Transcript Slide 1

T03: Keep it Simple…ICF-IID
Update & Strategies for the Future
OHCA/OCAL/OCID
Presented by:
2014 Long-Term Care Convention & Expo
John P. Fleischer, CPA, Principal
Columbus, Convention Center
Rosemary Orlando, CPA, Principal
April 29, 2014
What We Will Cover
Ohio Overview
National & State Trends
HB 59 Provisions
ICF/IID DODD - Stakeholder Agreement: 3/15/2013
Downsizing/Capital Considerations
CY2011 Audits
12/31/13 IAF Exception Reviews
H2
Objectives
Discuss agreement reached on ICF/IID Direct Care Ceiling
Analyze payment system and related strategies for ICFs/DD
for FY 2015 and beyond, including measurement tool
implications and upcoming reimbursement changes
Discuss possible downsizing strategies and opportunities
within department’s rebalancing framework
Describe strategies for capital improvement and
replacement projects impacting and enhancing
reimbursement
Update on department’s progress reaching “Grand Bargain”
downsizing/conversation goals
3
“Life itself is simple…
it’s just not easy”
-Steve Maraboli
4
Overview
GOVERNMENT
64 homes
15.2%
PROFIT
143 homes
34.0%
NON-PROFIT
2012 ICF-IID Type of Control
H5
213 homes
50.7%
N 17
Fulton
N1
Williams
NP 2
Defiance
Paulding
Henry
N1 P1
N8
Putnam
Wyandot
Hardin
Shelby
P1
Darke
Crawford
Marion
P3
Logan
N4
Union
Miami
Preble Montgomery
N3 P5
DC 1
Clark
N3 P3
Madison
N1 p1
Greene
N5
Hamilton
N 8 P 12
Clinton
DC 1
DC 1
Muskingum
Fairfield
P6
Perry
N2
Scioto
N2
N3
N 17
Noble
Monroe
Morgan
Meigs
Gallia
DC 1
NUMBER OF OHIO ICF-IIDs BY COUNTY
2012 DODD MEDICAID DATABASE
Harrison
N1
Athens
N2
N3
Lawrence
N 1 P 1 Jefferson
Washington
P3
Jackson
N1
Adams
Columbiana
P2
Belmont
Vinton
Brown
N1 P 4
P5
Hocking
N3
Pike
N1 P3
Tuscarawas
Guernsey
N 19 P 11
Highland
N3
Mahoning
N 14 P 4
DC 1
N 6 P 13
Licking
Ross
N4 P6
Wayne
Coshocton
N6
DC 1
Pickaway
Clermont
DC 1
Knox
P1
Delaware
Warren
N2 P5
N7
Carroll
Fayette
Butler
N3 P2
N3 P1
Stark
Holmes
P1
Franklin
N5
Portage
Summit
N 10
P3
N 9 P 13
Richland Ashland
P1
N7 P2
Morrow
P2
Champaign
P1
Trumbull
DC 1
Medina
DC 1
Auglaize
P1
N1
Lorain
N 13 P5
Huron
N1
N1
P3
Seneca
N3
Allen
Mercer
Erie
N3 P4
Geauga
N1
Cuyahoga
N 62 P 3
Sandusky
P4
Hancock
P2
Van Wert
Ottawa
N1
DC 1
Wood
Ashtabula
Lake
N3 P5
Lucas
Not for Profit (N)
For Profit (P)
Developmental Center (DC)
Total
*@ 4/21/14 952 DC Beds
277
143
10 *
430
Overview
147 Large
>8 beds
35.0%
273 Small
2012 ICF-IID Peer Groups
Ho7
<9 beds
65.0%
Overview
17.6%
60.5%
4 beds = 19
4.8%
5 - 8 beds = 254
9 - 16 beds = 74
17 - 24 beds = 20
8.3%
25 - 50 beds = 35
51 - 100 beds = 13
3.1%
4.5%
101 - 130 beds = 5
1.2%
2012 ICF-IID Bed Size
Summarized from state-wide averages from 2012 DODD Medicaid Cost Report Database
8
Overview
2,033,042 days
420 ICF/DDs 5,839
beds
H9
National Statistics
National Trends
Downsizing dictated in Mississippi
Michigan has eliminated all ICF beds
National Rebalancing Initiative
Ohio FY14 – 5,787 (certified) ICF beds, 952 DCs @ 4/21/14
Arizona operates no ICF’s or state operated institutions
University of Minnesota Study
Residential Services For Persons with Developmental
Disabilities: Status and Trends through 2011
www.rtc.umn.edu/risp/reports/
H 10
National Statistics
States with the largest number of persons living in
facilities of 16 or more residents as of June, 2011
CA
3,691
TX
4,585
Ohio
4,543
IL
5,073
11
NJ
3,955
National Statistics
States operating the largest number of STATE DD
Facilities (16+) in 2011
TX - 13
NY & OH - 10
MI - 9
IL - 8
NJ - 7
H 12
National Statistics
States with Highest Number of ICF/IID Residents
receiving HCBS Waiver Funded Supports
H 13
PA
FL
32,824
29,661
NY
OH
92,661
29,227
National Statistics
States with Greatest Number of People with ICF/IID
in Nursing Homes
NC
4,238
OH
TX
2,104
2,888
NY
2,123
H 14
National Statistics
Most ICF/IID Facilities (89.5%) on June 30, 2011 had
15 or fewer residents
