhance consumers’ lives, and expanding the array of supports to


augment their paid waiver supports.


Consumers and their families will benefit from:


o Greater ability to choose services that matter to them, given their unique


situations.


o Greater flexibility for consumers to respond to changing needs.


o Reduced bureaucracy and “red tape.”


o Support coordinators freed to focus on providing help that makes a real


difference.


o Confidence that their funding is fair compared to other consumers who are


similarly situated.


o Reduced likelihood of policy changes that cause significant disruption due


to budget deficits.


o Security of a financially stable system that will be there to serve them


down the road.


o Greater control over their lives.


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o Greater opportunity for the Agency to use new funds to serve the wait list


rather than resolve deficits.


A variety of other states use individual budgeting systems, and the federal


government is encouraging other states to do so. APD has researched how


other states design and implement individual budgeting systems to identify best


practices. The Agency would continue actively pursuing knowledge to enhance


Florida’s individual budgeting system.


The Florida Legislature included proviso language in the 2009 General


Appropriations Act requiring that the Agency submit a plan for individual budgets:


From the funds in Specific Appropriation 243, the agency in


consultation with the Agency for Health Care Administration shall


develop a plan to establish individual budgets for individuals enrolled


in the home and community based services waivers. The plan shall


provide for the following: an equitable distribution of available resources


among individuals based on an assessment process that includes client


characteristics and a valid formal assessment instrument; client choice


of services and providers once the individual budget is determined; any


formulas necessary to predict resource needs and establish individual


budgets; a recommended role for providers and support coordinators


during the assessment process to avoid any potential conflicts of


interest; a proposed schedule for implementation; and any suggested


statutory revisions necessary to implement individual budgets. The


agency shall consider input from stakeholder groups, including


self-advocates, family members, service providers, waiver support


coordinators, and advocacy organizations in developing the plan. The


plan shall be delivered to the Governor, the chair of the Senate Policy


and Steering Committee on Ways and Means, and the chair of the House


Full Appropriations Council on General Government & Health Care no


later than February 1, 2010.


In accordance with this proviso language, the following report contains an


overview of individual budgeting systems and APD’s recommendations on how


Florida might implement such a system, which APD has named “iBudget Florida.”


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Project Background


This plan for individual budgets comes after the Agency, its consumers, their


families, and the waiver support coordinators and providers who serve them have


experienced several years of significant change in the Florida developmental


disabilities system. APD, like other state agencies serving consumers with


developmental disabilities, faces several challenges in meeting the needs of its


consumers. The iBudget Florida system, as APD has termed its individual


budgeting initiative, is intended to help the Agency both address these


challenges and enhance consumers’ self-direction.


APD Challenges to Overcome


Managing funding is difficult


The Florida Constitution requires the state’s budget to be balanced. APD is


legally required to stay within its appropriation, as enacted into law by the state’s


elected representatives. However, APD has run annual deficits during the last


several years. In some years, the Legislature granted APD additional funding to


pay for the deficit, but APD is expected to pay back some of the money in future


years. Essentially, APD has carried forward debt from previous years it must pay


out of its current appropriation. Consequently, dollars that could be used to help


people who are on the wait list must be used to pay for services provided


previously to current waiver enrollees.


System is complex


Because of the difficulties of managing available funding across the ever


changing needs of thousands of people, policymakers have continually added


new methods to control and cut costs. For instance, the waiver program moved


from requiring prior service authorization for limited services to requiring it for all


services. Then, in accordance with state law, the Agency implemented the tiered


waiver system. The tier waiver system features four (4) waivers, three (3) of


which have a cap on a consumer’s total annual expenditures. Following the


implementation of the tiers and also required by state law was rebasing.


Rebasing reduced individuals’ cost plan of consumers to the amount actually


spent, under certain conditions. Most of these methods added a new set of rules


to follow in determining appropriate services and delivering them. They have


required significant APD staff and provider time to process service requests and


monitor their implementation. This results in unacceptable delays in getting


services to consumers who need them. It also frustrates and confuses


consumers.


Wait list is growing


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Because of the Agency’s deficit spending, during Fiscal Years 2007-08 and


2008-09, APD was limited by state law to enrolling only wait list consumers in


crisis if sufficient funds were available through attrition. The number of


consumers the Agency has enrolled under these conditions has averaged only


___ per year for the last ___ years. However, an average of __ consumers per


year join the wait list. This means that the wait list is growing.


More consumer control possible


The methods used to control costs have a downside for the consumers APD


serves besides the loss of services. These measures also limit consumers’


choices and flexibility to meet their needs. Ultimately, the system does not


support consumers’ self-direction to the degree that it could. Self-direction is a


philosophical goal; it is the belief that consumers with developmental disabilities


should have a say in the decisions that shape their day-to-day lives. It is further


the belief that resources are most efficiently utilized when those closest to the


situation, the individual and his or her family, make informed decisions on how


best to use limited resources.


Systems can be structured to be more or less self-directed. However, studies


show that consumers are more satisfied with their services when they perceive


they have greater control over their services. Because services are provided


using public funds, it is appropriate for there to be some limits on consumer


control to ensure that the public’s goals for the program are met. However, a


primary goal of the services is to help consumers live everyday lives in the


community, and the experts on how to do that are the consumers themselves.


Therefore, the system must allow these consumers themselves to express their


unique needs and tailor their services to fit them.


iBudgets as a Potential Response to these Challenges


For several reasons, APD believes that individual budgets can help address


these challenges.


Individual budgets and self-direction are an emerging best practice


encouraged by the federal government


Some evidence of this is in the federal government’s current application that


states use to ask for new waivers or amendments to their waivers. For instance,


in the section of the waiver application where states describe how funding for


consumers will be determined, the federal Centers for Medicare and Medicaid


Services (CMS) has a specific option which states can select. This is titled


“Prospective Individual Budget Amount,” described in the waiver application


technical guide as follows:


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Some states have developed and implemented methodologies that


determine a specific budget amount that is uniquely assigned to each


individual waiver participant. The assigned budget amount constitutes a


limit on the overall amount of services that may be authorized in the


service plan. This method is termed “prospective” because the amount


that is assigned is determined in advance of the development of the


participant’s service plan.


Additionally, as CMS states in the Home and Community-Based Services


Technical Guide, “CMS urges that all states afford waiver participants the


opportunity to direct some or all of their waiver services. Participant direction of


services has been demonstrated to promote positive outcomes for individuals


and families, improve participant satisfaction, and be a cost-effective service


delivery method.”


Can help with Agency challenges and achieve Agency goals


The Agency believes iBudgets can help increase system sustainability, facilitate


more consumer control, enhance equity, and simplify the system.


o Increase system sustainability: By precisely determining what each


person should receive within the Agency’s total appropriation, this method


should also increase APD’s ability to stay within its appropriation.


o Simplify the system: For instance, the method of distributing funds should


enable APD to eliminate the prior service authorization system as it exists


today, reducing the paperwork volume, and making it more responsive to


consumer needs.


o Facilitate consumer control: By simplifying the system and introducing


more flexibility in selecting among services, it will also give consumers


greater ability to make choices and manage resources within their


budgets.


o Enhance equity: By determining identical individual budgets for


consumers in like situations as measured by individual characteristics and


needs, equity is enhanced.


Vulnerabilities no greater than under current system


Currently, the Florida Constitution requires the Legislature to determine agencies’


budgets and to ensure that the entire state’s budget is not larger than the


available revenues. Because of the state’s decreased revenues, the ability of the


state to cover program deficits with new funding as it did for several years has


been exhausted. The Legislature instead has chosen to reduce expenditures by


eliminating and reducing services, reducing provider rates, and requiring some


consumers to reduce their services through their tier assignment.


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Individual budgets would not change the fundamental reality of the state’s budget


process. The Legislature will continue to decide how much to appropriate to


APD and the Agency will have a lawful obligation to operate within this amount.


Policymakers will still have the prerogative to reduce or increase the budget. The


challenge of effective advocacy will not cease. Such efforts, however, will be


much better informed and perhaps more effective as a result.


Should cutbacks become necessary, the iBudget approach would allow it to be


accomplished without the micromanagement strategies currently required to


affect expenditures. For example, there would be no need for policymakers to


choose from the list of offered services and select which one they feel least


important to consumers and, thus, most appropriate for elimination. All budgets


could be cut back equally so that consumers can determine how best to adjust


and no group of consumers would experience reductions disproportionate to their


peers. Tier implementation, for instance, affected about 25% of consumers.


