support coordination


Thanks to guest columnist and Executive Director of Special Gathering, Richard Stimson for this article

Many people within the mentally challenged community are receiving phone calls about the iBudgets.  This is a new thing from the Agency for Persons with Disabilities (APD).

One of the major differences is that APD may ask you to give up some money.  Perhaps they want you to give up $3,000 from your home-care services for which they will pay.  Under the iBudget, you can say back to them, “What about $1,000?  What if you give me $1,000, instead of $3,000?”  Then you must wait to see what APD says.

APD calls this a negotiation.  You will still be able to appeal; but APD is hoping they can find an amount you can agree to give up through these negotiation.  If you ask for an appeal, it will mean that you might win your appeal and you will get everything for which you have asked.  However, if you lose, then you will get nothing.

I have been to two of these negotiations.  These meetings feel like buying a car.  When you want to purchase a car, once you get a price from the sales person, you can ask for a lower price.  Then the sales person has to go and get their boss to sign off on the amount.

I really do not have any good advice.  If you just say, “No,” to the cuts and decide to appeal them it is all or nothing.  You may want to negotiate with APD and try to get something rather than chance getting nothing.

This is a comment to the entry, APD Changes.  This gives some clarification and slightly different point of view.  Thanks for your comment.

I have received this email as published at APD Changes also. I would also look at the descriptors. Your support coordinator can give you a copy.

I do know that the agency that operates the group home where my brother lives has had clients Res Hab reviewed. (This includes minimal level clients which means the possibility of clients being bumped down to basic level.) The email you posted did not have that rate for basic level but I think it is someting like 1,100 dollars.

I have heard that it is APD’s view that the organization APD had contracted with to approve services (and the level of those services) had been approving services incorrectly. APD no longer contracts with that agency and is approving services on there own (I think).

It appears from the email you posted that group home clients are being warned to review their support plans to make sure the support plan justifies the level of Res Hab. There appears to be an assumption that there is a problem with the way support plans are written.

I do not understand the line, “but the judge will only be looking at what was actually submitted. You will not be allowed to give the judge more documentation during your hearing”

If the problem is a support plan that was written incorrectly by a support coordinator and wrongly approved, why can’t a client inter new information that shows they need the service? It does make you wonder about the recent requirement on insurance (a long standing requirement that was never inforced). Will support coordinators become responcible for the loss services because of poorly written support plans?

One other thing. I wonder why the email you posted (unless I missed it) does not include supervision of self administration of medication under minimal Res Hab (the copy of the descriptors I have list that). In that every group home I know of administers the medication I would think this requirement would be met.

On Friday, June 3, 2011, there was a web meeting that District 7 Support Coordinators had with Tallahassee Agency for Persons with Disabilities (APD).  This meeting may have included Support Coordinators from around the state.  However, we have not knowledge of that.  Below is a statement that a support coordinator sent to Richard Stimson, Special Gathering Executive Director, about the meeting.

Hey, call me if you have time tomorrow.  The Host home issue is going to be BIG!  They (APD) talked about it in the web training on Friday. Anything to save a buck.  If people are not looking appropriate for Res Hab (residential habilitation) or NOT making progress, they are heading to the host home just like the good ole days of HRS (Health and Rehabilitative Services).  Hate to say it; but I think you were right.

You need to check this out with Support Coordinators you know, but it appears that the state is going to try to move clients that do not want to live in supportive living or who are unable to live in supportive living into host homes (foster homes).

While host or foster homes are not proposed in other states, Florida, like California, is known as a pace-setter across the nation.  This is a move backwards for people who are mentally challenged.  Having served on the Local Advocacy Council for several years, I learned that there is little or no oversight in this type of home.

As a ministry within the mentally challenged community, it is important that we be people of prayer for our members.

Good news for the mentally challenged community in Florida.  Thanks to the self-advocates who lobbied long and hard to make this happen!
It appears APD folks were left out of Medicaid reform!

This is from the

http://weblogs.sun-sentinel.com/news/politics/dcblog/2011/05/last_day_of_session_will_mean.html
The one group that is excluded from managed care is Medicaid recipients who are developmentally disabled, roughly 30,000 people. Developmental disabilities advocates lobbied lawmakers for months to exclude them from that plan and let them use the “iBudget,” an individualized spending plan that is capped. The House plan had originally looped them into the managed care plan, but the Senate insisted that they be allowed to use the iBudget.

This information was obtained from Aaron Nangle’ newsletter.  To receive Nangle’s newsletter, visit his website at waiverinfo@aol.com

Emergency Rule Lifted By Rick Scott

Details About How/When Rates Are Restored

Provider Update

The APD emergency rate reduction to provider rates will end at midnight, April 15. Provider rates will return to their March 2011 levels effective Saturday, April 16.

Rates for services provided between April 1 and April 15 will remain at the reduced rate.

To keep from issuing over 150,000 new service authorizations, APD is changing current service authorizations (April 1 – June 30). These service authorizations will have an approved amount based on the reduced rate for services provided between April 1 through April 15 and the old (higher) rate from April 16 through the service authorization end date.

Changed service plans will be available in ABC by close of business Monday, April 18.

Service authorization requests will be submitted to FMMIS the evening of April 18. Service authorizations are anticipated to be available Tuesday, April 19.

Billing is suspended until system changes are complete. APD anticipates that service authorizations will be available to Waiver Support Coordinators on Tuesday, April 19.  WSC must review and distribute these service authorizations. Once a provider has received a service authorization, they may begin billing for April services.