61.2% had 6 or fewer residents
States with Largest Numbers of ICF/IID Residents
H 15
TX
CA
IL
9,626
8,907
8,460
NY
OH
7,432
7,125
National Statistics
States with Greatest Increase of HCBS waiver
participants between 2001 and 2011
District Of Columbia
543.8%
Kentucky
483.5%
Ohio
416.3%
Indiana
364.2%
Texas
241.4%
H 16
National Statistics
As of June 30, 2011 ten states serving more than
1,000 people in large Public Facilities
CA
IL
MS
NJ
NY
NC
OH
TX
PA
VA
17
Grand Bargain
DODD / Stakeholder Agreement 3/15/13
Agreement to work toward downsizing 500-600 ICF
beds and converting another 500-600 to waiver funding
in the next 5 years. Targeted date is July 1, 2018
Waives large facility efficiency incentive changes for
FY15 for any facility submitting an approved downsizing
plan over next 5 years (must be approved by June 1,
2014)
No new non-extensive renovations for large facilities
(> 8 beds) permitted after July 1, 2013 unless approved
by DODD prior to July 1, 2013 or the renovations are
tied directly to an approved downsizing plan
18
Grand Bargain
DODD / Stakeholder Agreement 3/15/13
To set FY15 rates continue using average of all 4 quarters
for both numerator and denominator: March, June,
September, and December
Stakeholders work collaboratively with DODD on plan
and will identify any potential barriers
Allows filing of 90 day cost reports for facilities
participating in downsizing/conversions with retroactive
rate adjustments. DODD set aside $2.5 million to pay for
this
H 19
HB 59 Provisions….As Enacted
Cost based formula still in statute with various
parameters in temporary law
FY14 rollback was 1.47%
FY15 goal is “NO” rollback
Eliminate rollback by reducing ceilings
20
HB 59 Provisions….As Enacted
Franchise Permit Fee
FY14 $18.24
FY15 $18.17
Non-payment of bed tax
will result in held vendors
H.21
HB 59 Provisions….As Enacted
Targeted Statewide Average Caps
FY13
FY14
FY15
H 22
$282.92
$282.84
$282.77
House Bill (HB) 483/Senate Amendment
”Appropriation Mid-Biennium Review”
DODD provisions
Regulatory provisions agreed by DODD and Provider
Group
1) NO ROLLBACK
2) Statewide average will be $282.77
3) 7/1/14 Direct Care ceilings are left open in statute
H 23
House Bill (HB) 483/Senate Amendment
Regulatory (continued)
4) Will use the new 6 class RAC IAF groups
•
•
Likely small ceiling will be higher than large
FY14 Large $114.37, Small $109.09
5) Will use 2013 Cost Report Data
6) May, 2014 Medicaid days
7) Ceilings will be set at same levels to cover
approximately same percentage of costs for the large
and small peer groups
H 24
House Bill (HB) 483/Senate Amendment
Regulatory (continued)
8) Ceilings will be calculated mid to late July
so rates can be paid in August
Six bed State Contracted ICFs
Money follows the person
25
IAF Update
IAF Online Submission Project
Up and running 6/30/13
No longer need to submit disk
Still uses OMA (JFS) Software
Effective 9/30/13 providers only have 45 days to make
corrections to final scores
H 26
IAF Update
IAF 2014 Upcoming Enhancements
Reporting will be on-line (no longer use JFS software)
Goal: Go live date 9/5/14
Effective 9/30/14
H.27
IAF Update
IAF 2014 Upcoming Enhancements (continued)
Two new components
1) Roster
•
•
Real time admissions/discharges
Training – late Aug/early Sept
2) Assessment
•
Training – last Sept/early Oct
Will include exception review data
No further issues with computer crashes/restoring data
28
IAF Update
ICD Reimbursement Moves to Six RAC Classes
Increase to six RAC classes from four
Wage data was updated (CY 10-12)
Effective 07/01/14 Rates
Two additional classes created by subdividing class 3
Class 1, 2, & 4 ( which was renumbered as class 6)
will remain the same
No changes in the IAF questions
No change to statute required
29
IAF Update
RAC 4
Prior to 01/01/2013
30
RAC 4 with Wage Update
RAC 6
4 Recalc. CY10-12 Wage Data 6 Recalc. CY10-12 Wage Data
1.
