Alabama Waiver# AL.0001.R08.02 

AL Home and Community-Based Waiver for Persons with Intellectual Disabilities

Waiver Name:
AL Home and Community-Based Waiver for Persons with Intellectual Disabilities
Effective Date:
10/1/2019
Expiration Date:
9/30/2024

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 Table
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 Services Table
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 Services Table
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)

Waiver Name:
Alabama HCBS Living at Home Waiver for Persons with Intellectual Disabilities (LAH Waiver)
Effective Date:
10/1/2015
Expiration Date:
9/30/2020

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 Table
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 Services Table
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 Services Table
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.

Alaska Waiver# AK.1566.R00.00 

Alaska Individualized Supports Waiver

Waiver Name:
Alaska Individualized Supports Waiver
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Alaska Waiver# AK.1566.R00.00

Cost Neutrality

Cost Neutrality for Alaska Waiver# AK.1566.R00.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
620 620

Year 1 Waiver Services

List of Year 1 Waiver Services for Alaska Waiver# AK.1566.R00.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Individual Day Habilitation 15 minutes 204 261 $11.78
Group Habilitation 15 minutes 129 388 $8.25
Individual Supported Employment 15 minutes 67 1036 $13.33
Group Supported Employment 15 minutes 42 1328 $9.34

Year 5 Waiver Services

List of Year 5 Waiver Services for Alaska Waiver# AK.1566.R00.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Individual Day Habilitation 15 minutes 258 785 $12.95
Group Habilitation 15 minutes 163 490 $9.07
Individual Supported Employment 15 minutes 84 1309 $14.66
Group Supported Employment 15 minutes 53 1678 $10.27

Rate Determination Methods

Rate Determination Methods for Alaska Waiver# AK.1566.R00.00

The Department of Health and Social Service’s Office of Rate Review (ORR) is responsible for setting and reviewing Medicaid rates for home and community-based waiver services.

The public has regular opportunity to participate in and comment on the rate setting process. The department has worked very closely with the public to design the rate methods described in this waiver. This process includes:

• Numerous publicly noticed work sessions and webinars on all aspects of the methods described in this waiver

• Numerous meetings with provider trade associations that represent both providers and participants that live and work throughout the entire State of Alaska, including:

• Alaska Association on Developmental Disabilities

• Community Care Coalition

• AgeNet

• Assisted Living Association of Alaska

• Governor’s Council on Disabilities and Special Education

• Alaska Mental Health Trust

• Alaska PCA Association

• Alaska Care Coordination Network

• Regular updates with the public through the department’s E-Alert system

• Making information available on the department’s website, including rate charts, policy documents, and regulations.

Medicaid reimbursement rates for home and community-based waiver services are rebased at least every four years, and are annually adjusted for inflation in non-rebase years. The inflation factor is determined using the CMS Home Health Agency Market Basket in Global Insight’s Healthcare Cost Review. For state fiscal year 2018, the payment rates were not adjusted for inflation due to the State’s budget situation.

Reimbursement rates are set using provider cost reports. Providers report their costs in cost centers for: general service costs, non-covered costs, waiver services direct care costs (separate cost centers for each service) and non- waiver direct care costs. Non-covered costs include bad debt, fines, penalties, lobbying, fundraising, donations, entertainment, contingency funds, grant costs, certain marketing, and certain legal fees. Costs from the non-waiver direct care costs are not included in the rates because they are costs for services that are not reimbursed through home and community-based waiver services such a behavioral health, federally qualified health center services, etc.

All direct care costs, excluding room and board costs for residential services, and the applicable general service costs are included in rate setting after being geographically adjusted. The costs for each cost center after overhead has been allocated are inflated to the midpoint of the proposed rate year and are divided by units of service to arrive at raw rates. The applicable general service costs are allocated to each cost center based on a percentage that is determined by the following formula:

[cost center’s costs - building & maintenance costs] / [total costs - building & maintenance costs].

Additionally, to protect providers and participants of home and community-based waiver services from dramatic rate swings when rates are reestablished, reestablished rates or aggregate costs cannot increase or decrease more than 5%. The raw rates are converted into final rates after final adjustment from a comparison to the rates in effect during the state fiscal year preceding the effective date of the new, rebased rates.

Since rate increases or decreases cannot exceed + or - 5% (and aggregate increases or decreases for certain services) during rebasing, inflation adjustments in the non-rebase years following the rebasing and prior to the next rebasing are modified to allow the capped rates to gradually self-correct. Modified inflation adjustments only apply to the non-rebase years that follow the adjustment. The process starts over in the next rebasing.