If you have any questions or problems with your service authorization, Area Office staff can answer questions and make corrections to service plans.

Rates

The rate shown on the service authorization will be the old (higher) rate. The approved amount on the service authorization may not be equal to the old rate shown on the service authorization multiplied by the number of units. The service authorization for April may show an amount slightly less than the original rate multiplied by the number of units because of the reduced rate used from April 1 through April 15.

When billing for April, please remember to reduce the amount billed for services provided before April 16.   

Because of the rate change, services (other than monthly) should be billed daily by date in April. Please do not “roll-up” service rates used after April 15 with services provided during the April 1 through April 15 period.

Service Scenarios

The sections below describe how reduced rate service authorizations will be handled to increase the rates.

Service Plans with Approved Amount <= $1.00 or Rate = $0.00 : 

 Service Plans with Approved Amount <= $1.00 or Rate = $0.00 will not be updated by this process.

 Monthly Services (One unit per month billed)

The services below will be handled as follows:

For April,    

The reduced rate will be multiplied by 50% (.5).              

The old rate will be multiplied by 50% (.5).

These two amounts will be added together to get the blended amount for April

Each remaining month (May and June) will be billed at the old rate ($100.00)

New Service Authorization Amount (April-June) 92.50 + 100 + 100 = $292.50

 Example:

Reduced rate = $85, Old rate = $100, 4/1/2011-6/30/2011

For April,

$85 x .5 = $42.50

$100 x .5 = $50

$42.50 + $50 = $92.50 (blended amount for April)

92.50 + 100 + 100 = $292.50 New Service Authorization Amount (April-June)

Monthly Services

Res Hab Basic – Standard

Res Hab Ext 1 – Behavior Focus

Res Hab Ext 1 – Standard

Res Hab Ext 2 – Behavior Focus

Res Hab Ext 2 – Standard

Res Hab Min – Behavior Focus

Res Hab Min – Standard

Res Hab Mod – Behavior Focus

Res Hab Mod – Standard

Support Coordination – Limited

Support Coordination – Full

Support Coordination – Transitional

Support Coordination CDC+ – Limited

Support Coordination CDC+ – Full

 Unit Based Services

The services below will be handled as follows

Calculate number of days between begin date and 4/15/2011 = Reduced rate days (DaysReduced)

Calculate the number of days between 4/16/2011 and service authorization end date = remaining days (DaysRemain)

DaysReduced + DaysRemain = DaysSA

Approved amount / reduced rate = number of units (Units)

Units / DaysSA = units per day (UnitsDay)

UnitsDay * DaysReduced * reduced rate = 4/1/2011-4/15/2011 amount (ReducedAmt)

UnitsDay * DaysRemain * old rate = 4/16/2011-end of service authorization amount (RemainingAmount)

ReducedAmt + RemainingAmount = New Service Authorization Amount

 Example:

Reduced rate = $85, Old rate = $100, Period 4/1/2011-6/30/2011, Amount $8500

4/1/2011 – 4/15/2011 = 15 (DaysReduced)

4/16/2011 – 6/30/2011 = 76 (DaysRemain)

15 + 76 = 91 (DaysSA)

$8500 / $85 = 100 (Units)

100/91 = 1.0989 (UnitsDay)

1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)

1.0989 * 76 * $100 = $8351.64 (RemainingAmount)

$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)

Unit Based Services

In – Home Supports (Live-In Staff)

Res Hab Basic – Standard – Daily

Res Hab Ext 1 – Standard – Daily

Res Hab Ext 2 – Standard – Daily

Res Hab Min – Standard – Daily

Res Hab Mod – Standard – Daily

Residential Habilitation – (Live In Staff) – Daily

Respite Care – Day

Adult Day Training – Facility Based

Adult Day Training – Off Site

Behavior Analysis Level 1

Behavior Analysis Level 2

Behavior Analysis Level 3

Behavior Assistant Services

Companion

Dietitian Services

In – Home Supports (Awake Staff)

Occupational Therapy

Personal Care Assistance

Physical Therapy

Private Duty Nursing – LPN

Private Duty Nursing – RN

Residential Habilitation – (Quarter Hour)

Residential Nursing Services – LPN

Residential Nursing Services – RN

Respiratory Therapy

Respite Care – Quarter Hour

Skilled Nursing – LPN

Skilled Nursing – RN

Specialized Mental Health – Therapy

Speech Therapy

Supported Employment   Group

Supported Employment – Individual Model

Supported Living Coaching

Services Reduced by a flat 15 percent

The services below will be handled as follows

Calculate number of days between begin date and 4/15/2011 = Reduced rate days (DaysReduced)

Calculate the number of days between 4/16/2011 and service authorization end date = remaining days (DaysRemain)

DaysReduced + DaysRemain = DaysSA

Approved amount / reduced rate = number of units (Units)

Units / DaysSA = units per day (UnitsDay)

Reduced rate / .85 = old rate

UnitsDay * DaysReduced * reduced rate = amount prior to 4/16/2011 (amount 1)

UnitsDay * DaysRemain * old rate = amount after 4/15/2011 (amount 2)

Amount 1 + amount 2 = New Service Authorization Amount

 Example:

Reduced rate = $85, Period 4/1/2011-6/30/2011, Amount $8500

4/1/2011 – 4/15/2011 = 15 (DaysReduced)

4/16/2011 – 6/30/2011 = 76 (DaysRemain)

15 + 76 = 91 (DaysSA)

$8500 / $85 = 100 (Units)

100/91 = 1.0989 (UnitsDay)

$85 / .85 = 100 (old rate)