2.1762
1.
2.0888
1.
2.0888
2.
2.0311
2.
1.9206
2.
1.9206
3.
1.7274
3.
1.7084
3.
1.8935
4.
1.0000
4.
1.0000
4.
1.3593
5.
1.7434
6.
1.0000
IAF Update
2.0000
1.9500
Statewide Average IAF Scores
1.9000
1.8500
1.8000
1.7500
1.7000
1.6500
1.6000
1.5500
1.5000
1.4500
1.4000
3/11 6/11 9/11 12/11 3/12 6/12 9/12 12/12 3/13 6/13 9/13 12/13
SW Average RAC 4 1.8883 1.8801 1.8765 1.8750 1.8880 1.8783 1.8721 1.8079 1.7472 1.7221 1.7160
SW Average RAC 6
1.6816 1.6688 1.6688 1.6645
# of facilities
422
421
420
420
420
420
421
425
419
426
429
427
H 31
IAF Update
2
Comparison of RAC 4 and RAC 6
1.9
1.8
1.7
1.6
1.5
Large
1.4
Small
1.3
1.2
1.1
1
Large
Small
H 32
2012 RAC 4
1.8744
1.8514
2013 RAC 4
1.7506
1.7195
2013 RAC 6
1.7107
1.6521
IAF Update
IAF Exception Review – 5123:2-7-30
Started quarter ended 12/31/13
10 providers – approximately 50 individuals
2 day prior notification required
Department shall hold an exit conference
Written summary of findings
Can file rate reconsideration
33
IAF Update
IAF Exception Review-5123:2-7-30 (continued)
Must complete by 6/1/14
Future target 25-35 providers
Will impact annual scores & CPCMU
Selection criteria
•
•
•
•
H 34
Dec ’13 vs. Mar ’13 variance
Similar score for entire population
Certification/licensure survey findings
Target questions, not all 32
ICF CY2011 Audits
Auditor of State is conducting Audits
Ohio Department of Medicaid (formerly JFS) will
adjudicate the results
25 homes were selected
Audits to be conducted 2013-2014
Audits are taking much longer than expected
Five audits complete – reports posted on auditor
website
https://OhioAuditor.gov/auditsearch/search.aspx
Careful – Salvage Value Issue!!
