Transcript State Budget Webinar - Ohio Health Care Association

State Budget Webinar
April 22, 2015
Pete Van Runkle
State Budget Agreement
• Executive Budget (DODD) was mixture of good things
and challenging things
• Widespread concern about DODD proposal and actions
of providers and families
• Resulted in legislative skepticism toward DODD
initiatives, opened door to agreement
• Agreement negotiated between DODD and provider
associations, adopted in House version of HB 64
Impact of Agreement
• Mitigates the most onerous provisions of Executive
Budget
• Continues trend toward reducing ICF footprint
• Responds to DRO threat, but:
Michael Kirkman, the executive director of Disability Rights, said in a
statement that the House amendments “allow institutional providers to
maintain capacity and to backfill beds” that empty when people choose
community-based services. “With this missed opportunity, Ohio will
maintain its reputation as a leader in isolating people with disabilities in
institutions and segregated workplaces in violation of the Americans With
Disabilities Act,” Kirkman said. (Columbus Dispatch, April 20, 2015)
Implications for Providers
• Agreement still must go through Senate and
Conference Committee, but is not likely to
change significantly
• Providers should explore the details now to
begin planning and preparation
• Some provisions effective July 1, 2015
Grand Bargain (Updated)
• Original 2013 Grand Bargain:
– 1,200 beds to be converted or downsized by June 30, 2018
– At least 500 converted, 500 downsized
– Statute called for interim numbers, but never identified
• 2015 update establishes interim benchmarks/ milestones for conversions
only:
– 225 by June 30, 2016
– 350 by June 30, 2017
– 500 (or more) by June 30, 2018
• Note: Grand Bargain applies to ICFs with 16 or more beds, not 9 or more
Grand Bargain Considerations
• Conversions must be implemented by deadline, not just committed
• Will need to verify the numbers and monitor closely going forward
• Per DODD, does not include downsizing/conversion that occurred
before July 1, 2013
• No prescribed penalty for failing to meet numbers
• Will be issue in discussion about new payment system
• All operators of larger ICFs should give serious consideration to
downsizing and converting
Existing Incentives: ICF/IID
• Three month cost report (actual downsizing/conversion)
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Adjusts rate for increased per diem costs of operating smaller facility
Applies to downsizing and partial conversion
Rate change retroactive to project implementation date
Also applies to new ICFs created as result of downsizing
• Avoiding rate penalties on large ICFs (plan to downsize/convert)
– Efficiency incentives cut in half for indirect and cost of ownership
– Non extensive renovations combined with cost of ownership
Existing Incentives: Waiver
• Small increase in rates
• Temporary $2.04 increase for taking person
from ICF
New Incentives: ICF/IID
• Enhancements to 3 month cost report
– Recalculation of direct care rate to reflect (presumably) higher
case mix
– Large ICF permitted to receive small ICF capital ceiling
• Bed buy back opportunity
– $1 million per year state funding
– Details to be determined
• Potential restructuring of state grants for ICFs
More Incentives
• Total conversion incentives
– Payment for date of discharge
– Early termination of bed tax
– Potential forgiveness of state grant
• DODD backs off of 6 bed limit on showing of financial
infeasibility
• DODD agrees to work with providers to create
successful downsizing/conversion projects
New Incentives: Waiver
• 6% increase of waiver rates
• Continuation of $2.04 increase for ICF individuals
• Applying to CMS for approval of:
– Nursing to be added to IO Waiver July 1, 2016
– Daily or weekly waiver rates
• Rental assistance, bridge funding (state dollars)
ICF Reimbursement System
• System remains in statute
• Current system has two year shelf life
• Goal is to have new system in place by July 1, 2017
• DODD to issue RFP for out of state consultant by July 31,
2015, perhaps earlier
• ICF Reimbursement Workgroup to interact with consultant
• RPF will call for report by September 30, 2016
New Reimbursement System
• Constrain cost
• Include quality measures (Quality Measures
Workgroup: November 4, 2015, deadline)
• Include review of IAF and RAC grouper
Another Interim System
• Two year system (July 1, 2015-June 30, 2017)
• Continues “layering” of modifications on top
of cost based statutory formula to stay within
mean rate cap
First Year (SFY 2016)
• No change in modifications
• Direct ceilings recalculated to hit rate cap with no
rollback
• Rate cap increased by $0.65 to accommodate
increased cost from three month cost reports
• Cap reduced by $0.10 to reflect reduction of bed tax
• Final cap = $283.32
Second Year (SFY 2017)
• Rate cap increased by 2% to $288.27
• No accommodation for 3 month cost reports (included in the 2%)
• Possible additional cap increase at DODD’s discretion based on statutory
factors (e.g., actual ICF spending in SFY 2016, number of conversions,
three month cost report impact)
• Direct care ceilings fixed at SFY 2016 levels
• 2% increase delivered by “direct support personnel payment” of a set
percentage (to be determined) of each ICF’s per diem direct care costs
• Becomes “budget dial” in place of ceiling
Flat Rates
• Group 5: $206.90
• Group 6: $174.88
• These are maximums – if facility’s normal rate
is lower, the normal rate applies
Applicability of Flat Rates
• Do not apply to small ICFs (8 beds or less)
• Do apply to new admissions to a large ICF (9 beds
or more) beginning July 1, 2015
• “Large” includes smaller buildings licensed
together under one license
• Statute does not address readmissions or
transfers: “admitted as a resident to the ICF/IID”
Practical Considerations
• No impact on small ICFs
• For large ICFs:
– How does flat rate compare to normal rate?
