Waivers Review Employment and Day Services for: Alabama
Alabama Waiver# AL.0001.R08.02
AL Home and Community-Based Waiver for Persons with Intellectual Disabilities
Services
List of Services for Alabama Waiver# AL.0001.R08.02
Cost Neutrality
Cost Neutrality for Alabama Waiver# AL.0001.R08.02
Some HCBS waivers have a cost neutrality requirement. For HCBS 1915(c) waivers, the state must demonstrate that the waiver is cost neutral. In particular, the average per participant expenditures for the waiver and non-waiver Medicaid services must be no more costly than the average per person costs of furnishing institutional (and other Medicaid state plan) services to persons who require the same level of care. (CMS HCBS Waiver Application, Version 3.6., 2019).
Cost Neutrality Year 1 | Cost Neutrality Year 5 |
---|---|
5260 | 5260 |
Year 1 Waiver Services
List of Year 1 Waiver Services for Alabama Waiver# AL.0001.R08.02
Year 1 Waiver Service | Unit | # of Users | Avg. Units Per User | Average Cost |
---|---|---|---|---|
Day Habilitation Level 2 | 15 minutes | 1306 | 2525 | $2.47 |
Day Habilitation Level 1 w Transport | 15 minutes | 244 | 1799 | $2.26 |
Day Habilitation Level 2 w Transport | 15 minutes | 306 | 1792 | $3.05 |
Day Habilitation Level 3 w Transport | 15 minutes | 107 | 1722 | $3.84 |
Day Habilitation Level 1 | 15 minutes | 702 | 1856 | $1.94 |
Day Habilitation Level 3 | 15 minutes | 432 | 2009 | $3.53 |
Day Habilitation Level 4 w Transport | 15 minutes | 15 | 1005 | $4.85 |
Day Habilitation Level 4 | 15 minutes | 166 | 1867 | $4.53 |
Community Day Habilitation Level 1 | 15 minutes | 653 | 2525 | $4.76 |
Community Day Habilitation Level1 w Transport | 15 minutes | 122 | 1779 | $4.80 |
Community Day Habilitation Level 2 | 15 minutes | 653 | 2525 | $4.76 |
Community Day Habilitation Level 2 w/ Trans | 15 minutes | 306 | 1792 | $5.40 |
Community Day Habilitation Level 3 | 15 minutes | 432 | 2009 | $5.94 |
Community Day Habilitation Level 3 w/Trans | 15 minutes | 53 | 1722 | $6.58 |
Community Day Habilitation Level 4 | 15 minutes | 166 | 1867 | $9.06 |
Community Day Habilitation Level 4 w/ Trans | 15 minutes | 15 | 1005 | $9.70 |
Employment Support Individual Job Developer | 15 minutes | 5 | 320 | $10.00 |
Employment Support Individual Job Coach | 15 minutes | 5 | 320 | $7.50 |
Assessment/Discovery | 15 minutes | 10 | 120 | $10.00 |
Employment Small Group 1:2-3 | 15 minutes | 8 | 160 | $7.90 |
Employment Small Group 1:4 | 15 minutes | 10 | 200 | $4.52 |
Prevocational Facility Based | hour | 95 | 900 | $12.20 |
Prevocational Community Based | hour | 50 | 450 | $24.40 |
Benefits Counseling | 15 minutes | 6 | 40 | $10.00 |
Benefits Reporting Assistance | 15 minutes | 10 | 36 | $3.00 |
Community Experience 1:3 | 15 minutes | 60 | 4940 | $6.10 |
Community Experience 1:1 | 15 minutes | 10 | 4940 | $9.70 |
Supported Employment Transportation mile | mile | 25 | 40 | $0.52 |
Year 5 Waiver Services
List of Year 5 Waiver Services for Alabama Waiver# AL.0001.R08.02
Year 5 Waiver Service | Unit | # of Users | Avg. Units Per User | Average Cost |
---|---|---|---|---|
Day Habilitation Level 2 | 15 minutes | 515 | 2525 | $2.47 |
Day Habilitation Level 1 w Transport | 15 minutes | 85 | 1799 | $2.26 |
Day Habilitation Level 2 w Transport | 15 minutes | 110 | 1792 | $3.05 |
Day Habilitation Level 3 w Transport | 15 minutes | 30 | 1722 | $3.84 |
Day Habilitation Level 1 | 15 minutes | 240 | 1856 | $1.94 |
Day Habilitation Level 3 | 15 minutes | 700 | 2009 | $3.53 |
Day Habilitation Level 4 w Transport | 15 minutes | 10 | 1005 | $4.85 |
Day Habilitation Level 4 | 15 minutes | 115 | 1867 | $4.53 |
Community Day Habilitation Level 1 | 15 minutes | 435 | 1856 | $4.16 |
Community Day Habilitation Level1 w Transport | 15 minutes | 155 | 1779 | $4.80 |
Community Day Habilitation Level 2 | 15 minutes | 790 | 2525 | $4.76 |
Community Day Habilitation Level 2 w/ Trans | 15 minutes | 330 | 1792 | $5.40 |
Community Day Habilitation Level 3 | 15 minutes | 456 | 2009 | $5.94 |
Community Day Habilitation Level 3 w/Trans | 15 minutes | 75 | 1772 | $6.58 |
Community Day Habilitation Level 4 | 15 minutes | 203 | 1868 | $9.06 |
Community Day Habilitation Level 4 w/ Trans | 15 minutes | 31 | 1005 | $9.70 |
Employment Support Individual Job Developer | 15 minutes | 15 | 320 | $10.00 |
