support coordination

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.;


Sen. Rich, Vice Chair; Dem.;


Sen. Gaetz, Rep.;


Sen. Garcia, Rep.; 1-850 -487-5106

Sen. Oelrich, Rep.;

1-850 -487-5020

Sen. Richter, Rep.;

1- 850- 487-5124

Sen. Sobel Dem.,;

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.

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:                         


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  , 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


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


Representative Grimsley offered the following: 1


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


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


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

—————————————————– 184

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

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