During non-rebase years, the State will modify inflation adjustments so that reduced inflation adjustments are provided to codes where reductions over 5% were capped during the most recent rebasing. During non-rebase years, the State will also use the estimated savings realized from paying reduced inflation adjustments in place of full inflation adjustments to provide enhanced inflation adjustments to codes where increases over 5% were capped during the most recent rebasing. The enhanced adjustments will be, in aggregate, no more than the lesser of the estimated savings realized from reduced inflation adjustments provided that year or the amount necessary to offset the rate increases that were capped. Again, modified inflation adjustments—both reduced inflation and enhanced inflation—only apply to the non-rebase years that follow the application of the adjustment. The process starts over in the next rebasing.

The methodology to set care coordination rates established wages, fringe benefits, administrative and general costs and caseload size using public sources such as the Alaska Bureau of Labor Statistics, the Internal Revenue Services, and other States’ approved 1915(c) waivers. The rate for ISW care coordination presumes a caseload of 40 participants.

On or after January 1, 2018, the department will establish new rates for home and community based waiver services. The department will use a method that sets rates based on comprehensive cost surveys and financial audits from providers of the highest volume of Medicaid services in a given year. While reported costs from the high-volume providers is the most efficient starting point for establishing these rates, the costs will be adjusted upwards so that the final rates are accessible to all providers, large and small, in a manner that ensures that quality of care and services are available to Medicaid participants to the extent that such care and services are available to the general public. Additionally, to protect providers and participants of home and community-based waiver services and personal care attendant services from dramatic rate swings when rates are reestablished, reestablished rates or aggregate costs cannot increase or decrease more than 5% from the rates or costs that are in effect at the time the rates are reestablished. Rates that are capped at 5% can self-correct on an annual basis through enhanced or reduced inflation adjustments, and every four years when the rates are again reestablished.

While all rates for home and community-based waiver services and personal care attendant services are and will be reestablished at least every four years, the department may increase the Medicaid reimbursement rate or rates if it finds by clear and convincing evidence that the rate or rates established do not allow for reasonable access to quality participant care provided by efficiently and economically managed providers of services, and that increasing the reimbursement rate is in the public interest.

The State’s Office of Rate Review utilizes the list and guidelines for unallowable costs outlined in 7 AAC 150.170, which follow CMS PUB 15-1, chapter 21 guidelines. In response to the new rate methodology for these providers, Alaska has also recently revised regulations specific to this provider type, that once published will also include the list of unallowable costs. The new regulation citation is 7 AAC 145.533; these regulations became effective March 1, 2018, so are only available in final adopted form via this link: https://aws.state.ak.us/OnlinePublicNotices/Notices/View.aspx?id=188634

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Arkansas Waiver# AR.0188.R05.00 

AR Alternative Community Services

Waiver Name:
AR Alternative Community Services
Effective Date:
9/1/2016
Expiration Date:
8/30/2021

Services

List of Services for Arkansas Waiver# AR.0188.R05.00

Cost Neutrality

Cost Neutrality for Arkansas Waiver# AR.0188.R05.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4303 4403

Year 1 Waiver Services

List of Year 1 Waiver Services for Arkansas Waiver# AR.0188.R05.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 101 1838.01 $3.59

Year 5 Waiver Services

List of Year 5 Waiver Services for Arkansas Waiver# AR.0188.R05.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 121 1838.01 $3.59

Rate Determination Methods

Rate Determination Methods for Arkansas Waiver# AR.0188.R05.00

Case Management - The monthly rate for case management is $117.70. This rate is consistent with the rate paid for the preceding five years of this waiver.

Supportive Living - The maximum daily rate for supportive living is $391.95. Service providers develop a budget for each individual which justifies costs based upon the assessed need and the resulting level of support identified in the person-centered service plan. The budget to support the daily cost of supportive living must include the anticipated hourly rate to be paid each direct service staff, and the associated fringe costs, up to a maximum of 32%. The initial fringe costs associated with the waiver were set in 1990 and were based on the cost of fringe for state employees. A fringe benefit is a form of pay for the performance of services. DDS uses the IRS definition of fringe benefits. Examples of fringe benefits are holidays, annual leave, sick leave, FICA, SUTA, life insurance, retirement, WC, and health and medical insurance. The budget may also include a monthly fee of $100.00 for the cost of direct service staff supervision that rate was established in 1990. Providers may include up to 20% of the cost of salary and fringe, as indirect, administrative costs. Administrative costs include clerical/bookkeeping support, rent, supervisory support, utilities, salary fringe for supervisory/support staff, supplies/materials, quality assurance and training, advertising for recruiting/employing waiver direct delivery of service staff and other expenses. The salaries of senior executives and cost of general services (such as accounting, contracting, and industrial relations) fall under administrative costs. The budget may also include the costs of non-medical transportation as part of implementation of the PCSP. The rate for transportation is .42 cents per mile and is not subject to the 20% indirect cost charge. Each provider is responsible for independently setting the hourly rate paid for direct service staff. It is basically whatever the labor market pool will tolerate. Providers must be in compliance with Department of Labor relative to minimum wage but other than that DDS only deals with a capitated daily rate.