1.0989 * 15 * $85 = $1401.0975 (ReducedAmt)

1.0989 * 76 * $100 = $8351.64 (RemainingAmount)

$1401.0975 + $8351.64 = $9752.7375 (New Service Authorization Amount)

 Services Reduced by a flat 15 percent

CONSUMABLE MEDICAL SUPPLIES

IN HOME SUPPORTS MONTHLY – S.L.WAIVER

Personal Emergency Response – Service

Res Hab Basic – Behavior Focus

Residential Habilitation – (Day) Intensive Behavior in a Licensed Facility

Special Medical Home Care

Transportation – Mile

Transportation – Month

Transportation – Trip

One time or infrequent services

The services below will be handled as follows:

A list of these service authorizations is being provided to the Area Offices. Changes for these services will be handled manually by the Area Offices

Services

Adult Dental Services

Behavioral Analysis Services Assessment

Durable Medical Equipment

Environmental Accessibility Adaptations

Home Accessibility Assessment

Occupational Therapy Assessment

Personal Emergency Response – Installation

Physical Therapy – Assessment

Respiratory Therapy Assessment

Specialized Mental Health – Assessment

Speech Therapy – Assessment

Special Case for Res Hab Behavior Focus

The services listed below have the same procedure code of either “T2020U6” or “T2023U6” in the Rate table. However Res Hab Basic does not have any given rates as this service comes under services with negotiated rates. The business rule being applied is:

a) Take the pre-April 1 ABC service plan rate (old) and compare it with all the rates available in the old rate table.

 b) If a perfect rate match is found for the procedure code and rate, the matched rate will be used in the current service plan. Otherwise the ABC old service plan rate will be used in the current service plan.

Services

Res Hab Basic – Behavior Focus

Res Hab Min – Behavior Focus

Res Hab Mod – Behavior Focus

Res Hab Ext 2 – Behavior Focus

Res Hab Ext 1 – Behavior Focus – Daily

Res Hab Ext 2 – Behavior Focus – Daily

Res Hab Min – Behavior Focus – Daily

Res Hab Mod – Behavior Focus – Daily

 Problems That Might Occur

One time or infrequent services are being handled manually

Units may not be used on a daily basis so the calculated amount is not correct

Source:  http://apdcares.org/news/news/2011/new-rule.htm

  ______________________________________________________

Message From Aaron Nangle

The aim of win-win negotiation is to find a solution that is acceptable to both parties, and leaves both parties feeling that they’ve won, in some way, after the event.  I don’t believe that has happened  for either party, and that worries me.  Providers and families are very, very thankful to The Governor and to the Legislators for restoring rates, yet they are also  fully aware that there is not enough funding to serve everyone and future cuts are likely. The Governor has made it very clear that APD must stay within its budget, and he has an obligation to tax payers to balance the Florida budget.  

There are about 50,000 people who need services from The Agency For Persons With Disabilities- just over 30,000 are on the waiver and 19,000 on the waiting list.   Historically, the budget has not been enough to provide services for the 30,000 on the waiver.  Furthermore, many people have been waiting for services for five years or more. 

In this crisis, we have come together and worked towards solutions.  We need to continue to do so.  The absolute worst thing we can do is to panic and start blaming each other.  Let’s face it, the money wasn’t wasted on private jets for our workers or exotic retreats, it was spent on medically necessary services. 

In order to balance the APD budget and also serve everyone on the waiting list, people would need to cut their service utilization nearly in half.  In most cases that is an impossible request.  We can not tell people they can only live in their group homes for 182 days per year.  From this experience we have also learned that provider rates can not be cut by 30-40 percent.  The law requires that agencies pay their employees at least minimum wage, and minimum wage is usually not enough to keep dependable, quality, caring providers. 

The second rule of successful negotiation is to understand the wants and needs of the other party.  

http://www.youtube.com/watch?v=yA7nCI1Q8Kg

(video of meeting in the Governor’s office)

We have a lot of work to do.

__________________________________________

Ever Care Adult Care Services LLC,

Is Ready To Help

  We have beds available immediately and are prepared to help anyone in need during these difficult times. Behavior focused adult male, Standard female and male beds are available. Live near the beach, enjoy great daily activities. Contact – Mary Jo, 727-449-7045 or Email: mhscan@aol.com 

 See our website at http://evercareadultservices.com/

______________________________________
 

Call to Advertise your company & be listed on our websites.
We want people to have a true choice.

SupportCoordinators.Com  –  WaiverProvider.Com

FloridaGroupHome.Com  –  FloridaUnites.com

FloridaAutism.org  –  FloridaGuardianship.com

In every negotiation, there are winners and losers.  Perhaps there are other winners yet to be revealed. 

Who wins in Medicaid overhaul? | Top Story | Health News Florida.

Linda Howard’s note:  This is from an email I received this morning.  The first part of the entry contains comments  from Richard Stimson regarding the article.  I quoted the entire article but I also referenced it.  Go to the original article  to input your comments with the Miami Herald.

You know, it is like a horror movie, every time you think things have gotten as bad as they can, it gets worst.  This is the Miami Herald and they sound like they are supporting Governor Scott.

First statement in RED by Kingsley Ross – Is this saying agencies will stop providing services?  I got an email from another FARF person that said something similar.  It basically said at these rates services could not be provided in a safe way.

