Minutes of the PAD-CO meeting with DDD

Discussion with DDD (Sharon Jacksi, Barbara Ramsey, Christine Thomas) on 6/23/09; 11 PAD-CO members were present.

Below is a listing of topics and questions that were discussed.

Waivers

• HCPF had to okay the waivers and the funding caps and then forwarded the waivers to CMS/
• DDD & HCPF decided not to change all plans 7/1/09 when the new waivers went into effect.  They decided to have a “phase-in” approach where all new plans, or plans modified, after 7/1/09 would have to comply with the new waiver caps but when all the other plans came up for renew later then that is when the new waiver caps would apply.
• DDD stated that they received “hold harmless” funding in the past for Comprehensive waiver changes and that they did not get similar funding for the current SLS changes.  (They stated that the legislature did not appropriate the “hold harmless” funds but it was not clear as to whether DDD and/or HCPF submitted a funding request this legislative session or not.)
• To include some funding for the transition process, they decided to hold back $4 million (from the $40 million appropriated) to cover some of the “phase-in” (they also referred to this as the “transition”) approach.
• DDD will look at the caps and rates next fiscal year to figure out where the $4 million will be applied.

Funding caps

Question:  How were the funding caps for the SLS levels developed and by whom?

• DDD looked at the State appropriation of $40 million (the State legislature sets the appropriation amount for SLS funding), then they looked at all SIS ratings and this showed a “curve” (I think they implied it was a bell curve).  Then they analyzed all funding caps and how they affected the appropriation. Next they looked at the utilization rates and analyzed individual rates (e.g., respite services) and how many units were used.  DDD staff stated that they put in as many day hab units into this evaluation as was possible.
• DDD stated that some people are actually getting increases to their caps.
• Sharon Jacksi (DDD) said that they found out within the last two weeks that some CCBs had created “artificial caps” for their clients.  Some limited SLS plans to $13,000 and under and another CCB had limited their plans to less than $9,000.  (This data was not known when DDD and HCPF gathered and analyzed data to come up with the new funding caps and levels.  So, the outcomes were based on flawed data.)

Provider Rates

• There was a “rates” committee that had representatives from CCBs, DDD, HCPF, and providers.
• PAD-CO asked why geographical rates were not included in the final rates.  DDD stated that HCPF (long term benefits unit) determined that the State cannot allow for geographical cost-of-living allowances (so rates in Aspen are the same as rates paid in lower cost-of-living cities in the State).
• DDD said that personal care rates are higher in SLS than under Medicaid and EBD.
• PAD-CO raised the issue of transportation rates and that transportation needs varies by location and by the individual.  For example, individuals in the rural areas have further to travel than individuals in metro areas and para-transit is more expensive than other types of transportation.
• PAD-CO raised the issue of providers quitting because of the reduced rates.
• PAD-CO said that some rates substantially increased and asked why the rates weren’t just caps. The answer was that the State wanted uniformity in rates.
• PAD-CO gave an example of higher rates: a person who is at a level 6 SIS and attending day hab, the provider rate (for that level) went substantially higher.  This higher rate causes the person’s plan dollars to be utilized faster (thereby reducing the services provided).  DDD said that since the day hab provider could provide services at a lower rate then we may be able to negotiate “free services” from the day hab provider because they were now getting a higher rate.  (Comment:  What the DDD doesn’t realize is that providers average out the rates they receive from the population they serve so as to cover their operating expenses.  So, the people whose plans pay a higher rate are basically subsidizing other people’s whose plans pay at a lower rate.) 

Question: Can providers direct bill to Medicaid?

• DDD said that there is a lag time in getting providers paid.
• DDD is working this year to develop a process to allow individual and smaller providers to register as a Medicaid provider.

Question:  Will there ever be a requirement for Independent Contractors (ICs) to
get a Medicaid Number and meet similar rules required of PASAs?
 
RESPONSE:  All waiver providers must meet Medicaid qualifications whether the provider is delivering services as an individual, an agency or through an Organized Health Care Delivery System (OHCDS.)  The only OHCDSs delivering services for people with developmental disabilities in Colorado are the CCBs.  DDD is working to create system changes necessary to enroll all providers,  however the system is not in place yet and we don't anticpate it will be in place until the end of next year.

Utilization Rates

• Renee brought up an excellent point about utilization rates, which is that due to circumstances beyond parents’ controls (e.g., providers not showing up), parents were not able to utilize all the “allotted” funding and now our family member’s plans were reduced.
• DDD said that the average underutilization was estimated at 10% (the comparison was made between the IP Plans and what was actually paid).
• PAD-CO explained that the utilization rates do not represent the need but the SIS represents the need.  PAD-CO asked if we could get copies of this analysis.

SIS

• PAD-CO explained that PAD-CO had created a letter that explained the SIS evaluation process and that DDD had agreed to use this letter and that it would go out to all parents prior to the actual SIS evaluation meeting.  PAD-CO members stated that they never received a copy of the letter – either before or after the SIS evaluation.
• PAD-CO explained that the SIS process is counter-intuitive to the way parents have been taught to describe their family member(s).  Through the school years, parents were taught to focus on the positive aspects of their family member and to describe the things that were accomplished.  The SIS process is the opposite and parents needed to focus on all the things that their family members could not do.  Without realizing this “opposite” evaluation methodology, parents approached the SIS assessment with “here are the things that my family member can do.”
• PAD-CO stated that parents must be adequately trained on SIS and on all other types of resources (e.g., State Plan, EBD, home care allowance).
• Barbara Ramsey (DDD) stated that they were going to set up family forums to address this need.
• PAD-CO asked if there was a way that parents could request another SIS assessment because they were not properly informed/trained and DDD said there is a SIS dispute process.
• Sharon Jacksi agreed that communications could be better.