H 35
Audit / Settlements
H 36
Filing
Date
Audit
Deadline
Settlement
Deadline
CY08
4/13/09
4/13/12
4/13/14
CY09
4/14/10
4/14/13
4/14/15
CY10
4/14/11
4/14/14
4/14/16
CY11
4/14/12
4/14/15
4/14/17
Capital/Downsizing/Conversion
OAC 5123-2-3-26 (D) 1-8
Provisions More Onerous for Providers
•
•
•
•
•
H 37
Encourage Downsizing
Beds shall not exceed 8 for ICF, 4 for waiver
Encourage Non-Campus Settings
Removes Grandfather Provision
IMPORTANT to get project approved by both the
County and DODD
Capital/Downsizing/Conversion
Development Proposal Process
DODD will review projects on a case by case basis
Proposal must be in writing
Describe proposal accurately & completely
No clear guidance
Department has a lot of discretion
Approval must be received prior to 06/01/14 for
reimbursement changes not to apply to large peer
group
H 38
Capital/Downsizing/Conversion
Summary of DODD Approved Downsizing &
Conversion Plans (7/1/13 – 4/14)
CONVERSION
DOWNSIZING
NUMBER OF BEDS
APPROVED
*121
159
NUMBER OF BEDS
COMPLETED
35
37
*98 enrolled as of 4/21/14
H 39
Capital/Downsizing
Definition per HB 59 - "Downsized ICF/IID means an
ICF/IID that permanently reduced its medicaid-certified
capacity pursuant to a plan approved by the department
of developmental disabilities under section 5123.042 of
the Revised Code”
Facility must submit and receive DODD approval for
downsizing plan
Approval is conditioned on downsizing being
completed not later than July 1, 2018
Director has ability to waive development rule criteria
Facilities downsized after July 1,2011 but prior to July
1, 2013 would qualify for exemption from large group
reimbursement changes, but not for further nonextensive renovations
H 40
Capital/Downsizing
Downsizing Incentives
Ability to file 90 day Cost Report
Available to original ICF/IID and new ICF/IID Facility
Applies to facilities certified after 7/1/13
At least 10% less MCD certified Bed Capacity OR
At least 5 less Certified Bed Capacity
Due 90 days after the end of the Period
Retroactive rate adjustment to the certification date
for new facility
H 41
Capital/Downsizing
42
Capital/Downsizing
Additional Strategies:
Downsize beds with lowest COO Ceiling
Request increase in Base COO Ceiling at existing
facility
Conversion timing – Bed Tax
May 1st Assessment Date
Full Conversion – 1st quarter
Partial Conversion – 2nd quarter
H 43
Capital/Downsizing
Policy change to encourage Downsizing
Reduce by 50% the Indirect Efficiency Incentive for
large ICFs in FY15
Reduce Cost of Ownership Efficiency Incentive for
large ICFs in FY15
Eliminate Non-Extensive Renovation for large ICFs
H 44
Capital/Downsizing/Conversion Barriers
Funding and Housing Accessibility
Availability of Credit
No payment during waiting period before home is
certified
Slow Certification Process
Lot sizes
HUD Financing – will they allow release of collateral
Aging issues/Nursing needs
. 45
Capital/Downsizing/Conversion Barriers
No Capital Funds for downsized facilities
Repurposing Downsized Building
Providers with on-site day program can’t service folks on
waiver
Lose Franchise Fee on converted funds
Capital Investment doesn’t follow the person
Loss of specific services (younger individuals)
. 46
Downsizing Checklist
Issued by DODD to assist providers opening ICF’s:
Complete the following:
•
•
•
•
•
•
•
H 47
Development Application
New Medicaid provider agreement in MITS
Schedule feasibility study for licensure survey
Submit readiness letter to ODH
Schedule ODH Certification Survey
Setup Vendor Account with Ohio Shared Services
Complete New Level of Care (JFS 3697)
Capital Development Opportunities
DODD Six-Bed ICF Development Project
Up to 19 six beds
15 year Agreement
Move resident out of State operated DCs
DODD controls Admission/Discharge
Qualifies for $50 per day add-on
Creates a new peer group
Separate bucket of funds
Won’t pull fund from private ICF Program
No Direct Care Ceiling, but overall rate is limited to
average DC rate (currently $505)
H.48
Capital Development Opportunities
COUNTY
H.49
# Of 6-Bed ICFs
Guernsey
2
Gallia
4
Montgomery
2
Knox
3
Lucas
3
Seneca
3
Mahoning
2
Contacts
Department Resources:
Ann L. Weisent/DODD Review Manager
 [email protected]
 614-949-8792
[email protected] (Bibi)