First statement in GREEN by Brian Burgess – Is this saying that these cuts are this bad because of what happen in the past?  I think so.  Also from reading the article it appears they blame all of the appeals too (see second part in GREEN).  I also find the word use of “neediest” interesting.  I do not think they are talking financially because all waiver clients are on Medicaid.  I think they are talking about a new way to prioritize who gets services.  What would that look like?  Folks in Group Homes?  What happens to those in supportive living?

First statement in PURPLE by Miami Herald – Makes it sound like Scott had no other choice.  He had to do this.  I would take this to mean that the paper thinks Scott is within his authority to do this as an Emergency Rule!

Linda Howard note:  This is an article is from the Miami Herald.  Here is the web address.  Go there to input your comments regarding this latest action:

 http://www.miamiherald.com/2011/03/30/2142265_gov-scott-to-call-for-deep-cuts.html#storylink=addthis

AGENCY FOR PERSONS WITH DISABILITIES

Gov. Scott to call for deep cuts at agency for disabled

A $170 million deficit in the agency that serves the most needy in Florida has left Gov. Rick Scott with a tough call.

By Marc Caputo

TALLAHASSEE — Due to a shockingly large deficit, Gov. Rick Scott is planning to invoke his emergency powers and make deep cuts to the rates charged by group homes and case workers who help the developmentally disabled.

Scott could announce a 15 percent rate cut as early as Thursday to close the $170 million budget gap in the Agency for Persons with Disabilities, according to lawmakers who were briefed Wednesday.

The deficit — which exceeds the agency’s spending authority by nearly 20 percent — is partly the legacy of lawsuits, poor planning by the Legislature and a nearly $20 million veto by Scott’s predecessor, Charlie Crist, who starved the program of savings when he refused to trim provider rates last summer.

SYSTEM SHUTDOWN

Those who provide services to the nearly 30,000 Floridians with cerebral palsy, autism and Down Syndrome said they aren’t concerned with the origin of the deficit as much as the effect of deep rate cuts.

“This would be a catastrophe,” said Kingsley Ross, an advocate and lobbyist for Sunrise Community, a Miami-based group home operator.

For the past three years, Ross said, providers have shouldered rate cuts. They’re now operating on the thinnest of margins.

“The system can’t take this,” Ross said. “Eventually, we will have to cut jobs and reduce services.”

Scott’s spokesman, Brian Burgess, said the governor doesn’t want to harm the developmentally disabled. However, he said the state has put off tough choices for too long and the bill is due.

Burgess said paring the budget now will put the state in a better position to pay future expenses on the neediest. “Yes it’s painful,” Burgess said. “But we’re trying to alleviate the pain long term.”

Florida has a constitutional requirement for a balanced budget, but federally created Medicaid-related entitlement programs can go into deficit from time to time if the number of recipients increases or costs for needed services rise.

The Legislature estimated that next year the entire state budget will have a $3.75 billion shortfall. So lawmakers are trimming programs.

Troubled by the deficit in the Agency for Persons with Disabilities, Scott ordered an inquiry. The results of the investigation are scheduled to be released Thursday.

RECIPE FOR DISASTER

The Legislature tried to cut the program for the developmentally disabled last year, but Gov. Crist refused. He vetoed a 2.5 percent provider rate reduction.

Meantime, lawmakers didn’t budget enough money for the program to account for the fact that thousands of recipients had sued to block a system of service reductions and cuts to the program.

When times were flush five years ago, legislators expanded the rolls of the Medicaid program by about 5,000 — a move that brought cheers from advocates for the disabled. They had fretted that about 15,000 developmentally-disabled people were on a waiting list but unable to receive services.

But the waiting list has only grown. Medical costs have increased. But state tax collections plummeted and then flat-lined.

Add all those factors together, and the deficit in the $850 million program for the developmentally disabled is about $170 million, according to the Florida House’s proposed budget. The budget proposes to fix this year’s deficit by shifting money from special accounts. But the Senate offers no such solution, leaving Gov. Scott few choices. Neither he nor his fellow Republicans want to raise taxes to fill the deficit.

Scott’s proposal to reduce rates by 15 percent should save about $34 million. The rest of the deficit would be plugged by shifting agency money and reducing the rates of South Florida providers who get slightly higher reimbursements.

Sen. Joe Negron, a Stuart Republican who chairs the Senate’s health budget committee, and Rep. Matt Hudson, chairman of the House health budget committee, said they were briefed on the plan and support Scott.

 To record your input with the Miami Herald, please go to:  http://www.miamiherald.com/2011/03/30/2142265_gov-scott-to-call-for-deep-cuts.html#storylink=addthis

I received this e-mail from Laura Moheskey regarding the Florida DD waiver changes proposed by the state legislators.
 
Subject: Call to action
You are receiving an email from me because of one of the following reasons: You are a consumer or a family member of someone on the D.D. waiver OR you are a provider/agency that works with the D.D. waiver. Either way, this is an important email and I am asking you to PLEASE take some time and RESPOND to the CALL.

On Monday, I will be going to Tallahassee with a group called Peoples First of Brevard. This group is set up of individuals who are self advocates. My role is to only assist them and give guidance. It will be our third trip since November. Each time we go, we have had the opportunity to speak either in front of the Senate or the House. I believe this group is now being taken seriously in our State’s Capital.

On the 15th, 16th, and 17th there will be meetings by the Senate Subcommittee on Health and Human Services Appropriations the subject matter: MEDICAID REFORM.

Reforming the Medicaid system will have a harsh impact on individuals who are disabled and on the D.D. Waiver.

I am asking each one of you to take some time to call and email the following Senators on Monday, Tuesday and Wednesday.. Please tell them “One Size Does Not Fit All – Leave the DD waiver alone – NO HMO’s. . Be prepared to leave your name and zip code when you call.