Employment Support Individual Job Coach | 15 minutes | 15 | 160 | $7.50 |
Assessment/Discovery | 15 minutes | 18 | 120 | $10.00 |
Employment Small Group 1:2-3 | 15 minutes | 20 | 160 | $7.90 |
Employment Small Group 1:4 | 15 minutes | 25 | 200 | $4.52 |
Prevocational Facility Based | hour | 60 | 900 | $12.20 |
Prevocational Community Based | hour | 101 | 800 | $24.40 |
Benefits Counseling | 15 minutes | 30 | 40 | $10.00 |
Benefits Reporting Assistance | 15 minutes | 28 | 36 | $3.00 |
Community Experience 1:3 | 15 minutes | 85 | 4940 | $6.10 |
Community Experience 1:1 | 15 minutes | 30 | 4940 | $9.70 |
Supported Employment Transportation mile | mile | 55 | 40 | $0.52 |
Rate Determination Methods
Rate Determination Methods for Alabama Waiver# AL.0001.R08.02
The Alabama Medicaid Agency is responsible for establishing provider payment rates for waiver services. Payment made by Medicaid to the ID waiver providers are on a fee-for-service basis and are based upon a number of factors and all rates, with the exception of residential services, were formulated using the following: Current pricing for similar services, State-to-State comparisons, Geographical comparisons within the state, Comparisons of different payers for similar services. Rates do not vary geographically. The rates are posted on ADMH website.
For each waiver service, a HCPC code is determined with a rate assigned to each code. The Medicaid Management Information system (MMIS) pays the claim based upon the State's determined pricing methodology applied to each service by provider type, claim type, recipient benefits and policy limitations. All claims submitted for adjudication must pass certain edits in MMIS. Once a claim passes through edits, the system reviews each claim to make sure it complies with AMA policies. The MMIS then performs audits by validating claims history information against information on the current claim. Audits check for duplicate services, limited services, and related services and compare them to Alabama Medicaid policy to ensure that recipient benefits are paid according to current policies.
Rates established are reasonable and customary to ensure continuity of care, quality of care, and continued access to care. All rates are posted on ADMH's website. Re-evaluation of pricing and rate increases are considered as warranted based upon provider inquiries, problems with service access, and budgetary considerations. In cases where allocations from the state Legislature are received, rates increases are determined by the OA based on provider inquiries, problems with service access or where services have not been adequately adjusted due to budget constraints. The OA was involved with ODEP's VisionQuest Rates and Restructuring project and working on reviewing rates of service. A subgroup comprised of internal staff, external stakeholders (providers and advocacy), and Medicaid staff met monthly. Albeit all the work this group's did not truly come to fruition due to level funding by the legislature. However, using the information from the project another workgroup was formed and the rates were finally set after an examination of other state rates using the list compiled by ODEP SMEs and available on the Lead Center website entitled Review of HCBS Reimbursement Data for Day/Employment that includes most state information, but chose primarily a comparison of nearby states (NC, GA, LA, MS, AR, TN, SC). The group also looked at some of the information from the ODEP project. The group remains intact and assembled as necessary. Reimbursement rates (i.e. Day Habilitation and Prevocational) are associated with the minimum staffing ratios needed to support persons based on whether the service is delivered in a facility-based (provider controlled) setting or an integrated community setting, taking account of the different staffing ratios and costs that are applicable for services delivered in integrated community settings. There are four reimbursement rate levels based on four acuity tiers for both Facility Based Day Habilitation and Community Based Day Habilitation. An individual’s acuity tier is based on his/her ICAP score. Staffing ratios for both facility-based day habilitation and community-based day habilitation service provision vary based on acuity tier. For facility, the staffing ratios vary from a low of 1:15 to a high of 1:1.