Question: Do you know how many individuals are losing services and funding?

Sharon Jacksi said that DDD has breakdowns by level (she called them “winners” and “losers”) and will share this information when it is available.

DDD said there are approximately 100 people at level E across the State and these individuals are funded above the $35,000 cap.  PAD-CO questioned whether these people would be grandfathered under the new SLS waiver and DDD said that SLS was not meant to meet all needs, and that these folks might be changed to the comprehensive waiver.

Question:  Why did all of this have to change?

• DDD explained that CMS had conducted an audit of comprehensive services and the audit finding was that Colorado was out of compliance.
• Based on the audit findings, the DDD adapted the findings to all the waiver renewal requests.
• The rates used to be set by the CCBs because the State contracted with the CCBs using the “block grant” method (meaning they gave each CCB total dollar amount and allowed the CCBs to determine a lot of the details, like provider rates).  Because of the audit, the CMS/DDD wanted uniformity across programs and decided to set provider rates at the State level and not at the CCB level.  (Carrie asked a great question:  Do the provider rates under the waivers match the provider rates under the State Plan.  The answer from DDD was “no.”)
• The audit also required the State to have a uniform assessment process and the State budgeting process requires budget neutrality (meaning the Division cannot exceed their appropriated budget).

Question:  Why did the DDD combine certain levels?

• Sharon Jacksi (DDD) stated that they will be re-looking at this.  She also said that she will send out the PowerPoint presentation (if we want it) as this lays out how the levels were determined.  (She mentioned several times in the meeting that most of this information is on their website.)
• Sharon said that levels 3 and 4 were close to having the same needs and the “rates group” did not realize how costs affected services.
• If DDD wants to change the combining of levels, they need to amend the waiver and DDD stated that this “should not take long” (they said it shouldn’t take a year to get this through).
• DDD said they copied Day Hab comprehensive rates over to SLS and DDD did not fully realize the impact to these changes.

Question:  Why not include self-determination in the SLS waiver?

• DDD stated that they want to expand to all areas of the waivers but that will take time.
• CDASS is for medical assistance/attendant support (which includes health care, home maintenance and ????).
• DDD does not have legislation to expand CDASS. to other portions of the SLS program.
• DDD’s next highest priority is CDASS after the waivers are in place (apparently, CMS has asked for a couple of clarifications on the waivers and DDD is hopeful that they will be fully approved by 7/1/09 when the current waivers expire).
• CDASS will require the development of technical assistance documents, defined rates, training, etc.
• DDD wants CDASS to mirror HCPF and be flexible.
• PAD-CO asked if CDASS funding would be separate from the individual’s SLS plan and the DDD said “no”, that there wasn’t any more money available.
• DDD said that some CDASS services are available through the State Plan.

Behavioral Supports.  Is DDD looking to add this as a component?

DDD said “yes” and that there are questions on the community risk and they will add a specific section to the SLS for evaluating behavioral needs. 

PAD-CO asked how many people did not get the services by their CCBs.

• DDD said they don’t know but that wasn’t the issue, DDD needed to standardize provider rates.
• DDD said their contracts with the CCBs stated that the average per client had to be $13,000.
• DDD said that the intent was to have a managed care system where people get what they needed.  These changes make the system a “quasi-managed care” system.
• DDD said they had to go to a “fee-for-service” model and this was a way to redistribute the funds and services.

PAD-CO asked how we can implement needed changes to these new waivers, rates, and caps.

• DDD stated that they can’t make changes but can amend the waivers.
• They can change “bands” of services in the waivers, like transportation.

PAD-CO asked if the DDD would be receiving any stimulus funds for the waivers and the answer was “no.”

PAD-CO asked if there would be any new SLS slots because it seems as if there will be more funds available due to the reduced funding to families.  The answer was “no, there won’t be any new SLS slots.”

PAD-CO asked about wait lists and DDD explained that these are handled by the counties but DDD is considering making it one state-wide list.

Targeted Case Management – DDD determines the rates for these services and these services do not replace the SLS case manager and the funding does not come out of an individual’s SLS plan and funding.

Denver asked DDD to conduct a study of the CCB system.

• DDD is looking to put together a task force.
• In the next couple of months, DDD will have a renewed effort to evaluate (but not the conflict-of-interest issue) led by Tim Hall (he is the new Deputy Executive Director over the Vets and Disability Affairs.

After hearing the great input from PAD-CO, Sharon Jacksi was surprised at what is actually occurring and said that parents should let DDD know what’s going on.  She said that under the FAQ page, there is an e-mail address where questions/inquiries/and issues should be sent.

PAD-CO asked if a parent got an FAQ, could they take that to the CCB without retaliation.  Sharon Jacksi stated that they want to know about all instances of retaliation.

DDD said they would provide the written rate analysis to PAD-CO (the PowerPoint Presentation) and Judy Brown was the work leader on this effort.

Sharon Jacksi agreed to have more meetings to continue discussions and agreed to get us the “winners” and “losers” list.

Sharon asked the group to come up with a 2-page document that would identify themes or topics (e.g., respite).  This would help DDD organize and respond to questions and issues. 

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