I know everyone is busy, don’t assume someone else will do this. There are 31,000 people on the D.D. waiver. Emails are going around the State this weekend. If only a handful of folks do this then we might as well fold up now. The impact has to be HUGE.

Individuals who are disabled need a voice. Please let it be yours.

Thank you
Laura Mohesky

Here are the Senators on the Subcommittee on Health and Human Services Appropriations and contact info.:

Sen. Negron, Chair; Rep. http://www.facebook.com/l/288a8xoSJsZ6fJnZjXrpODgWTcQ;negron.joe.web@flsenate.gov

 1-888-759-0791

Sen. Rich, Vice Chair; Dem. http://www.facebook.com/l/288a83cSvzpvIUk5Wpf9VsfjhLA;rich.nan.web@flsenate.gov

1-850-487-5103

Sen. Gaetz, Rep.

http://www.facebook.com/l/288a8jR8p58zEGXul7iiPkCl_aA;gaetz.don.web@flsenate.gov

1-866-450-4366

Sen. Garcia, Rep.

http://www.facebook.com/l/288a88dtZCn5LcBue_gAaZmuarw;garcia.rene.web@flsenate.gov 1-850 -487-5106

Sen. Oelrich, Rep. http://www.facebook.com/l/288a84aAvehRK2Ye4VBeyxCcCiw;oelrich.steve.web@flsenate.gov

1-850 -487-5020

Sen. Richter, Rep. http://www.facebook.com/l/288a80sz_sOeSKuk1HgHVDrH_pw;richter.garrett.web@flsenate.gov

1- 850- 487-5124

Sen. Sobel Dem.,

http://www.facebook.com/l/288a8WXzC-xbWzfDFJ2ZssAE6IA;sobel.eleanor.web@flsenate.gov

1- 850-487-509

A friend attended the NACDD conference in Orlando. The Commissioner for the Administration on Developmental Disabilities (Sharon Lewis) spoke.  At a private meeting with a several others, policy was discussed.  Ms. Lewis said she thinks we are going to end up with “Global Waiver.” That we will see DD Waivers go away. That a state will have one waiver that applies to DD, TBI, Aids, etc. She also made reference to mid-class families not getting what they get now.
 
My source will check with the other people at the meeting to see if they heard the same thing.
 
Lewis also said in her speech (Informant did not know if she was talking about DD Councils or the DD population), that now that Kennedy was dead we had problems.

The Networks Self-Advocates traveled to Tallahassee to see the Florida legislators.  Here is several links to some of the articles their visit engendered.  The two people holding the sign are self-advocates from Titusville.

http://m.floridatoday.com/news.jsp?key=361250&rc=ne

http://miamiherald.typepad.com/nakedpolitics/2010/11/as-senate-opens-medicaid-reform-hearings-potential-clients-worry-about-hmos.html

http://www.tallahassee.com/article/20101118/CAPITOLNEWS/11180322/Lawmakers-take-on-Medicaid-reforms
http://floridacapitalnews.com/article/20101118/CAPITOLNEWS/11180322&theme=
http://staugustine.com/news/local-news/2010-11-18/lawmakers-mull-medicaid-overhaul
http://floridaindependent.com/15175/lawmakers-weigh-plans-for-medicaid-overhaul
http://www.pnj.com/article/20101118/NEWS01/11180320/Legislators-dive-into-Medicaid-reform

Last week, Governor Charles Crist of Florida vetoed a scheduled 2.5 percent cut in the amount that providers who work within the mentally challenged community will be paid for their services.  However, Crist did not veto a 2.5 percent that the legislature passed in the amount of services that mentally challenged people can purchase.

At first, this was seen as a great victory for our community.  However, thoughtful providers and advocates are having second thoughts about the true benefits for consumers and for the people who labor to make their lives better.

Had both been vetoed, this would have been a win-win situation for providers and for people purchasing services or the consumer.  Using the analogy of the old-time company store, if you purchase all of your supplies from the company store and your salary is cut from $10 a week to $7.50, this is a problem.  Yet, if the prices in the company store are also cut by an equal amount, people purchasing goods in the store will not see a cut in what they receive.  Flour that was once $1 is now, $.75.  Therefore the purchaser does not see any decrease in what they can purchase.

A short-sighted view says that providers have won.  But is that really true?  Some providers and advocates are having second thought.  After all, if the company store is still selling flour for $1 and consumers only have $.75 to purchase that bag of flour, no amount of figuring will mean that the store owner will make the same amount of money at the end of the week.  Providers and consumers have received a cut, whether we like it or not. 

In this case, salaries of consumers were cut but the prices of what can be purchased in the company store was not cut.  Some providers are seeing this situation is almost as bad for them and certainly worse for the consumer.  If as a consumer, I have always had $10 to spend in the store and now I have only $7.50, I’m looking for some place to cut my expenses.

As a provider, I may be paid the same amount of money for an hour of physical therapy but the consumers I serve can only afford to purchase 45 minutes of therapy.  I am only going to be paid $.75 for my services.  As a provider, I have lost $.25. 

Governor Crist did not do a favor for the providers by vetoing this bill.  And, providers are gradually realizing that this was not a victory for them or for the consumers.  As they are doing the math, they are putting away the confetti and plans for a victory party!