– Do IAF before deciding on new admission if there is
any question
– Consider doing IAFs for individuals on waiting list
– Ties into admissions review by county board/DODD
Future
• Like the reimbursement system as a whole,
this is a two year situation
• DODD’s goal is to encourage ICFs (especially
large ICFs) to focus on higher need individuals
• Issue likely to resurface in discussion of new
payment system
Admission Review
• Concept: intervention by county board and
DODD to find out if individual would prefer
waiver
• Does not apply to small ICFs
• Does not apply to transfers from another ICF
or readmissions
Review Process
• Large ICF cannot admit a person unless process followed
• Written notice from ICF to county board where person resides,
accompanied by all information ICF has about person
• Notice must be given at least 7 business days before admission
• County board responsibilities:
– Evaluate individual
– Counsel them on their needs and “least restrictive environment”
– Issue findings to individual and DODD using prescribed form
Review Timetable
• County board has 5 business days for their duties
• DODD has 7 business days to determine that “the
individual chooses to receive ICF/IID services
from the ICF/IID after being fully informed of all
available alternatives”
• DODD’s 7 days include the county board’s 5 days
Review Outcome
• ICF can admit if DODD does not meet its
deadline
• If person chooses waiver instead, 900 state
funded waivers per year available for ICF
diversion
• No mandate to give waiver, unlike exit waivers
Practical Considerations
• Again, no impact on small ICF
• Notice to county board can be given sooner than 7
business days before admission
• Consider having review done on waiting list
• Doing in advance eliminates/limits duration of vacancy
• Can combine with IAF review to identify Group 5/6
Options Counseling
• Concept: make people currently in ICFs aware of their
options and give them access to waivers
• Applies to all ICFs
• DODD to develop (with stakeholders) pamphlet that
describes “all of the items and services covered by
medicaid as ICF/IID services and as home and
community-based services”
• DODD distributes pamphlet to all ICFs
Counseling Responsibilities
• Facility staff provide the actual options
counseling to individuals and guardians
• Give pamphlet and “discuss” items/services
• Done annually, upon request, upon expression
of interest in HCBS
Exit Waivers
• 200 state funded waivers per year
• Budget bill makes individuals wanting to exit ICF priority on waiver
waiting list
• If individual/guardian indicates interest, ICF must refer to county
board for enrollment within 30 days, provided:
– Individual is eligible and chooses to enroll
– Waiver has available slot
– DODD has funding
• ICF does not lose bed
Practical Considerations
• Integrate with annual review of individual plan
• Inform about exit waivers (essentially, an
entitlement)
• Consider dovetailing with conversion strategy
• Exit waiver does not count as conversion unless
provider gives up ICF bed
Two Per Bedroom
• Requirement must be met by December 31,
2025
• Applies to all ICFs with more than two per
bedroom (except as exempted)
Exemptions
• Completed downsizing/conversion of at least
20% by January 1, 2015
• Room occupied only by children with
parent/guardian consent
• Same individuals live in the room from now
until 2025 and at least three want to keep
arrangement
Compliance Plan
• Must submit plan for DODD approval by December 31,
2015
• Plan must “include” downsizing/conversion (but also
can include reconfiguration)
• Can’t wait until 2025 to make “regular” progress
(looking for beds to be taken out over time)
• If downsizing, new ICFs must be no more than 6 beds
unless financially infeasible, then 8
Enforcement
• Can continue to use non complying rooms while plan
reviewed/implemented
• Must submit annual progress reports
• DODD can suspend admissions for failure to comply
with plan (unless provider not at fault) or to submit
report
• If no approved plan, could result in license revocation
Practical Considerations
• Does not apply if no more than 2 per bedroom
• Do any of the exemptions apply?
• How many beds need to be moved?
• Impact of existing downsizing/conversion plans?
• Make a reasonable plan – you have 10 years, but need to
make regular progress
• Keep plan submission deadline in mind
Bed Tax
• State Fiscal Year 2016: $18.07
• State Fiscal Year 2017: $18.02
Questions?