Service eliminations only affect those consumers who happen to use that


particular service, thus creating inequities in how reductions are applied.


Other options raise concerns


There are two other general options besides individual budgets.


One is to maintain the status quo. Given the program’s recent history, this


approach would likely involve additional legislatively-mandated reductions in the


amount or types of services provided or the rates for those services.


Unfortunately, it would do nothing to enhance consumers’ ability to make more


choices about their services, simplify the program, or make the program more


equitable. In fact, this approach would likely make the program more complex,


less equitable, and involve more restrictions on consumer choice.


Another option is to turn the program over to a managed care organization. The


state would pay a capitated rate per person to the managed care organization,


which would make decisions about consumers’ care. This option raises


questions about the funding that would be available for consumers’ care after the


organization charged for profit and overhead expenses. Also, the level of


overhead that is required to manage and coordinate the delivery of highly


specialized medical care does not appear to be necessary for most of the


services provided through APD. These services are much more amenable to


consumer and family management because they primarily consist of routine


assistance with daily life activities. The consumer and his or her family probably


know better than any outside professional the services they need to successfully


remain in the community.


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Nationally there is very limited experience with the provision of long-term care


services to consumers with developmental disabilities by managed care


organizations. Thus stakeholders have expressed concerns about consumers’


ability to self-direct and the sufficiency of the range of services that would be


available under such a system. Individual budgets offer an opportunity to use the


elements of a managed care system that are appropriate for long-term care for


individuals with disabilities without some of the associated elements of concern.


Individual budgets, in effect, are a type of managed care. An individual budget


acts as “capitation” to the individual, and the amount of funding allocated is


determined by APD’s overall budget, fulfilling two key elements of managed care:


adherence to an overall budget and established, known payment levels on a per


person basis.


Objectives for an Individual Budgeting System


The Agency has adopted the following objectives for an individual budgeting


system, and in collaboration with stakeholders has used them to evaluate


options:


o Empower consumers to direct their own lives.


o Seamlessly fit with a system of more flexible services.


o Provide for maximum control consistent with health and safety


requirements.


o Help consumers address their own unique support needs.


o Provide funding that is responsive to consumers’ differing


characteristics and situations, such as their abilities and levels of


natural support they receive.


o Consumers with greater support needs receive greater amounts of


funding.


o Protect consumers’ health, safety, and welfare.


o Enhance consumer outcomes.


o Create budgets in a way that is fair and transparent.


o Stakeholder involvement in development of individual budget


system.


o Algorithm is public and understandable.


o Similarly situated consumers receive similar amounts of funding;


Differently situated consumers receive different amounts of funding.


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o Promote accountability.


o Make Agency spending more predictable.


o Be able to forecast future needs for both consumers currently


enrolled on the waiver and on the wait list.


o Live within the Agency’s means.


o Agency does not have cost overruns.


o Budget-neutral in implementation.


o Meet Federal waiver requirements.


Process for Developing the iBudget Florida Plan


APD used the proviso language in statute to frame the overall requirements for


the iBudget Florida plan. Then, Agency staff conducted extensive research on


individual budgets to learn about specific options and best practices. APD also


used a variety of methods throughout the process to obtain input from the public


and from specific stakeholder groups.


Research


APD staff conducted extensive research on individual budgets in developing this


plan. For instance, Florida APD staff spoke with staff in eight states that have


implemented individual budgets or are in the process of doing so in order to learn


about their programs and experiences. Additionally, APD staff reviewed


consultant and research reports on developing and implementing individual


budgeting programs. APD also received Florida-specific advice from several


consultants. Finally, a consultant engaged by the Florida Developmental


Disabilities Council offered recommendations on individual budgeting during the


development of a strategic plan for serving consumers with developmental


disabilities in Florida. APD intends for these research efforts to be ongoing to


help the Agency continually enhance the iBudget Florida initiative.


Public and Stakeholder Input


APD used a multifaceted approach to gather comments from the public and


stakeholder groups.


o APD circulated a draft concept paper to stakeholder groups to get initial


feedback.


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o APD held seven (7) public meetings across the state to broadly introduce


the idea to consumers, families, waiver support coordinators, providers,


advocates, and APD staff and to learn their concerns about the system


generally and hear their questions and ideas.


o APD created a website featuring documents about the plan as it was


developed and the opportunity to share feedback.


o APD convened a group of seventeen (17) stakeholders including


consumers, families, waiver support coordinators, providers, advocates,


and other state Agency representatives. This stakeholder group met three


times and also met via conference call.


o After the plan was drafted and reviewed by the stakeholder group, APD


held a second set of five public meetings across the state to share the


plan with the public and stakeholders generally.


While all of these methods provided APD with useful feedback, the


stakeholder group was the primary means for receiving input. APD provided


the stakeholder group with a framework and a wide range of options for


designing an individual budgeting system. This group was very attentive,


thoughtful, and constructive. The stakeholders’ group’s feedback is the


foundation of this plan.


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Overview of Individual Budgeting Systems


Generic System Elements


Through its Medicaid Home and Community-Based Services waiver program, the


federal government offers states a wide array of choices for designing their


systems for serving consumers with developmental disabilities. States have


taken advantage of this flexibility with the result that no two states’ systems are


alike, and some states even have multiple approaches to serving their


consumers within their own system. (Florida is an example, with its Consumer-


Directed Care Plus program operating alongside its Home and Community


Based Services waivers.) However, there are some generic system elements


that each system must contain for it to function. The two (2) such elements that


are most relevant to this plan are processes for:


Determining and communicating funding available for each person’s needs


Selecting services that may be paid for with the funding


The general approach to these two processes under individual budgeting


systems and under the current APD system are described below.


Determining and communicating funding available for each person’s needs


The term “individual budget” can be confusing. This is because right now each


consumer enrolled on the waiver has an amount of funding that he or she has


been determined to receive—essentially, all waiver enrollees have an individual


budget now.


The individual budgets envisioned in this plan are:


o Determined through an algorithm, or mathematical formula that predicts


funding based on an individual assessment process and other consumer


characteristics; and


o Provided at the beginning of the service planning process, instead of


determined at the conclusion or being based on a tier cap set through


statutory criteria. This is called “prospective budgeting.”


APD also envisions providing more control over and flexibility in service selection


for consumers and families within the system to promote greater self-direction.


Algorithm


The core of the individual budgeting process is an algorithm which determines


waiver-enrolled consumers’ budgets. The variables, or elements, of this formula


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are consumers’ characteristics, such as their age, living situation, and needs


assessment process results.


While the term “algorithm” is intimidating, algorithms are widely used by


organizations as a standardized, objective, data-based method to make


decisions. One example of an algorithm is a person’s credit score, which


indicates to potential creditors what kind of a credit risk an individual presents.


These scores are generated by algorithms which consider data on an individual’s


credit history compared to other people’s patterns of credit and repayment.


Another example is online commerce, where a website recommends to the


online shopper some alternative products that might be of interest. Those


recommendations are developed using an algorithm. The algorithm is comparing


the products viewed by the user to a database of patterns of other shoppers’


viewing and purchasing history. Based on that, it uses its formula to determine


which products the shopper is statistically most likely to purchase and


recommends those.


APD’s proposed formula or algorithm for determining individual consumers’


budget amounts has been developed through careful research and study to


reflect the differences between individual needs, as will be described later in this


report and at length in the technical appendix. The data used in the formula is


determined to be reliable and valid; that is, it accurately measures what it is


supposed to measure.


In this system, consumers in identical situations as measured by the algorithm


will receive identical budget amounts. Those in different situations will receive


different budget amounts: those with higher levels of need will receive more, and


those with lesser needs will receive less. This arrangement is designed to


enhance the equity of the system.


The algorithm-based iBudget Florida approach contrasts with Florida’s current


system, where budgets are determined through conversations between the


consumer, his or her family, and his or her waiver support coordinator. They


develop a support plan listing the consumer’s needs and services desired. This


cost plan must comply with a variety of laws and rules, and then is subject to


review and approval by the Agency’s prior service authorization contractor. The


portion of the submitted cost plan that is approved by the third party prior service


authorization contractor becomes the individual’s budge or cost plan.


The current process is subject to greater variation in budget amounts between


similar consumers. Examples of reasons for this might be the varying skill of


waiver support coordinators in justifying funding requests or the availability of


family members who can advocate on the consumer’s behalf. However, even


the current process has an underlying rationality, as evidenced by our


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statistician’s being able to create an algorithm that has a good fit to the historical


cost data not only for our reference year but also the previous year. If the


system during our reference (FY 2007-08) and test (FY 2006-07) years had been


completely irrational and inequitable, any algorithm would model the funding


patterns poorly. The individual budgeting approach builds on the basic


underlying rationality of the previous system but seeks to enhance its equity.