For community, the staffing ratios vary from a low of 1:4 to a high of 1:1. Rate adjustments are then added if transportation to/from the service is included in the rate paid to the provider. Reviewing the rates is an ongoing process and all waiver service rates were not rebased, however have been reviewed. Those rates rebased included this far have been those service rates that support employment,(Discovery/Assessment, Benefits Planning, Individual Job Coaching and Benefits Reporting Service). To determine the rate for Supported Living service, utilization for in-home habilitation and personal care were reviewed to determine an average hours of both services per day. Once that number was determined, the yearly total of the service anticipated was calculated by the year and divided by twelve (12) to get the monthly total. Work continues on restructuring rates for the other services. The general public had opportunity to comment on the rates during the public comment period for the amendment. Any changes are noted. Should the state legislature pass an increase in our appropriations for either a provider dedicated staff wage increase, such as an hourly increase for DSPs, or for a COLA, for all or selected provided rates, these costs will be reflected in subsequent year payments and reported on Form 372. We will inform CMS of these changes but shall not amend the rates since the rate setting methodology will not change. Fee for service methodology was used with all services except residential rates which is based on Individual Residential Budgeting Instrument (IRBI) which factors in individual needs based on acuity and level of care identified. Residential Habilitation is the only residential service. Residential Habilitation Service is based on individual needs, ICAP levels, and acuity level and each participant receiving that service has a Individual Residential Budgeting Instrument (IRBI) completed and submitted. An Individual IRBI can be re-calculated and submitted as the needs and levels change. The rates for self-directed Adult Companion Service and Personal care were based using the same methodology used for traditional services but, reduced by 11% that accounts for the removal of administrative and indirect costs. Skilled Nursing rates are aligned with Medicaid’s payment for SPS and other waivers’ rates for the same service.
Some of the services were reviewed in 2016, but all were reviewed in July 2018 when the rates and restructuring workgroup met. The focus at that time was Residential Rates with suggested changes to the IRBI, personal care rates and nursing rates. Also, the workgroup that met several times in the Spring of 2019 to review the waiver in preparation for the renewal reviewed the rates. Again, the focus was on increases in the IRBI, nursing rates and personal care. The suggestions were put into the budget request and the Alabama Legislature appropriated the funds to increase the IRBI by 2.5% ,Personal Care by 5.6% , and Personal Care on the worksite by from $4.35 per 15 minute unit to $6.00 per 15 minute unit to encourage employment.
The rates were reviewed, and some rates increased in 2016, the legislature did provide an increase for 2020 for Residential Services that increased the service by 2.5% which was added into Appendix J information. Personal Care will also be increased by 5.6%, and Supported Employment Individual Job Coach is receiving a 50% increase to incentivize employment for waiver. Community Experience and Community Prevocational Services have been based on the staffing level needed based on the acuity of the person receiving these services in the community.
Alabama Waiver# AL.0391.R03.00
Alabama HCBS Living at Home Waiver for Persons with Intellectual Disabilities (LAH Waiver)
Services
List of Services for Alabama Waiver# AL.0391.R03.00
Cost Neutrality
Cost Neutrality for Alabama Waiver# AL.0391.R03.00
Some HCBS waivers have a cost neutrality requirement. For HCBS 1915(c) waivers, the state must demonstrate that the waiver is cost neutral. In particular, the average per participant expenditures for the waiver and non-waiver Medicaid services must be no more costly than the average per person costs of furnishing institutional (and other Medicaid state plan) services to persons who require the same level of care. (CMS HCBS Waiver Application, Version 3.6., 2019).