As those involved in Christian ministry within the mentally challenged community, we must continue to pray for wisdom from our elected officials and the providers who work within our community

Thanks to George Andrews, Medwaiver Support Coordinator, for sending this information:                         

  MANAGED CARE FOR PERSONS WITH DISABILITIES & MEDICAID BENEFICIARIES

Issue:  2.7 million Floridians including 30,000+ APD DD consumers will be required to join an HMO, Preferred Provider Networks (PPN) to receive benefits if Governor Crist doesn’t veto the new managed care bill  This will profoundly impact the quality, quantity and choices of services received. 

Read 66 page Bill:(HB 7223 > reconciled Senate/House version). DD section primarily on page 53 line 1471 to page 57 line 1585. 

Who:   Persons with Developmental Disabilities including Medicaid beneficiaries forced to join private manage care companies. 

When:  Managed Care will be phased in over the next 4 years with some changes 7-1-10. “By January 1, 2014, the agency shall begin implementation of statewide long-term care managed care for persons with developmental disabilities, with full implementation in all regions by October 1, 2015.”(line 1480-83)  House bill was heard in only 1 committee (not health committee) and passed all within 7 days (April 12-19, 2010)

Where:  Scope is the entire State of Florida, instead of continuing the current pilot project to ascertain if it really cuts cost and how if effects quality and availability of services. 

How:  The state will be divided into six regions that HMOs and PPNs will operate the managed care of all 2.7 million FL Medicaid beneficiaries.  The state will pay a monthly fee for each Medicaid beneficiary to the HMOs or PPNs instead of a fee for service.

Why:  HMOs and insurance companies have promoted a radical shift away from fee for service delivery system to a Medicaid managed care model that is privately operated with the promise that it will save the state 3% to 15%.  Additional motivation for this change was the $3 billion shortfall in revenues to meet the overall state budget along with the increasing Medicaid costs.  The problem is that the not so certain savings that were promised by HMOs, these savings will actually be used instead to pay for the HMO profits and administration.  

Impact of Change:  Medicaid beneficiaries such as DD Medicaid Waiver consumers will have less choice in selecting their providers.  Support Coordinators and other providers will be eliminated since HMOs / PPNs will hire their own case managers and decide which new cheaper providers to use.  As a result, quality and quantity of services will most certainly decrease since manage care providers have a vested interest in cutting services to maximize their profits.  If you like HMOs, you may like the change. 30,000 people with disabilities and their families including over 2.7 million other voting Floridians will be negatively impacted.  HMOs and PPNs are based on a medical model not on the special needs of DD consumers.  Over 15,000 persons with disabilities will remain on the wait list.  No impact in reducing the wait. There will also be thousands of people that will likely lose their job once implemented since HMOs and PPNs would employ their own people discarding many of the current providers of care.  Billions of state funded dollars may also leave the State of Florida if any of the new HMOs or PPNs are located outside of the state.  How does this change improve Florida’s economy and jobs?

Action you can take:  Get involved now! Contact Governor Crist.  Call, fax (850) 487-0801  email Charlie.Crist@MyFlorida.com  , or write a letter to Governor Crist @:  Office of Governor Charlie Crist State of Florida The Capitol 400 S. Monroe St. Tallahassee, FL 32399-0001.  In addition to telling him in a polite, respectful manner you are against this mandated managed care change, tell him briefly how it will affect you in a very short example.  (A sample letter is below).   Tell as many elderly and disabled people on Medicaid about this and offer to help them contact Governor Crist to veto.  Be sure to thank the governor for his veto protecting the most vulnerable, poor and disabled in addition to standing on principle of opposing the same legislatively manipulated process this bill took as the teacher Merit pay bill. Managed Care bill: Total time in House =1 week, no notice to 2.7 million beneficiaries,

only 1 committee had input and was clearly an abuse of the intended legislative procedure and process. 

Solution: Governor Crist vetoes bill. If reductions in state programs are still necessary to balance budget, then do take across the board reductions instead of managed care bill.  This bill removes choice and capriciously eliminates providers that have in many cases known for years the beneficiaries and their needs.  Eliminating providers such as support coordinators will be removing independent third party advocacy for the most vulnerable, poor and disabled population without a voice. If governor does not veto, at least require HMOs to respect the choice of DD consumer as to whether keep the current support coordinator and other providers.  This demonstrates respect for choice and some continuity. Or instead increase the scope of the pilot study currently underway or allow more time to study the results of the current pilot project to see if it actually works.

Here is how your State of FL Representative voted on this bill.  (Info provided is subject to change)

                       “A society will be judged on how it treats its weakest members”.

Dear Governor Crist,                 

ISSUE:  House and Senate Bill Related to Medicaid Reform and Implementation of HMO Management of the HCBS Medicaid Waiver  HB 7723

Question:  Should the State be Divided Into Regions Managed by HMO’s and Preferred Provider Networks

ANSWER:  NO!   PLEASE VETO THIS BILL

I realize you have difficult budget decisions to make. But please DO NOT SIGN the Medicaid Reform Bill.

The House and Senate adopted these bills, written largely if not entirely by a lobbyist for one of the HMO’s, without due consideration for the data available from the pilot study of this being conducted in the Miami-Dade area of the state. The reviews from those areas are mixed and hardly conclusive in showing that they improve the quality of life for any of the disabled citizens they are supposed to serve. In fact, there are numerous concerns among a great many recipients of services in those areas regarding the loss of choice and the significant decrease in the quality of services received under the HMO system. These bills were rushed through both the House (introduced in only 1 committee and 1 week later  voted on house floor-does that sound familiar?) and Senate with limited transparency and little deliberation–as if the deals for approval were made well in advance of the readings.   Is this the type of example and values we want to teach our young voters?  The message sent was that the rich and powerful can quickly force a dramatic change on the elderly and disabled without any notice or input from the very people the new law will affect.  