Prospective Budgeting


An important difference between an individual budgeting system and APD’s


current system is when the budget amount is provided to the consumer. In


individual budgeting, the consumer learns what his or her budget is


prospectively, at the outset of the planning process. This can make the service


planning process simpler for the consumer, his or her family, and his or her


waiver support coordinator. By knowing the amount of resources the state will


provide, the consumer, his or her family, and his or her waiver support


coordinator can plan based on their priorities. The prospective approach


mitigates any possible conflict of interest or pressure the support coordinator


might feel to either reduce the costs or increase services unnecessarily. The


prospective approach also encourages the use of community and natural


supports.


The National Association of State Directors of Developmental Disabilities


Services (NASDDS) studied states’ individual budgeting processes. In a report,


Mosley differentiated individual budgeting approaches from more traditional


approaches saying, “In many states [, the . . . budget is built through a


developmental process in which people receiving support and their planning


teams actively participate in a series of structured decisions. … The statistical


analysis…essentially takes the place of the step-by-step decision-making


procedure.”1


Selecting services that may be paid for with the funding


While a goal of the iBudget Florida initiative is to enhance consumers’ self


direction, some individual budgeting systems in use in other states do not provide


for much self-direction. For instance, in such systems, the algorithm-based


processes determine a prospective budget, but restrictive system policies and


procedures or limited provider availability leave little room for consumers to make


real choices.


1 Moseley, C., Gettings, R., Cooper, R., “Having It Your Way: Understanding State Individual Budgeting


Strategies”, National Association of State Directors of Developmental Disabilities Services, 2003.


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However, APD wishes to increase consumers’ opportunities for self-direction.


The proposed elements that enhance self-direction are a key feature of this plan.


Accordingly, APD envisions revising the array of waiver services available and


the way that services are selected and approved to make it much more flexible


and responsive. An important step would be to eliminate the current prior service


authorization system and replace it with a limited service review that would be


required only in certain circumstances. For example, one way to do this might be


to broaden the scope of some services so that support workers will be able to


provide assistance for a greater variety of needs (this is the concept of the new


Flexible Benefit Service being developed by APD now). That way a consumer


would have more flexibility in meeting his or her needs day-to-day. This new


flexible service delivery system would be a very important part of iBudget Florida.


Note that APD recommends maintaining the Consumer Directed Care Plus


(CDC+) program as an option for its consumers. APD envisions that everyone—


including participants in CDC+–would have their budgets determined through the


individual budgeting process. Once the budgets are determined, however, CDC+


participants would follow the CDC+ program processes and policies rather than


iBudget Florida processes and policies to select and manage their supports and


services.


Individual Budgeting in Other States


Several states use or are in the process of implementing individual budgeting


approaches with at least some portion of their waiver enrollees. Some examples


are Colorado, Connecticut, Georgia, Minnesota, Oregon, and Wyoming.


In speaking with APD staff, Jon Fortune, a consultant with the Human Services


Research Institute who has extensive experience in developing and


implementing individual budgeting programs, said that states can implement


individual budgeting system in a budget-neutral manner and through them have


been able to contain costs.


An independent evaluation of Wyoming’s DOORS program, which is one of the


longest-running individual budgeting initiatives, stated that its program


“…continues to perform as it was originally intended: distributing waiver funds


equitably across the population of individuals enrolled in the HCBS waivers while


matching consumer needs with available supports.” This evaluation also stated


that consumers, families, and providers were all generally satisfied with the


approach. However, the report noted that system costs did increase over time


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and attributed them to increased waiver enrollment and the nature of that state’s


process for funding exceptional and changed needs.


Discussions with officials in other states lead APD staff to believe that Florida is


well-positioned to implement an individual budgeting approach coupled with a


self-directed system. Florida already has many of the necessary elements for


successful implementation: a relatively simple administrative structure,


standardized fee-for-service rates, independent waiver support coordination, a


large number of providers, and a valid and reliable assessment instrument with


which the entire population of waiver enrollees has been assessed. These


elements support consumer choice and self-direction and make implementation


easier. For instance, Connecticut still uses provider contracts in some instances,


and Oregon and Colorado’s systems use intermediary organizations to


coordinate services (counties in Oregon’s case and community centered boards


in Colorado’s), both of which provide challenges to implementation. South


Dakota has nineteen (19) providers, which limits consumer choice. Wyoming’s


budgets are equitable, but the rates vary by provider, which means some


consumers’ purchasing power is less than others.


Individual Budgets in Florida


An individual budget determined through an algorithm and provided prospectively


in the planning process is not a new idea in Florida. The concept has been


explored twice. An early program was implemented in the late 1990’s in District


13 of the Developmental Services program under the Department of Children &


Families. This approach considered a consumer’s living setting, primary


challenge, and level of need to place him or her in one of forty-three (43) funding


levels, establishing a funding range. While this program was not formally


evaluated and ran for a short time, it was reported to have been well-received by


consumers and providers and simplified processes significantly.


The concept was also proposed in 2002-03 by a contractor, Mercer Management


Consulting, which was assisting the Developmental Disabilities Program in a


redesign effort. Mercer recommended using an assessment instrument to


determine budget amounts with consumers and families having greater flexibility


in selecting and managing services.


Algorithms


As stated previously, individual budgeting uses a mathematical formula, or


algorithm, to determine budget amounts for waiver enrollees. This section


describes how algorithms are developed and what other states’ algorithms are


like.


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Development of Algorithm Options


The process for developing an algorithm involves statistical analysis and


modeling. The goal is to develop a formula that fits a data pattern of past


expenditures or service use; essentially, the formula tries to replicate


mathematically the decisions that were arrived at through the process of


discussions between waiver support coordinators and consumers and the


functioning of laws, rules, and policies governing service approval and use.


This formula is then used to generate future budget amounts similar to those


patterns of past expenditures or service use based on current characteristics of


people. For instance, if in the reference year or years, the 50-year-olds in


supported living with assessment scores indicating higher levels of need


generally received more funding than 30-year-olds in supported living with


assessment scores indicating lower levels of need, the algorithm will duplicate


those general relative patterns for future funding for similar people.


Algorithms are developed through trial and error. Statisticians test different


combinations of variables to see which combination works best to describe


previous funding patterns. There are several criteria used to determine which


algorithm out of several possible ones is the best choice; these criteria are that it


has a higher R² value, has fewer variables rather than many, and uses valid and


reliable data.


o “R²” is a statistical measure of how well an algorithm “fits” the data it is


trying to explain. A value of 1.0 is perfect fit; a value of 0 indicates no


relationship. The reported R² of some other states’ algorithms include:


o Louisiana: .46


o Georgia: .75


o Colorado: .26 & .51 (two waivers)


o Oregon: .45


o Minnesota: .55


o Wyoming: about .80


o An algorithm that uses fewer variables works better statistically; the more


variables, the more complicated the formula is. Other states’ algorithms


also vary in the number of variables they use. For instance, Colorado’s


uses four (4) variables, while Minnesota’s uses twenty-eight (28).


o Valid and reliable data is important to accurately build a model. If it is built


on inaccurate information, it will predict inaccurately.


Algorithms are refined over time as experience is gained in their use and new


data is collected and tested. For instance, Wyoming’s algorithm had an initial R²


value of .50, but is now about .80 after refinement. Note, that due to inequities


that are present in any human system, we do not seek perfect correlation with


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our reference year. Additionally no algorithm is perfect in its predictability. There


are always “outliers” (a statistical term)–individuals whom the model does not


precisely fit. States that have implemented this type of system initially may see


as many as 2-25% of individuals falling outside the model. Over time,


refinements to the assessment process and data elements reduce these outliers.


However, APD expects that for a number very unique individuals, funding


decision will have to continue to be made on an individual basis. APD will


establish guidelines for how budgets will be established for individuals who are


not accommodated in the model.


APD chose the Fiscal Year 2007-08 as its reference year; that is, APD sought to


pattern its individual budgets after the funding patterns of that year. APD felt that


this year was (1) recent enough to be linked to current assessment data and (2)


of recent years, based on the policies governing the system and the level of


expenditure that year, in general during that year consumers’ service patterns


had the greatest likelihood of reflecting their service needs compared to other


recent years. The recommended algorithm has a relatively high R² of .___,


which indicates that the funding patterns of that year were overall rational and


thus appropriate for basing an algorithm.