Cost Neutrality Year 1 | Cost Neutrality Year 5 |
---|---|
569 | 569 |
Year 1 Waiver Services
List of Year 1 Waiver Services for Alabama Waiver# AL.0391.R03.00
Year 1 Waiver Service | Unit | # of Users | Avg. Units Per User | Average Cost |
---|---|---|---|---|
Day Habilitation (Hab) Level 1 with Transport | 15 minutes | 67 | 3568 | $2.26 |
Day Hab Level 2 with Transport | 15 minutes | 78 | 3690 | $3.05 |
Day Hab Level 3 with Transport | 15 minutes | 31 | 3468 | $3.84 |
Day Hab Level 4 with Transport | 15 minutes | 5 | 2947 | $4.85 |
Day Hab Level 1 | 15 minutes | 112 | 4510 | $1.94 |
Day Hab Level 2 | 15 minutes | 107 | 3729 | $2.74 |
Day Hab Level 3 | 15 minutes | 48 | 3858 | $3.53 |
Day Hab Level 4 | 15 minutes | 5 | 2960 | $4.53 |
Employment Small Group | 15 minutes | 20 | 3018 | $3.84 |
Individual Job Developer | 15 minutes | 2 | 320 | $10.00 |
Individual Job Coach | 15 minutes | 2 | 160 | $5.00 |
Prevocational Services | hour | 8 | 795 | $12.20 |
Benefits and Career Counseling | 15 minutes | 3 | 40 | $10.00 |
Community Experience 1:1 | 15 minutes | 5 | 868 | $16.80 |
Community Experience Small Group | 15 minutes | 10 | 868 | $13.46 |
Community Experience Self Directed | 15 minutes | 3 | 868 | $11.85 |
SE Emergency Transportation mile | mile | 10 | 1923 | $0.52 |
SE Emergency Transportation item | item | 10 | 1923 | $0.52 |
Year 5 Waiver Services
List of Year 5 Waiver Services for Alabama Waiver# AL.0391.R03.00
Year 5 Waiver Service | Unit | # of Users | Avg. Units Per User | Average Cost |
---|---|---|---|---|
Day Hab Level 1 with Transport | 15 minutes | 67 | 3568 | $2.26 |
Day Hab Level 2 with Transport | 15 minutes | 78 | 3690 | $3.05 |
Day Hab Level 3 with Transport | 15 minutes | 31 | 3468 | $3.84 |
Day Hab Level 4 with Transport | 15 minutes | 5 | 2947 | $4.85 |
Day Hab Level 1 | 15 minutes | 112 | 4510 | $1.94 |
Day Hab Level 2 | 15 minutes | 107 | 3729 | $2.74 |
Day Hab Level 3 | 15 minutes | 48 | 3858 | $3.53 |
Day Hab Level 4 | 15 minutes | 5 | 2960 | $4.53 |
Employment Small Group | 15 minutes | 20 | 3018 | $3.84 |
Individual Job Developer | 15 minutes | 2 | 320 | $10.00 |
Individual Job Coach | 15 minutes | 2 | 160 | $5.00 |
Benefits and Career Counseling | 15 minutes | 3 | 40 | $10.00 |
Prevocational Services | hour | 8 | 795 | $12.20 |
Community Experience 1:1 | 15 minutes | 5 | 868 | $16.80 |
Community Experience Small Group | 15 minutes | 10 | 868 | $13.46 |
Community Experience Self Directed | 15 minutes | 3 | 868 | $11.85 |
SE Emergency Transportation mile | mile | 10 | 1923 | $0.52 |
SE Emergency Transportation item | item | 5 | 10 | $100.00 |
Rate Determination Methods
Rate Determination Methods for Alabama Waiver# AL.0391.R03.00
The Alabama Medicaid Agency is responsible for establishing provider payment rates for waiver services. Payment made by Medicaid to LAH waiver providers are on a fee-for-service basis and are based upon a number of factors:
• Current pricing for similar services
• State-to-State comparisons
• Geographical comparisons within the state
• Comparisons of different payers for similar services
For each waiver service, a HCPC code is determined with a rate assigned to each code. The Medicaid Management Information system (MMIS) pays the claim based upon the State's determined pricing methodology applied to each service by provider type, claim type, recipient benefits and policy limitations. All claims submitted for adjudication must pass certain edits in MMIS. Once a claim passes through edits, the system reviews each claim to make sure it complies with AMA policies. The MMIS then performs audits by validating claims history information against information on the current claim. Audits check for duplicate services, limited services, and related services and compare them to Alabama Medicaid policy to ensure that recipient benefits are paid according to current policies.
Rates established are reasonable and customary to ensure continuity of care, quality of care, and continued access to care. Re-evaluation of pricing and rate increases are considered as warranted based upon provider inquiries, problems with service access, and budgetary considerations. In cases where allocations from the state Legislature are received, rates increases are determined by the OA based on provider inquiries, problems with service access or where services have not been adequately adjusted due to budget constraints.
The Operating Agency has an Employment First Interagency Team that is comprised of a subgroup charged with rate restructuring and methodologies for provider payment rates. This subgroup is currently receiving technical assistance and training on rate restructuring and methodologies. The subgroup is comprised of internal staff, external stakeholders, and Medicaid staff. Medicaid staff actively participated in this subgroup which meets monthly. This group is charged with developing at least one, but preferably multiple rate methodologies that uses incentive payments and braided funding to meet positive outcomes. Once developed, these methodologies will be presented to the Developmental Disabilities Advisory Subcommittee. The subcommittee will decide which methodology best meets the needs of stakeholders. Once vetted the Operating Agency will post relevant information on its departmental website, notify stakeholders of the posting, and accept public comment for 30 days. The waiver will be amended to update the rate methodology with consideration of the public comments. Should the state legislature pass an increase in our appropriations for either a provider dedicated staff wage increase, such as an hourly increase for DSPs, or for a COLA, for all or selected provided rates, these costs will be reflected in subsequent year payments and reported on Form 372. We will inform CMS of these changes but shall not amend the rates since the rate setting methodology will not change.