Respite Care - The prospective rate is developed as described for supportive living, with the exception that transportation costs and the supervisory fee may not be included. The maximum daily rate is the same. This maximum rate is applied to two waiver services (supportive living and respite) because these waiver services are closely related and can serve as a substitute for one another. Without respite there would be a need for increased supportive living staff/hours to be approved in order to assure health and safety in the absence of the unpaid caregiver. There are many components of supportive living to include transportation, but the waiver recipients would only be approved for the components that they need based on a person centered service plan as approved by a physician and DDS.

Adaptive Equipment, PERS and Environmental Modifications - the rate is prospective based on actual cost with a cost maximum of $7,687.50 per individual per year. The maximum was based on average consumer needs at the time of limitation setting in 1990. The annual maximum includes Adaptive Equipment, PERS and Environmental Modifications.

Personal Emergency Response System - the rate is prospective based on actual cost of installation, purchase and monthly service fees.

Specialized Medical Supplies, Supplemental Supports, and Community Transition - the rate is prospective based on actual costs with a maximum of $3,690.00 per year. The maximum was based on average consumer needs at the time of limitation setting in 1990. The annual maximum includes Specialized Medical Supplies, Supplemental Support and Community Transition.

Consultation - the annual maximum for an individual is $1320.00. This maximum is increased from the previous 5 years of the waiver.

Crisis Intervention - The maximum rate is $127.10 per hour. The annual maximum is $2640.00. There was no annual maximum for this service in the preceding 5 years of the waiver.

Supported Employment - Supported employment cannot exceed $3.59 per 15 minute unit with a maximum of 32 units a day, 5 days per week for the first year. The service may be provided up to 52 weeks in a year. The resulting maximum is $29,868.00 per year.

The rates included in this waiver were initially set in 1990. The State proposes that within 12 months from the effective date of this waiver renewal, AR will submit an amendment to implement a new rate methodology for all services. AR will consult with CMS during the development of the rate methodology and will comply with all public notice requirements.

Arkansas will submit a timeline for rate methodology amendment, well in advance, but no longer than three months after approval date of this renewal.

Rate Determination Responsibility: DDS is responsible to develop and present all proposed rates to the DMS. The Division of Medical Services is responsible for the approval of rates and methodologies.

Rate Determination Public Comments: Public comments are sought on an informal basis as the State develops the draft waiver document. Public comments are sought on a formal basis as the State promulgates the waiver document according to the AR Administrative Procedures Act. The Act requires advertisement in a newspaper of statewide circulation, and public hearings. the State collects all comments and makes changes as necessary. The Act requires that the document is presented for legislative review and recommendations. After legislative review and advice the document is duly promulgated.

The budget for each individual is determined through the Person Centered Service Plan development process. The multi-agency team includes the chosen case manager, the individual or their legal representative. All other persons attending are at the discretion of the individual or their legal representative and include other professionals as invited. The members of the team will determine services to be provided, frequency of service provision, number of units of service, cost for those services, and ensure the participant’s desired outcomes, needs and preferences are addressed. The team members and a physician via a 703 certify the person’s condition (level of care) and appropriateness of services initially and at the annual continued stay review date. A person centered services plan revision can be requested at any time that the person’s needs change. The waiver services included in the plan of care must be prior approved by DDS.

California Waiver# CA.0336.R04.00 

CA HCBS Waiver for Californians w/DD

Waiver Name:
CA HCBS Waiver for Californians w/DD
Effective Date:
1/1/2018
Expiration Date:
12/31/2022

Services

List of Services for California Waiver# CA.0336.R04.00

Cost Neutrality

Cost Neutrality for California Waiver# CA.0336.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
130000 150000

Year 1 Waiver Services

List of Year 1 Waiver Services for California Waiver# CA.0336.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community-based Day Services daily 57081 206.45 $64.05
Community-based Day Services hour 24431 500.04 $19.85
Therapeutic/Activity-Based Day Services month 130 11 $50.00
Therapeutic/Activity-Based Day Services hour 503 80.08 $43.88
Mobility-Related Day Services hour 110 68.27 $37.48
Prevocational Services daily 9655 226.92 $36.94
SE Incentive Payment 30 days one time 63 1 $1000.00
SE Incentive Payment 6 months one time 0 1 $1250.00
SE Incentive Payment 12 months one time 0 1 $1500.00
Supported Employment Individual hour 1195 128.21 $36.57
Community Based Training Service hour 4 166.67 $14.99