The algorithm recommended by APD in this report considers a consumer’s age,


living setting, and assessment subscores from the Questionnaire for Situational


Information (QSI) as well as answers on some individual questions from the QSI.


This data is valid and reliable, according to researchers. The algorithm also


features fewer variables rather than many, and has a relatively high R². Thus,


this algorithm meets the criteria outlined above.


APD’s contracted statistician tested the consistency of the recommended


algorithm against data from FY 2006-07. The recommended algorithm had a


similar fit to the FY 2006-07 data. This supports the algorithm and the approach


of individual budgeting generally, since it indicates that APD’s funding patterns


are consistent year to year and the algorithm successfully models them.


APD is interested in refining this algorithm as other states have done, and is


planning to collect additional data for testing for use in future algorithms. APD


views the algorithm proposed in this plan as a starting point to be used in the


initial stage of a phase-in of individual budgets. Stakeholders proposed a variety


of variables that they believed might correlate with costs, but APD did not have


reliable and valid data available to test their suggestions. APD would like to


collect data that might be used for new variables, test its predictiveness, and


refine the algorithm for use in the later stages of the phase-in of individual


budgets.


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Please see the technical appendix for a full discussion of the statistical aspects of


algorithms and the details of the development of the algorithm recommended in


this report.


Elements of Other States’ Algorithms


As discussed above, each state’s system is unique, and thus each state must


develop its own algorithm. For instance, some states serve children and adults


in the same waiver, while other states serve children and adults in separate


waivers. States serve different disability diagnoses. States offer different arrays


of services and have different rates. States also use different assessment


instruments to supply some data for the algorithms. Accordingly, state


algorithms vary. For instance, some algorithms have a large number of


elements, or variables, and others just a few. The specific variables themselves


also vary. Some examples of variables in other states’ algorithms are:


o Subscales or sections from assessments


o Overall scores from assessments


o Individual questions from assessments


o Diagnosis


o Age


o Living situation


o Services received


o Chronic conditions


o Mental health status


o Community safety risk


Some states’ algorithms include all of these variables, while others use just a


few. A table listing elements of some other states’ algorithms is included as


Appendix __ of this report.


Needs Assessment Instruments


A recommended element of individual budgeting is the use of a standardized


needs assessment instrument to collect information about consumers. In fact,


the federal government is encouraging states to implement needs assessmentinformed


individual budgets. Using a standardized needs assessment instrument


with established reliability and validity allows a state to have important


information about each person served.


There are a limited number of needs assessment instruments for developmental


disabilities for use by states. The two primary instruments promoted nationally


are the Inventory for Client and Agency Planning (ICAP) and the Supports


Intensity Scale (SIS). States use data from both of these instruments in


algorithms. For instance, Georgia, Colorado, and Oregon use the SIS, while


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Wyoming and Indiana use the ICAP. States have also have developed their own


instruments, as Florida has done with the Questionnaire for Situational


Information (QSI); other examples are Minnesota and Connecticut. States that


use national instruments still generally have a state supplement to collect


information they need but that the national instruments do not collect.


APD has assessed the full population of waiver enrollees and the majority of


individuals on the wait list using the QSI. The QSI was developed by melding


components of two previous needs assessment instruments developed by


Florida, the Florida Status Tracking Survey and the Individual Cost Guidelines.


APD proposes using data from the QSI in the algorithm. Reasons for doing so


include:


o More than 50,000 assessments have been completed, including the full


population of consumers enrolled on the waiver and a large portion of


individuals on the wait list. This provides a very strong base for


development of an algorithm since it includes a vast range of experiences


compared to using a limited sample of a few hundred or few thousand


individuals to develop an algorithm, as some other states have done.


o Validity and reliability studies by an independent researcher have


established the validity and reliability of the QSI. Additionally, these


studies indicate the QSI is comparable to similar instruments, including the


Supports Intensity Scale. Further information is available in the technical


appendix.


o The QSI does contribute to the algorithm which has a relatively high rsquare.


This means the QSI does perform a useful function in cost


prediction.


o APD can revise the QSI to meet state needs. As noted previously, other


states using national instruments typically use a state supplement to


gather additional necessary data. Thus even if APD were to use a


national instrument, APD would likely still use a QSI-like instrument to


obtain more information about its consumers. APD can revise the QSI to


gather new information as the need for it emerges.


o The QSI is administered by trained and certified APD staff. This avoids


problems that some other states have experienced where administrators


with a strong stake in the results have intentionally or unintentionally


biased the results.


It is important to remember that the data from the assessment is only one part of


the algorithm. That is, the assessment scores alone do not determine a


consumer’s budget. In fact, in the recommended algorithm presented in this


report, other data, such as age and living setting, contribute more to determining


the budget than does the assessment.


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Assessment instruments generally undergo a continual process of refinement.


There are a variety of ways to improve an instrument, from changing the way that


assessors are trained or administer an instrument, to revising the scoring


formula, to rewording questions, or adding or deleting questions for purposes of


calculating subscale and overall level scores. APD intends to work with


stakeholders to continually enhance the QSI. These enhancements are


expected to enable the QSI to be an even better predictor of individual budgets in


the future.


The Questionnaire for Situational Information is included as Appendix ___ of this


report.


Other System Elements


As stated previously, APD is interested in simplifying the system and enhancing


its consumers’ ability for self-direction. Accordingly, APD recommends a variety


of changes to its system in addition to the process for determining budget


amounts. These changes will give consumers more control and flexibility.


Simultaneously, they will reduce the bureaucracy that our partners in the system


such as waiver support coordinators and providers encounter day-to-day in


serving our consumers. APD is also looking to implement new processes for


quality assurance and monitoring of health and safety that are necessary under a


new system of greater consumer control and flexibility. Some of these changes


are:


o Increasing the flexibility in the service array. This primarily involves


grouping similar services into service families, allowing consumers to


switch among services in a service family with limited or no review. It


might also involve broadening the scope of some services, so that one


worker could do a wider array of tasks, simplifying service coordination


and billing.


o Elimination of the prior service authorization process. It would be replaced


with streamlined, more personalized process that would require little to no


review for many decisions, reserving more intensive review for situations


involving health and safety concerns or extraordinary funding requests.


o Creating a virtually paperless system. For instance, consumers’ central


records would be online and service authorizations would be submitted


electronically.


o Freeing up waiver support coordinators’ time and reframing their role to


refocus on person-centered planning, locating and developing community


resources, and coordinating supports. For instance, a good deal of their


time is current spent on paperwork related to the prior service


authorization process. The new process envisions a much reduced


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paperwork burden on waiver support coordinators, with the intent that they


use their time to support consumers instead.


o Increasing monitoring of consumers’ service patterns to ensure health and


safety and appropriate use of funding. For instance, having service


records maintained electronically will provide APD insight into what


services consumers have chosen to receive. APD can search for


indicators of potential health and safety risks and provider manipulation


and take action to investigate them and address.


o Providing training, information, and tools for managing budgets and


making good decisions to consumers and families. These might include


online budget development and management tools, provider directories


including quality evaluations by consumers and families, and training on


decision-making delivered via the web, by waiver support coordinators,


and through group meetings held by the area office or Family Care


Councils. It would also include a renewed emphasis on identifying and


using non-waiver-funded community supports.


o Creating a process for consumers with exceptional needs or significantly


changed needs to apply for additional funding. There are consumers


served by APD whose needs are so unique that the algorithm cannot be


designed to accommodate them. This is typical in any process of


modeling, or creating an algorithm, simply because of the variability in


most populations. Also, some consumers may have significant changes in


their needs during a fiscal year which require additional funding. A


process would be instituted to allow consumers who truly need additional


funds to address critical health and safety risks to apply for such funding.


Implementation Issues for Consideration


As stated in the introduction, individual budgeting will not guarantee a perfect


system, though APD leadership believes it will be an improvement over the


current system. Implementation issues to consider include:


o Like under the current system, individual budgets will not guarantee that


each consumer will have full funding for all waiver services they want,


believe they need, or have been determined medically necessary.


Individual budgets will instead distribute the available funding equitably


according to the variables in the algorithm. This funding will be generally


responsive to individual needs, so that consumers requiring more support


will receive more funding than consumers with fewer support needs. Note


that under federal law, the waiver is the payer of last resort and is


designed to work in conjunction with other paid and unpaid resources to


meet a person’s needs. To mitigate this issue, under this system, waiver


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support coordinators will be freed to spend more time doing personcentered


planning and obtaining natural and community resources to


augment APD-funded budgets.


o Individual budgets will not precisely tailor funding to a consumer’s needs.


