Transcript Medicaid & Supporting People with Developmental Disabilities

HCBS Waiver
Program
More dialing for dollars
Agenda
 Quick overview of the
HCBS Waiver program
 Recent developments
 Open conversation
HCBS Waiver Basics
 Program enacted in 1981
 No substantial changes in federal law in
recent years
 [Still] an “alternative” to Medicaid
institutional services (NFs and ICFs/MR)
 State flexibility
 Selection of services and supports
 Number of people served
Landscape
 Nationwide: 285 HCBS waiver programs
that support people of with disabilities of
all types
 104 HCBS waiver programs for people
with developmental disabilities
 Scope: programs range from fewer than
100 participants to over 46,000
Importance to states ….
 Waiver program now the primary
financing vehicle for community services
 Refinancing of community systems –
leverage existing and new dollars
 States have enormous latitude in benefit
design and population targeting
 Cost control/containment – capped
Medicaid
20+ Years – Observations
 Program congruent with principles of
person and family-centered supports
 But, still large gap between philosophy
and practice
 Waiver programs cannot escape generic
problems (e.g., workforce, quality)
 Most issues/problems in HCBS waiver
operation have their roots in state – not
federal – policy
Waiver evolution/change
1. Pay for existing service array, principally
residential and day services
2. Diversify service and support array
3. Person-centered planning and greater
flexibility in service plan content
4. Individual/family-directed services
 Program’s strong point always has been
that it change with the times
Program defects
 Housing
 Tie to institutional eligibility (tail
wagging the dog)
 High maintenance/high cost of
operations
 Imperfect connections to physical
health
Key Development #1:
Federal Policy Directions
 CMS: tightening requirements for HCBS waiver
programs to conform to generic federal
Medicaid law
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Free choice of provider
Access to covered services
Contracting
State Medicaid agency oversight
 Key document: Olmstead Letter #4 (January
2000)
Key Development #2
“Supports Waivers”
 Growing number of states now operating inhome/family support waiver programs
 Target individuals (adults and children) who live
with their families
 Benefit package does not include residential
services
 Cap on overall cost of services
 Individual/family service selection
 Examples: CO, OK, OR
 Aim: divert demand from residential services by
strengthening services for people who live with
their families
Key Development #3:
Individual/Family Direction
 Independence Plus Waivers
 CMS-created vehicle for states to offer
individual/family-directed (consumerdirected) services
 Two types (templates):
 HCBS waiver program
 Section 1115 Research and Demonstration
Waiver
Independence Plus
 Mandatory Features/Capabilities
 Person-centered planning
 Support brokerage
 Individual budgets
 Emergency services
 Worker background checks
 Employment agents (financial intermediaries)
 Individual/family direct management, including
hiring, firing and supervising workers
 States must spell out a more robust quality
management plan
Independence Plus
 Two states have I/P HCBS waiver programs for
people with developmental disabilities –
 New Hampshire (children)
 Louisiana (individual/family selected option
within reformulated waiver program)
 Florida’s I/P waiver includes individuals with
developmental disabilities along with people
with other disabilities
Key Development #4:
Quality
 CMS raising HCBS waiver program quality
management performance thresholds
 Some states have struggled with quality –
program growth outstripped QM/I capabilities
 HCBS Quality Framework – A new foundation?
 Going forward: All states will be required to spell
out full-scale/full featured QM/I systems
 Goal – Shift from periodic CMS review of waiver
programs to alternate framework
Quality Management Functions
Focus
Design
Discovery
Remedy
Improvement
Participant Access
Participant-Centered
Service Planning and
Delivery
Provider Capacity and
Capabilities
Participant Safeguards
Participant Rights and
Responsibilities
Participant Outcomes
and Satisfaction
System Performance
QUALITY
FRAMEWORK
Key Development #5:
Systems/Management
Redesign
 Many states grafted waiver program onto
pre-existing systems/processes
 Programs now large scale
 States rethinking how they manage/operate
programs
 Prompting: payment/allocation redesign
 Process redesign
 System architecture (business model)
redesign
 Focus on I/T Systems
Dialing for dollars
 Waiver remains the primary tool to acquire FFP
 States vary in terms of maximizing
HCBS/dollars
 Maximization strategies –
 Reprogram existing state dollars as matching funds
 E.g., In-home/family support waivers
 Tap local (county) dollars as match
 Fundamentally, few federal barriers to
expansion