Year 5 Waiver Services

List of Year 5 Waiver Services for California Waiver# CA.0336.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community-based Day Services daily 65865 206.45 $64.05
Community-based Day Services hour 28191 500.04 $19.85
Therapeutic/Activity-Based Day Services month 150 11 $50.00
Therapeutic/Activity-Based Day Services hour 579 80.08 $43.88
Mobility-Related Day Services hour 130 68.27 $37.48
Prevocational Services daily 11139 226.92 $36.94
SE Incentive Payment 30 days one time 125 1 $1000.00
SE Incentive Payment 6 months one time 113 1 $1250.00
SE Incentive Payment 12 months one time 94 1 $1500.00
Supported Employment Individual hour 1379 128.21 $36.57
Community Based Training Service hour 4 166.67 $14.99

Rate Determination Methods

Rate Determination Methods for California Waiver# CA.0336.R04.00

The rate methodologies for services provided in this waiver are as follows:

Behavior Intervention Service

This service is comprised of the following subcategories:

A. Non-Facility-Based Behavior Intervention Services– Providers in this subcategory are Behavior Analyst, Associate Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, Psychiatrist, Psychiatric Technician, Crisis Team, Client/Parent Support, Parent Support Services, Individual/Family Training Providers, Family Counselor, Behavior Intervention Training and Behavioral Technician. There are two rate setting methodologies for all providers in this subcategory (except psychiatrists – see below.) If the provider does not have a “usual and customary” rate as described below, then the rate is established using the median rate setting methodology.

1) The usual and customary rate methodology – Per California Code of Regulations (CCR), Title 17, Section 57210(a)(19), a usual and customary rate “means the rate which is regularly charged by a vendor for a service that is used by both regional center consumers and/or their families and where at least 30% of the recipients of the given service are not regional center consumers or their families. If more than one rate is charged for a given service, the rate determined to be the usual and customary rate for a regional center consumer and/or family shall not exceed whichever rate is regularly charged to members of the general public who are seeking the service for an individual with a developmental disability who is not a regional center consumer, and any difference between the two rates must be for extra services provided and not imposed as a surcharge to cover the cost of measures necessary for the vendor to achieve compliance with the Americans With Disabilities Act.”

2) The median rate setting methodology – This methodology applies if the usual and customary rate methodology is not applicable to the provider. The Department calculates median rates for each regional center, and these rates are subsequently certified by each of the regional centers. The Department calculates the statewide median rates based on the individual regional center median rates. Verification of individual regional center median rates is subject to verification through the department’s biennial fiscal audit of the regional center. Rates for new providers where rates are set through negotiation with regional centers are capped at either the statewide median rate or the venturing regional center’s median rate, whichever is lower unless a regional center demonstrates an increase to the fixed new vendor rate is necessary for a provider to provide the service in order to protect a beneficiary’s health and safety needs. As required by the contract between regional centers and the State, regional centers must maintain documentation on the process to determine, and the rationale for granting, any negotiated rate, including consideration of the type of service and any education, experience and/or professional qualifications required for the service. In addition, contracts or agreements between the regional center and service providers shall expressly require that no more than 15 percent of regional center funds be spent on administrative expenditures.

This methodology requires that rates negotiated with new providers may not exceed the regional center’s current median rate for the same service, or the statewide current median rate, whichever is lower .

Effective July 1, 2016, these median rates were increased for the purpose of enhancing wages and benefits for provider staff who spend 75 percent of their time providing direct services for consumers as well as administrative expenses for service providers.

3) Schedule of Maximum Allowances - The rates for psychiatrists are determined by the “Schedule of Maximum Allowances (SMA).” State regulations define the SMA as the current rate established by the single-state Medicaid agency for services reimbursable under the Media-Cal program. The SMA is the maximum amount that can be paid for the service. For providers who have a usual and customary rate that is less than the SMA, the regional center shall pay the provider’s usual and customary rate.

B. Crisis Support – The following two rate methodologies apply for these providers;

1) The usual and customary rate methodology – As defined previously or, if the provider does not have a usual and customary rate;

2) The median rate setting methodology - As defined previously.

Community Living Arrangement Services

This service is comprised of the following subcategories:

A. Licensed/Certified Residential Services – Providers in this subcategory are Foster Family Agency/Certified Family Home, Foster Family Home, Small Family Home, Group Home, Adult Residential Facility, Residential Facility for the Elderly, Out of State Residential Facility, Adult Residential Facility for Persons with Special Health Care Needs and Family Home Agency, Enhanced Behavioral Supports Homes, and In-Home Day Program Services.