That is impossible for any algorithm, given the variety of factors that


impact a person’s needs and the challenge of measuring them and


translating them into variables in a formula. Some examples of factors


that are theorized to impact a person’s needs are the natural supports


available to a consumer, the consumer’s own goals and preferences for


his or her life, and the availability of providers in an area. However, the


recommended algorithm explains a large portion of the variability in


funding patterns—___%, indicating that it captures much of what affects


funding. Also, note that the new system would allow consumers to more


precisely tailor services to their needs. If a consumer felt the funding


determined by the algorithm was insufficient, he or she could apply for


additional funding, though the request would be subject to thorough


review. Conversely, if a consumer felt all funding determined by the


algorithm was not needed, he or she could use only what was needed.


o Some consumers may experience increases in their iBudgets compared to


current cost plan amounts, while others may experience decreases. APD


has performed initial reviews to assess health and safety under this initial


iBudget, as will be described below. APD is proposing a phase-in of the


new budgets, as many other states have done. This will allow consumers


time to adjust to new budget amounts. It will also allow APD to study the


way the system works and fine-tune as needed. Note that when tiers


were implemented, no phase-in period was provided even though some


consumers experienced reductions to their cost plans of up to ___%.


Again, if a consumer’s health and safety would be compromised under the


iBudget amount as determined by the algorithm, he or she could apply for


additional funding.


While these are important issues, APD believes that they can be mitigated and


that the overall outcomes of greater system simplicity, greater sustainability,


more equitable funding, and increased self-direction are worthwhile.


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Detailed Agency Proposals


Following are discussions about the various elements of the system. For each


element, the report describes the current functioning of the system, the feedback


APD received from stakeholders and the public about that element, and the APD


proposal for revising that element. For the most part, APD adopted the options


that received the most support from the stakeholders participating in our iBudget


Florida Stakeholders’ Group. Please see Attachments ___ for the handouts


provided to the stakeholders listing a range of options for their consideration.


These were intended to be a starting point for discussion, and stakeholders were


also encouraged to suggest additional options.


A few caveats:


o Some system changes would require federal government approval.


Based on initial discussions with the federal government and other states’


waivers approved by the federal government, APD believes the proposals


contained in this plan have a good likelihood of being approved, but such


approval is not guaranteed.


o Finally, while upon initial review the Agency believes these


recommendations are feasible, upon actual implementation, issues may


arise that require modification to these proposals.


Funding Determination


As its name implies, individual budgeting approaches begin with changes to the


way that systems determine the funding available for each person. This change


is by using a mathematical formula, or algorithm, to set budgets. Along with the


Ph.D.-level statistician that APD engaged to advise on this initiative, APD has put


much thought and effort into selecting an algorithm that is as fair and equitable


as possible given the limitations of the reliable and valid data that are currently


available to the Agency. The relatively high R² value of the algorithm indicates


that it does a good job of generally replicating the funding patterns of our


reference year, Fiscal Year 2007-08, as well as another test year, Fiscal Year


2006-07. However, besides the selection of an algorithm, an individual


budgeting system requires three other key decisions: a process for handling


requests for meeting extraordinary and changed needs; the overall allotment of


Agency appropriations between individual budgets, one-time expenditures, and


meeting extraordinary and changed needs; and a schedule for phasing in


individual budgets over time.


Important to note is that algorithms can be works in progress. They can be


refined over time as states see in practice how they function, identify and collect


data that can be used in a new version, and test refinements that improve an


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algorithm’s ability to predict appropriate amounts of funding for each person.


With nearly 30,000 waiver enrollees, Florida would be one of the largest states to


adopt an individual budgeting approach. The large number of enrollees with the


wide range of variation in individual circumstances is a challenge for algorithm


development. However, with the relatively high R², APD believes that this initial


algorithm would function well, and believes that refinements over time could


enhance it even more. APD would be committed to ongoing enhancement of its


algorithm.


Current System


Budget development begins with conversations between the consumer, his or


her family, and his or her waiver support coordinator. They develop a support


plan and cost plan listing the consumer’s needs, resources, and services desired.


This cost plan must comply with a variety of strict laws and rules, including tier


limits on service availability, and then is subject to review and approval by


several entities, including the Agency’s prior service authorization contractor. If


needs change, the waiver support coordinator requests additional services


through the prior service authorization process.


Feedback from Stakeholders and the Public


Feedback includes the following:


Want to build a model tailored to Florida rather than simply adopting


another state’s algorithm.


Concern that funding for meaningful day activities will be eroded or


insufficient.


Concerns on using diagnosis in the model; don’t feel it’s appropriate.


Want to know the model details, including statistical details.


Questions on how to ensure validity and reliability of data used in model.


Want fairness to those living at home.


Consider how to adequately fund transportation costs through the


algorithm.


Concern that individuals on the Family and Supported Living Waiver had


their expenditures artificially capped during the reference year (FY 2007-


08).


Want fairness to those with significant support needs


Want the availability (or lack thereof) of natural supports in a home


considered in funding process.


Concern that iBudgets are a way to make cutting consumers’ budgets


easier.


Concern on how children are treated by the QSI and in the services


provided by APD.


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Recommendations


Algorithm


Development Process


APD engaged Dr. Xu-Feng Niu, Professor of Statistics at Florida State University,


to develop and recommend options for an algorithm.


The work of developing the algorithm involved several steps. These are


described in detail in the technical appendix. In summary, these were:


o Identifying the reference year, or dependent variable, and making


appropriate adjustments. As previously noted, Fiscal Year 2007-08 was


selected. The policy decisions which impacted the funding patterns of this


year compared to previous and later years were analyzed, and some


adjustments made to account for changes.


o Examining the Agency’s data to ensure it is reliable.


o Testing ___ variables to identify the combination of variables that best met


the criteria for selecting an algorithm. This process involved allowing the


computer to select the best variables among different sets of them; the


computer would select the variables for inclusion in models that met basic


statistical requirements. Over ___ different models were identified and


then evaluated based on additional statistical requirements.


o After best candidate models were identified, APD evaluated them based


on non-statistical criteria, such as ability to fund services critical for health


and safety.


A major challenge in developing an algorithm was the lack of valid and reliable


data to use as variables. Stakeholders suggested a variety of factors which


might correlate with funding. However, for many of these, APD lacked the data


to use. APD intends to work to collect data to test for use in future versions of an


algorithm. However, this recommended algorithm very adequately meets the


criteria for selecting an algorithm. APD proposes using this algorithm in the initial


phase-in of individual budgets while the Agency works with stakeholders to


define new variables to test, collect necessary data, evaluate the variables’


predictiveness, and refine the algorithm.


Recommended Algorithm


Based on Dr. Niu’s work, APD recommends an algorithm including the following


elements:


Add here


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This algorithm best met the criteria outlined previously in the report: a higher R²


value, has fewer variables rather than many, and uses valid and reliable data.


Add examples


Full details are in the technical appendix.


Implementation and Further Refinement


APD proposes that individual budgets be determined at the beginning of each


fiscal year, using the most recent data for each consumer.


APD also proposes an ongoing process of refinement of the algorithm, including


analysis of algorithm impact, collection of new data for potential use in the


algorithm, and development of new versions.


Process for Funding Exceptional Needs and Changed Needs


Add here


Determining Overall System Funding


Add here


Phase-In of Individual Budgets


Add here


Other Issues


Stakeholders have expressed concern that individual budgets would be used as


a means to reduce waiver-enrolled consumers’ budgets. They see this as


potentially being accomplished in two ways:


o By reducing the total appropriation, so that the available funding to be


allocated to consumers is less.


o By enrolling some or all individuals on the wait list on the waiver and then


allocating current funding to them as well as to the current enrollees.


Recent history offers ample evidence that it is quite possible to reduce the


budget under the current system. Similarly, it would be quite possible for the


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Legislature to implement reductions to existing enrollees in order to provide


services to wait list consumers. No management approach will ever negate the


need for effective advocacy. It could very well be the case that advocacy efforts


will be more successful as this approach will generate clear and credible


information related to service needs that are not available today, especially as it


relates to the wait list population.