The current system involves the Agency for Persons with Disabilities (APD) playing a significant role in quality assurance and private contract HCBS Medicaid Waiver providers who advocate for the needs of their caseloads working together to get the needs of the developmentally disabled citizens of the state met. It has been working very well and though harsh, the cost containment efforts of this current system are finally showing significant gains while still allowing the State of Florida a good measure of control over the quality of services provided. Surrendering the entire service system over to greedy, profit-hungry HMO entities is NOT the way we want the State of Florida to go. 

If you still are inclined to support this proposal, please first consider increasing the scope of the pilot study currently underway or allow more time to study the results of the current pilot project to see if it actually works.  Make sure this proposal is proved before inflicting this drastic change on more than 30,000 people with disabilities and their families and over 2.7 million other voting Floridians.  There will also be thousands of employees within companies that will likely lose their job once implemented since HMOs and PPNs would employ their own people.  Billions of state funded dollars may also leave the State of Florida if any of the new HMOs or PPNs are located outside of the state.  Will this improve our economy and jobs? 

I am earnestly asking you to VETO the Medicaid Reform Bill and allow the current system with any necessary cost reductions to work. There are NO winners in this bill with the sole exception of HMO’s.

Thank you.

Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 1 of 8 CHAMBER ACTION

Senate House

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Representative Grimsley offered the following: 1

2

Amendment (with title amendment) 3

Remove lines 379-384 and insert: 4

(9)(a) The agency, in consultation with the Agency for 5 Health Care Administration, shall establish an individual 6 budget, referred to as an iBudget, demonstration project for 7 each individual served through the Medicaid waiver program in 8 Escambia, Okaloosa, Santa Rosa, and Walton Counties, which 9 comprise area one of the agency. For the purpose of this 10 subsection, the Medicaid waiver program includes the four-tiered 11 waiver system established in subsection (3) or the Consumer 12 Directed Care Plus Medicaid waiver program. The funds 13 appropriated to the agency and used for Medicaid waiver program 14 services to individuals in the demonstration project area shall 15 be allocated through the iBudget system to eligible, Medicaid-16 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 2 of 8

enrolled clients. The iBudget system shall be designed to 17 provide for enhanced client choice within a specified service 18 package, appropriate assessment strategies, an efficient 19 consumer budgeting and billing process that includes 20 reconciliation and monitoring components, a redefined role for 21 support coordinators that avoids potential conflicts of 22 interest, a flexible and streamlined service review process, and 23 a methodology and process that ensure the equitable allocation 24 of available funds to each client based on the client’s level of 25 need, as determined by the variables in the allocation 26 algorithm. 27

1. In developing each client’s iBudget, the agency shall 28 use an allocation algorithm and methodology. The algorithm shall 29 use variables that have been determined by the agency to have a 30 statistically validated relationship to the client’s level of 31 need for services provided through the Medicaid waiver program. 32 The algorithm and methodology may consider individual 33 characteristics, including, but not limited to, a client’s age 34 and living situation, information from a formal assessment 35 instrument that the agency determines is valid and reliable, and 36 information from other assessment processes. 37

2. The allocation methodology shall provide the algorithm 38 that determines the amount of funds allocated to a client’s 39 iBudget. The agency may approve an increase in the amount of 40 funds allocated, as determined by the algorithm, based on the 41 client’s having one or more of the following needs that cannot 42 be accommodated within the funding as determined by the 43 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 3 of 8

algorithm and having no other resources, supports, or services 44 available to meet those needs: 45

a. An extraordinary need that would place the health and 46 safety of the client, the client’s caregiver, or the public in 47 immediate, serious jeopardy unless the increase is approved. An 48 extraordinary need may include, but is not limited to: 49

(I) A documented history of significant, potentially life-50 threatening behaviors, such as recent attempts at suicide, 51 arson, nonconsensual sexual behavior, or self-injurious behavior 52 requiring medical attention; 53

(II) A complex medical condition that requires active 54 intervention by a licensed nurse on an ongoing basis that cannot 55 be taught or delegated to a nonlicensed person; 56

(III) A chronic co-morbid condition. As used in this sub-57 sub-subparagraph, the term “co-morbid condition” means a medical 58 condition existing simultaneously with but independently of 59 another medical condition in a patient; or 60

(IV) A need for total physical assistance with activities 61 such as eating, bathing, toileting, grooming, and personal 62 hygiene. 63

64

However, the presence of an extraordinary need alone does not 65 warrant an increase in the amount of funds allocated to a 66 client’s iBudget as determined by the algorithm. 67

b. A significant need for one-time or temporary support or 68 services that, if not provided, would place the health and 69 safety of the client, the client’s caregiver, or the public in 70 serious jeopardy unless the increase is approved. A significant 71 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 4 of 8

need may include, but is not limited to, the provision of 72 environmental modifications, durable medical equipment, services 73 to address the temporary loss of support from a caregiver, or 74 special services or treatment for a serious temporary condition 75 when the service or treatment is expected to ameliorate the 76 underlying condition. As used in this sub-subparagraph, the term 77 “temporary” means lasting for a period of less than 12 78 consecutive months. However, the presence of such significant 79 need for one-time or temporary support or services alone does 80 not warrant an increase in the amount of funds allocated to a 81 client’s iBudget as determined by the algorithm. 82

c. A significant increase in the need for services after 83 the beginning of the service plan year that would place the 84 health and safety of the client, the client’s caregiver, or the 85 public in serious jeopardy because of substantial changes in the 86 client’s circumstances, including, but not limited to, permanent 87 or long-term loss or incapacity of a caregiver, loss of services 88 authorized under the state Medicaid plan due to a change in age, 89 or a significant change in medical or functional status that 90 requires the provision of additional services on a permanent or 91 long-term basis that cannot be accommodated within the client’s 92 current iBudget. As used in this sub-subparagraph, the term 93 “long-term” means lasting for a period of more than 12 94 continuous months. However, such significant increase in need 95 for services of a permanent or long-term nature alone does not 96 warrant an increase in the amount of funds allocated to a 97 client’s iBudget as determined by the algorithm. 98