There are two rate setting methodologies for all providers in this subcategory (with the exception of Out of State Residential Facility and Enhanced Behavioral Supports Homes – see below).

1) Alternative Residential Model (ARM) methodology – This is the most typical methodology used in setting rates for the licensed/certified providers ventured to provide residential services. Within this methodology, 14 different rate/service levels were established using a cost-based study of providers using actual costs. Individual providers apply to be ventured at one of these rate/service levels based upon the staffing ratios, service design, personnel qualifications and use of consultant services described in their program design. The allowable costs used to calculate ARM rates include the following cost components: wages and benefits for direct supervision (those activities in which direct care staff provide care, supervision, training and support to promote the consumer’s functioning) personnel, consultant services, general administrative costs (ex. staff training, licenses), housing, furniture, insurance, utilities, food, housekeeping supplies and laundry services, personal care items, transportation, and wages and benefits (for management and staff providing cooking, house cleaning, maintenance). Note: This is not the rate that is claimed for FFP. See Appendix I-5 for a description of the method used to isolate and exclude room and board costs from the rate for purposes of Medicaid payment.

Effective July 1, 2016, these rates were increased for the purpose of enhancing wages and benefits for provider staff who spend 75 percent of their time providing direct services for consumers as well as administrative expenses for service providers. The rate schedule, effective January July 1, 2016 can be found at the following link: http://www.dds.ca.gov/Rates/docs/CCF_rate_July2016.pdf

Pursuant to Section 4681.5(b) of the Welfare and Institutions Code, effective July 1, 2016, the Department of Developmental Services established a rate schedule for residential community care facilities ventured to provide services to a maximum of four persons with developmental disabilities. The 4-bed or less rate schedule can be found on at the following link: http://www.dds.ca.gov/Rates/docs/CCF_rate_July2016.pdf.

2) The median rate setting methodology – This methodology, as defined previously, is applicable for In-Home Day Program services and licensed/certified settings when the program service design (e.g., personnel qualifications, mandated staff ratios, programming, use of consultants) is not addressed within the ARM rate setting structure detailed above, and;

3) Out-of-state rate methodology – This methodology is applicable for out-of-state residential providers. The rate paid is the established rate for that service, paid by that State in the provision of that service to their own service population of individuals with developmental disabilities.

4) Enhanced Behavior Supports Homes rate methodology - There are two components to the monthly rate for Enhanced Behavioral Supports Homes: 1) the facility component, and 2) the individualized services and supports component. The allowable costs used to calculate the facility component include payroll costs of facility staff and facility related costs such as lease, facility maintenance, repairs, cable/internet, etc. The allowable costs used to calculate the individualized services and supports component include the salaries, wages, payroll taxes, and benefits of individuals providing individualized services and supports and other consumer specific program costs. The rate of payment for both components may not exceed the rate limit determined by the Department. Note: This is not the rate that is claimed for FFP. See Appendix I-5 for a description of the method used to isolate and exclude room and board costs from the rate for purposes of Medicaid payment.

B. Supported Living Services provided in a consumer’s own home (non-licensed/certified) – Supported Living Services providers are in this subcategory. Maximum rates for these providers are determined using the median rate methodology, as defined previously. In addition, effective July 1, 2016 these rates were increased by 5 percent.

Day Services

This service is comprised of the following subcategories:

A. Community-Based Day Services – There are two rate setting methodologies for providers in this subcategory.

1) Rates set pursuant to a cost statement methodology – This methodology is used to determine the applicable daily rate for Activity Center, Adult Development Center and Behavior Management Program providers. This methodology is also used to determine the applicable hourly rate for Independent Living Program and Social Recreation Program providers. Under this methodology, new vendors are assigned a “new vendor” rate, based on the type of service provided, until a permanent rate is established, within upper and lower limits, using actual cost information as described below. Unless otherwise authorized by statute, effective July 1, 2004, all new providers of services are reimbursed at the fixed new provider (vendor) rate unless a regional center demonstrates an increase to the fixed new vendor rate is necessary for a provider to provide the service in order to protect a beneficiary’s health and safety needs.

Effective July 1, 2016, these rates were increased for the purpose of enhancing wages and benefits for provider staff who spend 75 percent of their time providing direct services for consumers as well as administrative expenses for these service providers. In addition, Independent Living Program provider rates were increased by 5 percent.

a) For the day services providers identified above, the cost-based rates are calculated based on 12 consecutive months of allowable costs related to services to consumers and actual days or hours of consumer attendance. Only costs attributable to the provision of the specific service are included. The following allowable cost information is utilized in determining the rate:

• Total gross salary and wages for all employees (direct service and supervisory) attributable to the provision of the specific service.