Implementation Issues


Add here


Consumer and Family Control


At the heart of self-direction are opportunities for consumers and families to have


control over the services they receive. Policies and processes should offer real


choices. The system should provide supports to facilitate good decision-making,


such as information about available paid and unpaid services, service quality,


and likely outcomes of different choices. However, under the agreement with the


federal government, APD is responsible for ensuring the health, safety, and


welfare of the consumers it serves. Accordingly, APD must implement


reasonable limits on self-direction so that health, safety, and welfare are


protected. This is clearly a delicate balance to strike, and APD has come to the


recommendations listed below through thoughtful discussions with stakeholders


and the public. The general approach advocated by stakeholders is to begin with


enhanced self-direction, though not to the extent ultimately possible. That is


because so much of the iBudget processes will be new, and there will be a


learning curve for all involved in the system. As everyone gains experience and


implementation is successful, self-direction could be expanded over time.


APD also recognizes that some consumers and families will not wish to change


the services themselves or the processes by which they are selected and


managed. We believe that such consumers will be able to basically maintain


their status quo if desired, though if the algorithm determines a different budget


amount for them, they may need to make some changes to their service


package.


Feedback from Stakeholders and the Public


Feedback includes the following:


Is interest in greater consumer control?


Concern that consumers and families would be required to do more


paperwork.


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System now does provide for adequate consumer control.


System now does not provide for adequate consumer control.


Some consumers don’t have natural supports to help exercise selfdirection.


Some families will be unable to manage a budget.


Concern that consumers’ natural supports might not let them make


desired choices.


Concern that some providers may not cooperate or may be manipulative.


Consumers may make poor choices that put them at risk.


Consumers need opportunities to make choices and learn from the poor


ones.


Recommendations


APD recommends enhancing consumer and family control by dramatically


revising the service selection process, such as by scaling back the service review


process and by offering a revised service array. The role of the waiver support


coordinator will also be reframed so that he or she can be a strong support to the


consumer and family as they exercise self-direction. Within this framework,


however, APD must institute policies and procedures to ensure that choice is


exercised in ways that comply with state and federal laws and regulations and in


manners that still protect health and safety. Thus, APD proposes the following


policies, procedures, and tools for supporting consumers and families in making


wise choices:


o Overspending will be discouraged through:


o Periodic allocation of funds: Limits on spending to ensure funds last


through the year (system will not pay more than this amount for


services billed during this period): 85% of budget allocated at


beginning of each month over 12 months; however, 10% would be


allocated at the beginning of the plan year, and 5% would be in


emergency reserve. This would allow consumers to meet


unusually high service requirements. Funds not used in early


months would be carried over to later months, though unused funds


could not be carried over to a succeeding fiscal year.


o The waiver support coordinator issues service authorizations, so


that person monitors service usage to guard against overspending.


o Use of point-of-sale “swipe” cards, if technologically possible, to


track budget use real-time and refuse services if insufficient funds


are available.


o Overspending will be addressed by:


o Working with the consumer to adjust his or her budget.


o Requiring additional reviews for future changes (limit flexibility to


make changes).


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o Allocating additional funds temporarily to meet critical health and


safety needs.


o Finding a representative to assist in decision-making.


o For consumers who repeatedly overspend, require the use of a


mentor paid from the consumer’s budget.


o There would be a requirement to set aside funding for residential


habilitation services, nursing services, therapies, and behavioral services,


with no reductions to these amounts made without area office review.


o Consumers would be allowed to negotiate rates with providers up to the


maximum permitted in rule.


Please see the sections on service array and service review for more information


about the processes for providing consumer and family control.


Implementation Issues


Providing training to consumers and families about the new opportunities for selfdirection


will be critical. Waiver support coordinators, providers, and Agency staff


would also need training in the new processes and system philosophy so that


they could function in their new roles.


Enhancing consumer control will also require enhancing the Agency’s information


technology. For instance, APD is interested in adopting a system like Indiana’s


online budget development tool, which helps consumers clearly see what the


budgetary tradeoffs would be between using different amounts and types of


services. Such a system would need to include timely information about services


provided so that accurate budget amounts remaining can be displayed. The


Agency’s ABC system would also need to be enhanced.


Services Available under the Waiver


As stated previously, three of Florida’s waivers (Tier 1, 2, and 3) already offer a


wide range of services to its consumers. (The array offered in Tier 4 is more


limited.) Thus some might ask why the array should be revised. APD is


proposing doing so because the way in which services are defined affects the


process of selecting, coordinating, and managing them. For instance, the narrow


service definitions which differ slightly from one another require very specific and


detailed prior service authorization review. It also limits the work that one worker


can do, limiting consumers’ flexibility day to day. Accordingly, APD is suggesting


changes, which are outlined below.


Current System


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Currently, the Tier 1, 2, and 3 waivers offer 27 services. The tier 4 waiver (the


former Family and Supported Living Waiver) offers 13 services. These are listed


in Appendix ___. The services to be offered to waiver enrollees are specified in


the waiver application, which is approved by the federal government. The scope


and allowable frequency, duration, and intensity of each service are specified in


the Florida Medicaid Services Handbook, which is adopted in rule. The


handbook also specifies provider qualifications. The medical necessity of each


service requested by a consumer must be reviewed and determined by the


state’s prior service authorization contractor, APS. Only those determined


medically necessary may be provided to a consumer.


Florida tends to define its services more narrowly than some other states.


Florida also offers a larger number of services to its enrollees than most other


states.


Feedback from Stakeholders and the Public


Feedback includes the following:


o Start from scratch with new handbook rather than revising the current


handbook.


o Do like the idea of very broad services. This gives flexibility to meet the


real needs of the consumer.


o If services are grouped in service families, make sure they are logically


grouped.


o Very broad services might be more challenging for consumers to


navigate—for instance, it may be hard to know exactly how to meet their


needs.


o Questions about how rates would be determined for services that are


broadened to encompass existing services.


Recommendations


APD recommends adopting a modified version of a system proposed by Mercer


Management Consulting. This system would group waiver services into eight


service families. Once approved for at least one service within a service family,


consumers would generally be able to add additional services within that family


with little or no review, as long as those changes fit within the consumer’s


budget. The proposed service families and the services they would encompass


include:


Add here


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This structure should require minimal changes to individual services. If any


changes to rates are required, they will be made so as to have as neutral an


impact as possible.


Implementation Issues


Add here


Service Review (Prior Service Authorization)


Every state must provide for some review of requested services. The federal


government requires that states be effective and efficient in their use of Medicaid


funds. The entity that oversees states’ waiver programs, the Centers for


Medicare and Medicaid Services, expects that assessed needs be the basis for


paid services and supports. States have some flexibility in the design of their


service review processes; for instance, they can go beyond the federal minimum


requirements for service review. Florida is one state that has done so. The


drawback has been a complex process that is expensive, time-consuming and


detracts from consumer flexibility. Accordingly, this is one of the main system


changes envisioned under individual budgeting.


Current System


Based on a 2001 legislative mandate, APD implemented the Prior Service


Authorization (PSA) review process to address the growing needs of services for


consumers enrolled on a waiver. The PSA process provides a standardized


review of services to ensure that consumers receive medically necessary


services, which is a federal and state requirement for the provision of Medicaid


services. The Agency currently contracts with APS Healthcare to conduct PSA


reviews on waiver services. The purpose of the PSA review process is to ensure


that consumers on waivers receive medically necessary services at the


appropriate intensity, frequency, and duration. The program ensures statewide


consistency in the approval of medically necessary waiver services for


consumers in accordance with Chapter 409, Florida Statutes; Chapter 59G,


Florida Administrative Code; and Chapter 42, §440.230, Code of Federal


Regulations.


The PSA review process starts when the waiver support coordinator assists the


client and/or the family in developing a support plan and cost plan. PSA reviews


are conducted by contractors who are knowledgeable of the services that are


covered by the tier waivers, the criteria for the use of waiver services, as well as


services covered under the Florida Medicaid State Plan.


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PSA contracts are fixed-priced—the contractors receive the same amount of


money whether the services are approved, denied, reduced, or terminated. PSA


contractors are paid for the number of reviews that they complete, with a


minimum yearly amount built into their contracts. There is no monetary incentive


for denying, reducing, or terminating services. The PSA program continuously


strives to help consumers with developmental disabilities receive the services


and supports which are medically necessary to help them to live and work as


they choose.