99 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 5 of 8

The agency shall reserve portions of the appropriation for the 100 home and community-based services Medicaid waiver program for 101 adjustments required pursuant to this subparagraph and may use 102 the services of an independent actuary in determining the amount 103 of the portions to be reserved. 104

3. A client’s iBudget shall be the total of the amount 105 determined by the algorithm and any additional funding provided 106 under subparagraph 2. A client’s annual expenditures for 107 Medicaid waiver services may not exceed the limits of his or her 108 iBudget. 109

(b) The Agency for Health Care Administration, in 110 consultation with the agency, shall seek federal approval for 111 the iBudget demonstration project and amend current waivers, 112 request a new waiver if appropriate, and amend contracts as 113 necessary to implement the iBudget system to serve eligible, 114 enrolled clients in the demonstration project area through the 115 Medicaid waiver program. 116

(c) The agency shall transition all eligible, enrolled 117 clients in the demonstration project area to the iBudget system. 118 The agency may gradually phase in the iBudget system with full 119 implementation by January 1, 2013. 120

1. The agency shall design the phase-in process to ensure 121 that a client does not experience more than one-half of any 122 expected overall increase or decrease to his or her existing 123 annualized cost plan during the first year that the client is 124 provided an iBudget due solely to the transition to the iBudget 125 system. However, all iBudgets in the demonstration project area 126 must be fully phased in by January 1, 2013. 127 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 6 of 8

(d) A client must use all available services authorized 128 under the state Medicaid plan, school-based services, private 129 insurance and other benefits, and any other resources that may 130 be available to the client before using funds from his or her 131 iBudget to pay for support and services. 132

(e) The service limitations in subparagraphs (3)(f)1., 2., 133 and 3. shall not apply to the iBudget system. 134

(f) Rates for any or all services established under rules 135 of the agency shall be designated as the maximum rather than a 136 fixed amount for individuals who receive an iBudget, except for 137 services specifically identified in those rules that the agency 138 determines are not appropriate for negotiation, which may 139 include, but are not limited to, residential habilitation 140 services. 141

(g) The agency shall ensure that clients and caregivers in 142 the demonstration project area have access to training and 143 education to inform them about the iBudget system and enhance 144 their ability for self-direction. Such training shall be offered 145 in a variety of formats and, at a minimum, shall address the 146 policies and processes of the iBudget system; the roles and 147 responsibilities of consumers, caregivers, waiver support 148 coordinators, providers, and the agency; information available 149 to help the client make decisions regarding the iBudget system; 150 and examples of support and resources available in the 151 community. 152

(h)1. The agency, in consultation with the Agency for 153 Health Care Administration, shall prepare a design plan for the 154 purchase of an evaluation by an independent contractor. The 155 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 7 of 8

design plan to evaluate the iBudget demonstration project shall 156 be submitted to the President of the Senate and the Speaker of 157 the House of Representatives for approval not later than 158 December 31, 2010. 159

2. The agency shall prepare an evaluation that shall 160 include, at a minimum, an analysis of cost savings, cost 161 containment, and budget predictability. In addition, the 162 evaluation shall review the demonstration with regard to 163 consumer education, quality of care, affects on choice of and 164 access to services, and satisfaction of demonstration project 165 participants. The agency shall submit the evaluation report to 166 the Governor, the President of the Senate, and the Speaker of 167 the House of Representatives no later than December 31, 2013. 168

(i) The agency shall adopt rules specifying the allocation 169 algorithm and methodology; criteria and processes for clients to 170 access reserved funds for extraordinary needs, temporarily or 171 permanently changed needs, and one-time needs; and processes and 172 requirements for selection and review of services, development 173 of support and cost plans, and management of the iBudget system 174 as needed to administer this subsection. 175

(10) The agency shall develop a transition plan for 176 recipients who are receiving services in one of the four waiver 177 tiers at the time qualified plans are available in each 178 recipient’s region pursuant to s. 409.989(3) to enroll those 179 recipients in qualified plans. 180

(11) This section expires October 1, 2015. 181

182

183 HOUSE AMENDMENT Bill No. HB 7225 (2010) Amendment No. 311719 Approved For Filing: 4/14/2010 1:57:04 PM Page 8 of 8

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T I T L E A M E N D M E N T 185

Between lines 4 and 5, insert: 186

providing for an establishment of an iBudget demonstration 187 project by the Agency for Persons with Disabilities, in 188 consultation with the Agency for Health Care 189 Administration, in specified counties; providing for 190 allocation of funds; providing goals; providing for an 191 allocation algorithm and methodology for development of a 192 client’s iBudget; providing for the seeking of federal 193 approval and waivers; providing for a transition to full 194 implementation; providing for inapplicability of certain 195 service limitations; providing for setting rates; providing 196 for client training and education; providing for 197 evaluation; requiring a report; requiring rulemaking; 198