• Fringe benefit costs associated with salary and wage costs.

• Operating expenses including furniture, staff recruitment, license or certification fees, association dues or fees.

• Management organization costs (costs for administrative support provided for the delivery of the specific service.)

The total of the allowable costs above is then divided by the vendor’s actual hours or days of consumer attendance to determine the daily or hourly rate per consumer.

CONTINUATION OF I-2(a) RATE DETERMINATION METHODS CAN BE FOUND UNDER MAIN(B) OPTIONAL.

California Waiver# CA.1166.R00.00 

California Self-Determination Program Waiver for Individuals with Developmental Disabilities

Waiver Name:
California Self-Determination Program Waiver for Individuals with Developmental Disabilities
Effective Date:
7/1/2018
Expiration Date:
6/30/2021

Services

List of Services for California Waiver# CA.1166.R00.00

Cost Neutrality

Cost Neutrality for California Waiver# CA.1166.R00.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1000 2500

Year 1 Waiver Services

List of Year 1 Waiver Services for California Waiver# CA.1166.R00.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment hour 9 53.48 $36.57
Prevocational Supports Day 70 107.68 $35.67
Community Integration Supports (Community Based Day Services) Day Day 440 92.92 $70.82
Community Integration Supports (Community Based Day Services) Hour hour 194 239.48 $19.85
Community Integration Supports (Therapeutic/Activity-Based Day Services) Month month 2 6 $131.78
Community Integration Supports (Therapeutic/Activity-Based Day Services) Hour hour 2 37.35 $44.85
Community Integration Supports (Mobility Related Day Service) hour 2 17.47 $57.87

Year 3 Waiver Services

List of Year 3 Waiver Services for California Waiver# CA.1166.R00.00

Year 3 Waiver Services Table
Year 3 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment hour 23 106.96 $36.57
Prevocational Supports Day 174 215.36 $35.67
Community Integration Supports (Community Based Day Services) Day Day 1101 185.84 $70.82
Community Integration Supports (Community Based Day Services) Hour hour 485 478.96 $19.85
Community Integration Supports (Therapeutic/Activity-Based Day Services) Month month 5 12 $131.78
Community Integration Supports (Therapeutic/Activity-Based Day Services) Hour hour 5 74.69 $44.85
Community Integration Supports (Mobility Related Day Service) hour 5 34.94 $57.87

Rate Determination Methods

Rate Determination Methods for California Waiver# CA.1166.R00.00

Rates for all services, with the exception of financial management services, are negotiated between the waiver participant and each provider selected by the participant. When the participant is the sole employer of an individual who provides a service to the participant, the wage rates negotiated must comply with applicable federal, state and local minimum wages. The maximum monthly rates for financial management services established by DDS are based on the number of services participants utilize. Should there be any changes in the rate methodology the State will undergo public comment process. Information about payment rates will be made available to waiver participants via pre-enrollment informational meetings, during the SDP orientation as well as the online posting of the approved waiver application.

In developing the proposed rate methodologies, the Department has received input from the Self-Determination Program Workgroup was formed in December 2013. Workgroup members consist of an array of stakeholders including consumers, family members, service providers, and representatives of regional centers, advocacy groups, and the State Council on Developmental Disabilities. Since its formation, the Workgroup has assisted DDS in shaping the framework of the Self-Determination Program based on the law in which it is authorized. Meetings have been open to the public where input was welcomed and received.

Colorado Waiver# CO.0293.R05.00 

CO Supported Living Services (SLS)

Waiver Name:
CO Supported Living Services (SLS)
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Colorado Waiver# CO.0293.R05.00

Cost Neutrality

Cost Neutrality for Colorado Waiver# CO.0293.R05.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5569 5938