Feedback from Stakeholders and the Public


Feedback includes the following:


o There is general dislike of the current prior service authorization process.


o Scaling back the prior service authorization process is great but we need


something to meet federal requirements for assessing necessity of


services.


o There are concerns about granting consumers too much control such that


health and safety are compromised, especially considering the variety of


changes being contemplated in the APD system.


o Tailor level of review to the nature of the need; for instance, more


intensive, medically-oriented, complex needs would require more in-depth


review.


o If use different entities to review (such as the 14 area offices), institute


policies and processes to standardize and refine them as much as


possible to ensure consistent results across the state.


Recommendations


APD recommends adopting a system which involves graduated levels of review,


ranging from no review for many service decisions to intensive review when


health and safety is at critical risk or additional funding beyond that determined


by the algorithm is requested. Reviews would be performed by a combination of


area office staff, central office staff, and perhaps technical experts under


individual contracts with the Agency, such as dentists or therapists.


o First iBudget cost plan, whether new to the waiver or transitioning to


iBudgets: The Area office will conduct an informal service review to


identify the medical necessity of service groups identified on a consumer’s


first cost plan under iBudget. Additional reviews will not be required for


many consumers.


o Adding a new service family: Consumers will have the flexibility to choose


between the services within service families on their plan as long as they


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stay within their budget. If a consumer chooses to access a new service


family, a service approval will be required.


o Request to receive additional funding (permanent or temporary):


Consumers will be required to work within their individual budgets. There


may be rare circumstances where the consumer experiences a significant


life change and the current budget no longer meets their need. If a


consumer requests services that exceed their individualized budget


amount, the services must be reviewed for medical necessity.


o Trigger Services: The following services will trigger a formal service


review if they are added as a new service, or if their amount increases:


o Intensive Behavioral Residential Habilitation


o Nursing Services


o Therapies


o One Time Services: Consumers would be required to access services


within their budget allocation. If there is a one-time service need that


cannot be met within their budget without jeopardizing health and safety, a


service and funding approval process can be initiated for the following


one-time services:


o Environmental Accessibility Adaptations


o Durable Medical Equipment


o Non-routine dental work


o Changes in the type of place where a consumer lives: If a consumer is


changing his or her living setting, requiring a new service family and new


individual budget amount, a service review will be required.


o Pattern of overspending: Consumers who overspent their iBudget within


the last 12 months will require a service review on an annual basis.


Additional reviews (such as when they desire to adjust their services) may


be required as part of a corrective action plan.


o Forensic Involvement: Consumers who have criminal or forensic


involvement may require a service and approval process to ensure that


their needs are met and to protect the safety of others.


Implementation Issues


APD may need additional staff in the central office or area offices to conduct


reviews. This could be accommodated by shifting resources currently expended


on the prior service authorization process or reprioritizing activities of existing


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staff. APD may also need to contract with individual technical specialists such as


dentists or therapists to assist with reviews.


Training would also be necessary to help all parties in the system understand


how the new service review process would work.


Waiver Support Coordination


Waiver support coordinators currently play a very important role in the system.


With individual budgets, APD envisions that their role will change will still remain


an important one. Waiver support coordinators will continue to help coordinate


services. However, they will also be called upon to support consumers’ selfdirection


even more than they are now. Their monitoring role will also grow given


the new system design and emphasis on self-direction. This will be offset by


decreasing the amount of time they have to spend on paperwork.


Current System


Once enrolled on the waiver, the consumer selects a waiver support coordinator


who advocates on behalf of the consumer and helps to get their needs met


through natural and community resources, state agency programs, and the


Medicaid waiver program. The waiver support coordinator makes referrals to


other agencies or programs, develops the support and cost plan that identifies


services needed, and coordinates overall service delivery. Although a support


coordinator is selected when the consumer first enrolls on the waiver for


services, a request for a change can be made if for any reason the consumer is


not satisfied with their support coordination services.


Waiver support coordinators are independent contractors under Medicaid


agreements to develop supports and services for consumers on the Medicaid


waiver program. When the waiver support coordinator works with a consumer


and family to plan and coordinate services, the following key activities are


performed:


• Meet with the consumer and his or her family and develop a support plan.


• Based on the supports and services identified in the support plan, the


waiver support coordinator will develop a Cost Plan to identify services, cost,


frequency, and duration of services, and service providers.


• The waiver support coordinator develops, locates, and coordinates with


the providers to provide the supports and services once they are approved.


There are currently three levels of support coordination which are offered—


limited, full, and transitional—though many consumers are constrained in their


selection. Adults may choose either limited or full support coordination. Children


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must use limited support coordination. Transitional support coordination is


reserved for consumers who are being discharged from a public or private


Intermediate Care Facility for the Developmentally Disabled (ICF/DD). These


levels of support coordination differ based on the number and nature of required


contacts with the consumer.


Feedback from Stakeholders and the Public


Feedback includes the following:


o Desire for greater flexibility in choosing level of support coordination.


o Waiver support coordinators play an important and multifaceted role in the


APD system. Need to ensure they are still available to help consumers


and families.


Recommendations


APD recommends maintaining the current three levels of support coordination


but renaming “transitional” support coordination to “enhanced” support


coordination and revising the criteria for what options are available to which


consumers.


o Children would receive funding in their iBudget for limited waiver support


coordination, but could choose to use other funds in their iBudgets to


receive full or enhanced waiver support coordination.


o Adults would receive funding in their iBudget for full support coordination,


but most could choose to receive limited support coordination.


o Certain consumers would be required to receive full support coordination


for at least a period of time. These include consumers who:


o Are newly-enrolled in the waiver


o Have had forensic involvement


o Have complex medical needs


o Have complex behavioral needs


o Will soon be are or are transitioning from school


o Are changing their residential setting to group home or supported


living from a different setting


o Have a recent alcohol or drug abuse history


o Are having difficulty managing their care or funding


o Consumers required to receive enhanced support coordination for a


minimum period of time would include consumers discharged from an


ICF/DD or from a forensic placement.


APD also recommends that waiver support coordinators continue performing the


general tasks as they currently do. As stated previously, APD envisions that the


tasks related to processing prior service authorizations should decrease


significantly for most consumers, which should reduce their workload. Thus APD


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proposes reframing their role to emphasize those activities which truly support


consumers with developmental disabilities: person-centered planning, help


create social connections, increase access to community resources, and train


consumers and families in self-direction and budget management. APD would


provide additional training to support coordinators to help them understand and


carry out their revised role in a new system.


APD recommends maintaining the Agency’s current approach to conducting


needs assessments, where trained and certified APD staff conducts the needs


assessments rather than providers or waiver support coordinators. This protects


the objectivity of the assessments. However, providers and waiver support


coordinators are important sources of information for the needs assessment


process, and APD would continue to encourage their involvement in that role.


Implementation Issues


Significant training will be required for waiver support coordinators. This will be


to introduce the support coordinators to their revised role and new processes. It


will also provide them with additional skills and knowledge so that they can


enhance their abilities to develop and locate natural and community supports. It


will also enable them to provide education and training on budget management


and smart decision-making to the consumers they serve.


Consumers, families, and providers will also need training to understand waiver


support coordinators’ role in the new system.


APD will also need to fully implement the envisioned electronic system for


maintaining client records and processing service authorizations and other


paperwork. This will be essential if waiver support coordinators are to be truly


freed up from their current paper-oriented responsibilities to provide greater


support to consumers.


Providers


Current System


The Agency for Persons with Disabilities relies heavily on the private sector in its


efforts to provide waiver services for consumers with developmental disabilities.


With the exception of services provided in the APD Developmental Disability


Centers (DDC’s) and forensic programs, all direct service is privatized. Agencies


providing services must be approved by APD. The service provider must be


under contract as a provider or willing to become a contracted provider in order


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for the Agency to pay for the service. The client has the right to choose the


provider that is most cost-effective and best suited to their needs. If a service is


to be paid for by one of the Medicaid waivers, the provider also will be required to


meet Medicaid and Medicaid Waiver requirements. APD currently has over


10,000 actively enrolled waiver providers.


Feedback from Stakeholders and the Public


o Please ensure that providers are still able to provide services and be paid


for doing so.


o Providers may wish to expand the range of services that a provider might


offer


o Guard against the potential risk of exploitation of consumers by some


providers who don’t have consumers’ best interests at heart.


Recommendations


APD proposes that providers be limited to those who are enrolled in the Medicaid


program (participants in the Consumer-Directed Care Plus program would still be


allowed to use non-Medicaid-enrolled providers). APD is not recommending


incorporating the flexibility for consumers to directly hire their own workers in the


iBudget system.