 ODM (formerly ODJFS)
 614-752-3573
Josh Anderson
 [email protected]
 614-387-0576
Ashley Rupejko
 [email protected]
 614-644-7596
o.50
Expense per Diem
2012
2011
2010
2009
2008
2007
Number of Facilities
420
415
418
413
417
416
Nursing Salaries
$ 98.71
$ 98.75
$ 99.97
$ 99.72
$ 98.61
$ 97.78
$ 80.90
Therapies
3.28
3.48
3.27
2.87
2.69
3.00
3.50
Social Service
1.06
1.07
1.09
1.07
1.32
1.19
1.42
Activities
1.25
1.26
1.43
1.46
1.70
1.71
1.51
Payroll Taxes & Fringe Benefits
32.71
33.81
33.21
33.67
32.76
32.99
24.09
Off-Site Active Treatment
38.21
38.97
37.63
37.65
36.18
31.63
-
Franchise Permit Fees
18.41
15.99
14.34
13.39
11.01
9.67
9.88
Utilities
5.04
5.43
5.54
5.50
5.62
5.23
3.75
Dietary Wages & Dietician
4.30
4.29
4.38
4.47
4.56
4.53
4.38
Dietary Food & Enterals
7.17
7.00
6.95
7.01
7.21
6.84
5.91
Program & Other Supplies
2.71
2.69
2.66
2.68
2.67
2.89
2.04
Administrator
3.04
3.02
3.10
3.04
2.90
3.02
2.29
Other Administrative Personnel
3.80
3.79
3.72
3.72
3.71
3.73
4.08
Consulting & Management Fees
3.20
3.47
2.57
2.90
2.59
3.34
2.56
Laundry & Linen
1.65
1.70
1.67
1.86
1.90
1.82
1.82
Housekeeping
3.17
3.29
3.45
3.50
3.70
3.75
3.26
Legal & Accounting
1.39
1.48
1.62
1.48
1.59
1.93
1.76
Insurance
1.70
1.63
1.90
1.74
1.66
1.83
0.99
25.37
24.03
22.80
24.09
24.09
22.72
13.12
6.27
6.38
6.34
5.99
6.49
6.15
5.00
16.55
16.70
16.81
16.63
15.61
15.25
12.51
3.75
4.07
4.02
4.50
3.64
3.69
1.65
14.81
14.94
16.77
16.55
17.40
17.23
15.04
$ 297.55
$ 297.24
$ 295.24
$ 295.49
$ 289.61
$ 281.92
$ 201.47
Home Office Costs
Maintenance Expenses
Capital Costs
Other Non-Reimbursable
Other
Grand Total Expenses
. 51
2000
385
Average Hourly Wage by Position
H.52
Average Hours per Resident Day by Position
o.53
Home and Community Based Final Rule-CMS 2249-F-2296-F
Published January 16, 2014
Effective March 17, 2014
Final Rule applies to programs under Sections 1915 (c), 1915 (i)
and 1915 (k) of Medicaid
1915 (c) - HCBS Waivers
1915 (i) – State Plan HCBS
1915 (k) – Community First Choice
Defines HCB (Home and Community Based) Setting
Guidance on Person Centered Planning
Streamline Waiver for great application
H.54
Home and Community Based Settings
What they are
Integrated in the community
Full access to the community
Individual selection of setting
Individual makes own life choices
Individual choice of services and provider of services
o.55
Home and Community Based Settings
Provider-Owned or Controlled Housing
Individual provided rights and protections through a
signed lease or other legal document
Physically Accessible
Privacy
Roommate Choice
Individual sets schedule
Individual has ability to receive visitors at his/her
discretion
“Landlord” can provide other support services as
selected by individual
Unmet Requirements MUST be justified and
documented in Service Plan
H.56
Home and Community Based Settings
What they are not
Setting that provide Inpatient Services
Same grounds or adjacent to public institution
•
•
•
ICF
Hospital
Mental Health Institution
Transition
Existing 1915 (c) and 1915 (i) waivers will work with CMS on a
plan to come into compliance
CMS may approve plans with transition periods up to 5 years
H.57
Home and Community Based Settings
Person-Centered Plans
Apply to services under 1915 (c) and 1915 (i)
•
•
•
•
•
H 58
Address long term supports and needs and health
Directed by the Individual
Defined outcome in the most integrated community
setting
Service delivery as preferred by the individual
Considers overall health and welfare
Omnibus Issues
Waiver Reimbursement
Rates frozen since 2005
Effective 7/1/14 three percent increase in waiver rate
(approximately .20/hour)
Employment First
New Adult Services Rule 5123-2-1-06
MyCareOhio – (formerly ICDS)
Does not include ICF or Waiver Residents
7 demonstration multi-county regions
NE Ohio Region effective 5/1/14
Health homes (care coordination)
H 59
Program Administration
MITS Issues/9400 Processing
Patient Liability Issue
Defect in System
Facility responsibility to notify JFS/file 9400
Help Desk/614-466-7575
Lisa Durben (Rasmussen) – [email protected]
H 60
Thank
You!
John P. Fleischer, CPA
[email protected]
Rosemary Orlando, CPA
[email protected]
HW&Co.
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