Year 1 Waiver Services

List of Year 1 Waiver Services for Colorado Waiver# CO.0293.R05.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Specialized Habilitation Support Level 1 15 minutes 547 1189 $2.60
Specialized Habilitation Support Level 2 15 minutes 759 1482 $2.86
Specialized Habilitation Support Level 3 15 minutes 271 1457 $3.18
Specialized Habilitation Support Level 4 15 minutes 190 1508 $3.75
Specialized Habilitation Support Level 5 15 minutes 204 1845 $4.64
Specialized Habilitation Support Level 6 15 minutes 122 2026 $6.66
Supported Community Connections Level 1 15 minutes 1323 1213 $3.16
Supported Community Connections Level 2 15 minutes 1334 1587 $3.45
Supported Community Connections Level 3 15 minutes 429 1810 $3.91
Supported Community Connections Level 4 15 minutes 303 1644 $4.48
Supported Community Connections Level 5 15 minutes 283 1807 $5.40
Supported Community Connections Level 6 15 minutes 209 1555 $7.10
Prevocational Services Level 1 15 minutes 153 1596 $2.60
Prevocational Services Level 2 15 minutes 137 1572 $2.86
Prevocational Services Level 3 15 minutes 34 1747 $3.18
Prevocational Services Level 4 15 minutes 13 1536 $3.75
Prevocational Services Level 5 15 minutes 9 1598 $4.64
Prevocational Services Level 6 15 minutes 8 1396 $6.66
SE Job Coaching Group Level 1 15 minutes 250 1748 $3.47
SE Job Coaching Group Level 2 15 minutes 174 1672 $3.82
SE Job Coaching Group Level 3 15 minutes 38 1160 $4.24
SE Job Coaching Group Level 4 15 minutes 18 995 $4.91
SE Job Coaching Group Level 5 15 minutes 13 1575 $5.85
SE Job Coaching Group Level 6 15 minutes 2 821 $7.65
SE Job Coaching Individual 15 minutes 661 206 $14.34
SE Job Development Individual Support Level 1-2 15 minutes 18 171 $14.34
SE Job Development Individual Support Level 3-4 15 minutes 2 43 $14.34
SE Job Development Individual Support Level 5-6 15 minutes 2 73 $14.34
SE Job Development Group 15 minutes 4 174 $4.58
SE Job Placement Group Session 1 1 $1.00
SE Job Placement Individual Session 2 1 $1.00
Life Skills Training 15min 2 631 $10.71

Year 5 Waiver Services

List of Year 5 Waiver Services for Colorado Waiver# CO.0293.R05.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Specialized Habilitation Support Level 1 15 minutes 584 1339.16 $2.60
Specialized Habilitation Support Level 2 15 minutes 809 1677.2 $2.86
Specialized Habilitation Support Level 3 15 minutes 289 1385.85 $3.18
Specialized Habilitation Support Level 4 15 minutes 203 1317.35 $3.75
Specialized Habilitation Support Level 5 15 minutes 217 1901.27 $4.64
Specialized Habilitation Support Level 6 15 minutes 131 2041.21 $6.66
Supported Community Connections Level 1 15 minutes 1410 1356.12 $3.16
Supported Community Connections Level 2 15 minutes 1423 1614.3 $3.45
Supported Community Connections Level 3 15 minutes 457 1993.4 $3.91
Supported Community Connections Level 4 15 minutes 323 1643.57 $4.48
Supported Community Connections Level 5 15 minutes 301 1892.04 $5.40
Supported Community Connections Level 6 15 minutes 223 1556.2 $7.10
Prevocational Services Level 1 15 minutes 163 1595.86 $2.60
Prevocational Services Level 2 15 minutes 146 1572 $2.86
Prevocational Services Level 3 15 minutes 37 1919.01 $3.18
Prevocational Services Level 4 15 minutes 14 1536 $3.75
Prevocational Services Level 5 15 minutes 9 1598 $4.64
Prevocational Services Level 6 15 minutes 9 1395.67 $6.66
SE Job Coaching Group Level 1 15 minutes 266 1900.25 $3.47
SE Job Coaching Group Level 2 15 minutes 186 1742.51 $3.78
SE Job Coaching Group Level 3 15 minutes 40 1159.51 $4.24
SE Job Coaching Group Level 4 15 minutes 19 1089.1 $4.91
SE Job Coaching Group Level 5 15 minutes 14 1685.08 $5.85
SE Job Coaching Group Level 6 15 minutes 2 966.96 $7.65
SE Job Coaching Individual 15 minutes 704 245.16 $14.20
SE Job Development Individual Support Level 1-2 15 minutes 19 171.39 $14.20
SE Job Development Individual Support Level 3-4 15 minutes 2 70.48 $14.20
SE Job Development Individual Support Level 5-6 15 minutes 2 79.55 $14.20
SE Job Development Group 15 minutes 4 173.15 $4.53
SE Job Placement Group session 1 1 $1.00
SE Job Placement Individual session 2 1 $1.00
Life Skills Training 15 minutes 2 631 $12.03

Rate Determination Methods

Rate Determination Methods for Colorado Waiver# CO.0293.R05.00

The Home and Community Based Service (HCBS) waiver Supported Living Services (SLS) utilizes Fee-for-Service (FFS), negotiated market price, and public pricing rate methodologies. Each rate has a unit designation and reimbursement is equal to the rate multiplied by the number of units utilized. HCBS SLS FFS rate schedules are published through the Dept’s provider bulletin annually and posted to the Dept’s website.