Implementation Issues


APD recommends enhancing training for providers to ensure that they fully


understand the new self-direction afforded to consumers under the new system


as well as any new policies and processes. The Agency would also seek to


revise waiver assurances, handbook provisions, and other governing documents


to dovetail with any relevant new policies and processes.


Quality Assurance and Quality Improvement


Quality assurance and quality improvement will be of even greater importance in


a more self-directed system. For instance, since consumers and families will


have greater control over service decisions, this will be balanced with more


intense scrutiny of the results of those decisions and intervention as necessary to


assure health and safety. APD is taking a broad approach to this issue,


considering every stakeholder in its system as a partner in assuring and


improving quality.


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Current System


The Agency for Health Care Administration, in cooperation with APD, is in the


process of engaging a new quality assurance contractor under a new quality


assurance program. The new quality assurance program is based on the


Centers for Medicaid and Medicare Quality Framework. This structure has four


levels: Design, Discovery; Remedy and Continuous Improvement.


o Design: The key design element of the new APD model is the


maximization of technology-based resources in order to overcome the


effects of limited time, long distances and a small pool of contract labor.


The strategy is to automate the consumer central record and allow the


contracted quality assurance provider to remotely monitor required


documentation via secure internet connections.


o Discovery: This activity is chiefly the responsibility of the contracted


quality assurance provider. Discovery occurs through the process of


remotely reviewing the provider submitted documentation contained in the


consumer central record and conducting face-to-face provider reviews


following a person-centered approach. Discovery data is to be submitted


electronically to the Agency. Discovery can also be initiated by the


Agency as necessary.


o Remedy: This level involves the APD Area Offices and the Central Office


as necessary. The areas will react to information identified through the


discovery process by taking such steps as may be necessary to remedy


reported deficiencies.


o Continuous Improvement: This level is the joint responsibility of the


contracted provider, the area offices and headquarters. Under the


leadership of designated staff from headquarters structured and


continuous quality improvement activities will be initiated and managed.


Feedback from Stakeholders and the Public


Feedback includes the following:


o Support revision of the quality assurance system to be more


understandable, less bureaucratic, and more person-centered.


o Concern that consumers may make poor choices that put their health and


safety at risk.


o Concern that consumers may be at risk of exploitation by providers and


natural supports.


Recommendations


APD recommends enhancing the current quality assurance and quality


improvement system in four main areas:


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Health & safety


Budget management


Outcomes


Compliance


Some methods of doing so for each area include:


Health & safety:


Requirement for use of full or enhanced waiver support coordination by


certain consumers who present higher risks to their own health and


safety or that of others (e.g., those with forensic involvement).


Competency-based training for providers.


Utilization reviews by the central office and area offices to identify


service patterns of concern.


Review of services by area certified behavior analysts and nursing staff


based on QSI scores or other indicators.


Limits on certain flexibility in selecting and changing critical services,


such as nursing, therapies, or residential habilitation.


o Budget management:


Training for consumers and families at all levels of skill.


Timely information on spending through web-based tools. This would


facilitate smart decision-making and monitoring:


Consumers & families


Waiver support coordinators


Area office staff


Contracted Quality Assurance reviewers


Policies to deter overspending


Corrective action plans to address consumer overspending


Data analysis of spending patterns to identify consumers at risk of


overspending and review spending in the aggregate to see if additional


policies or controls are necessary to help consumers spend


appropriately.


o Outcomes:


Training for all parties in the system on outcomes under a more selfdirected


system so all can have reasonable expectations and be able


to support achievement of these outcomes.


Training for support coordinators on handling issues of poor choicemaking


so that they may have reasonable expectations and be able to


support consumer choice while protecting health and safety.


Central Office review of support plans to assess consumer goals under


new system to review the outcomes that are being pursued.


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Procedures for waiver support coordinators to access area office


support and direction in addressing problematic consumer choicemaking.


o Compliance:


Training for consumers and families on provider responsibilities so that


they have appropriate expectations and know how to evaluate whether


they are or are not met, and how to respond appropriately.


Revise relevant waiver assurances signed by providers and the


Medicaid Developmental Disabilities handbook to clarify expectations


for and responsibilities of providers under a more self-directed system.


Central office review of service patterns to identify provider noncompliance.


Review of service delivery against support plan to assess whether


services are being delivered.


Publicly share information about non-compliant providers to inform


consumer and family decision-making.


Implementation Issues


Revisions to the quality assurance contract may be necessary to ensure its


processes align with the revised system, though APD is hopeful that given the


design of the revised system, few significant changes would be necessary.


As stated, training on the new system, processes, and expectations will be


necessary for all partners in the system: consumers, families, waiver support


coordinators, providers, APD staff, and advocates.


Also critical will be implementation of information technology that allows for online


monitoring and management of budget status and service usage. For


instance, the system will need to be able to link provider information on services


delivered so that consumers and waiver support coordinators know what funds


have been spent or are still available. Information technology systems and APD


processes will also need to support on-line maintenance of consumer central


records. These will have to be searchable so that APD can conduct data


analysis to identify service patterns of concern or otherwise learn about APD


consumers’ status and experiences.


APD will also need staff available in the central office and area offices to follow


up on indicators of problems, such as consumers with health and safety risks or


providers suspected of taking advantage of consumers’ new control.


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Implementation


APD plans to phase individual budgets in over time, with the schedule dependent


upon receipt of required federal approvals for changes in the waiver system.


APD would like to begin the first phase in Fall 2010, involving a limited number of


consumers in two or three areas. Such a first step would enable the Agency to


explore how the system works in practice and make refinements as needed.


During this time, the Agency would also be enhancing its needs assessment


instrument, gathering new data, and refining the algorithm. A wider phase-in


would begin in the Summer or Fall of 2011.


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Conclusion


In conclusion, an individual budgeting approach could be an improvement over


the current system, making the system simpler, more sustainable, more


equitable, and more supportive of self-direction. While there may be transitional


issues to address, they can be mitigated through a careful phase-in. Consumers


and families would benefit from having greater ability to choose services that fit


their unique needs, stronger support from support coordinators, less frustration


from excessive red tape, and greater ability to control their own lives. By


enhancing system sustainability, they will also benefit from a stronger system


that can serve them now and into the future.


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Glossary


Area or Region—The name for the Agency’s local service district. The areas and


region and the respective counties they comprise are:


o Area 1: Escambia, Okaloosa, Santa Rosa, and Walton


o Area 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,


Jefferson, Liberty, Leon, Madison, Taylor, Wakulla, and Washington


o Area 3: Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette,


Levy, Putnam, Suwannee, and Union


o Area 4: Baker, Clay, Duval, St. Johns, and Nassau


o Area 7: Brevard, Orange, Osceola, and Seminole


o Area 8: Charlotte, Collier, Glades, Hendry, and Lee


o Area 9: Palm Beach


o Area 10: Broward


o Area 11: Dade and Monroe


o Area 12: Flagler and Volusia


o Area 13 Hardee, Highlands, and Polk


o Area 14: Citrus, Hernando, Lake, Marion, and Sumter


o Area 15: Indian River, Martin, Okeechobee, and St. Lucie


o Suncoast Region: De Soto, Hillsborough, Manatee, Pasco, Pinellas, and


Sarasota


o Note that there is no Area 5 or 6.


Home and Community-Based Services (HCBS) Waiver—A program which offers


supports and services to assist consumers with developmental disabilities to live


in their community. A few examples of the 28 services that APD consumers


enrolled in one of the Agency’s HCBS waivers may be able to receive are adult


day training, respite, and residential habilitation services. HCBS waiver services


are funded with state and federal monies.


ICAP—Inventory for Client and Agency Planning. This assessment instrument


measures both adaptive and maladaptive behaviors and gathers additional


information to determine the type and amount of special assistance that people


with disabilities may need.


Reliability—A statistical concept involving evaluating an instrument’s consistency


in its measurement across time and across interviewers.


SIS—Supports Intensity Scale. This assessment instrument is designed to


measure the relative intensity of support that an individual with a developmental


disability needs to participate fully in the community.


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Subscale—A measure of a specific element of a construct. For example, the


main construct measured by the QSI is an individual’s need for support. The


subscales of the QSI measure specific elements of this need: need for functional


support, physical support, and behavioral support.


Validity—A statistical concept involving evaluating whether an assessment


instrument measures what it was intended to measure.


Wait list—The Agency’s record of consumers who have expressed a desire to


receive Medicaid Waiver services and have met initial eligibility standards.


Waiver Support Coordinator—A Medicaid waiver-enrolled provider who assists a


consumer with obtaining needed supports and services.

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