The Dept has adopted a rate methodology incorporating the following factors for all services not included in the negotiated price or public pricing methodology described below:

A. Indirect and Direct Care Requirements:

Salary expectations for direct and indirect care workers based on the Colorado mean wage for each position, direct and indirect care hours for each position, the full time equivalency required for the delivery of services to HCBS Medicaid clients, and necessary staffing ratios. Wages are determined by the Bureau of Labor Statistics and are updated by the Bureau every two years. Communication with stakeholders, providers, and clients aids in the determination of direct and indirect care hours required for service delivery. Finally, collaboration with policy staff ensures the salaried positions, wage, and hours required conform to the program or service design and are in compliance with the Code of Colorado Regulations and statute.

B. Facility Expense Expectations:

Incorporates the facility type through the use of existing facility property records listing square footage and actual value. Facility expenses also include estimated repair and maintenance costs, utility expenses, and phone and internet expenses. Repair and maintenance price per square foot are determined by industry standards and vary for facilities that are leased and facilities that are owned. Utility pricing includes gas and electricity which are determined annually through the Public Utility Commission who provides summer and winter rates and thermostat conversions for appropriate pricing.

Finally, internet and phone services are determined through the use of the Build Your Own Bundle tool available through the Comcast Enterprise website.

C. Administrative Expense Expectations:

Identifies computer, software, office supply costs, and the total number of employees to determine administrative and operating costs per employee.

D. Capital Overhead Expense Expectations:

Identifies and incorporates additional capital expenses such as medical equipment, supplies, and IT equipment directly related to providing the service to Medicaid clients. Capital Overhead Expenses are rarely utilized for HCBS services but may include items such as massage tables for massage therapy or supplies for art and play therapy.

All Facility, Administrative, and Capital Overhead expenses are reduced to per employee cost and multiplied by the total FTE required to provide services per Medicaid client. To ensure rates do not exceed funds appropriated by the Colorado State Legislature, a budget neutrality adjustment is applied to the final determined rate.

Following the development of the rate stakeholder feedback is solicited and appropriate, necessary changes may be made to the rate. HCBS SLS FFS rates utilizing the methodology described above include:

1. Personal Care

2. Respite

3. Mentorship

4. Health Maintenance Activities

5. Homemaker

6. Supported Employment: Job Coaching (Individual)

7. Supported Employment: Job Development (Group)

8. Non-Medical Transportation

9. Behavioral Services: Behavioral Line Staff

10. Behavioral Services: Behavioral Plan Assessment

11. Behavioral Services: Behavioral Consultation

12. Behavioral Services: Behavioral Counseling (Individual and Group)

13. Massage Therapy

14. Movement Therapy

15. Hippotherapy

16. Home Delivered Meals

17. Peer Mentorship

18. Life Skills Training

19. Transition Set-Up

The HCBS SLS waiver utilizes a negotiated market price methodology for services in which reimbursement will differ by client, by product, and frequency of use. The services utilizing the negotiated market price methodology include:

1. Respite: Group or Overnight Group

2. Supported Employment: Job Placement (Individual or Group)

3. Recreational Facility Fees/Passes

4. Specialized Medical Equipment and Supplies (Disposable Supplies or Equipment)

5. Personal Emergency Response System

6. Home Accessibility Adaptations

7. Assistive Technology

8. Vehicle Modifications

The HCBS SLS waiver utilizes a public pricing methodology for public services. Services with public pricing methodology are reimbursed at the price paid by the general public for the same service. The services utilizing the public pricing methodology include:

1. Non-Medical Transportation-Public Transit will be reimbursed at the RTD discounted rates applied to seniors 65+, individuals with disabilities, and Medicare recipients. The RTD rates can be found at the following link: http://www.rtd-denver.com/Fares.shtml and the discounted rates reimbursed by Medicaid are denoted by a single*.

RTD rates are updated annually in January. The Department will update the rates and fee schedules annually in January to align with annual changes.

For the above services case managers coordinate with providers and determine a market price that incorporates the client needs, product required, and frequency of use. The Dept's HCBS SLS waiver administrator reviews and approves the market price determined and authorized by the case manager.

After implementation of the rate, only legislative increases or decreases are applied. These legislative rate changes are often annual and reflect inflationary increases or decreases. Rates for the HCBS SLS waiver are reviewed for appropriateness every five years with the waiver renewal. Rates were last reviewed in 2018.

Rates are communicated via Departmental noticing in provider bulletins, tribal notices and are made available on the Dept’s external website to be accessed by stakeholders and providers any time.

Tiered rates are used in the Dept's rate setting model to reimburse those services for which the level of provider effort and the intensity of service are variable based upon the differing support needs of individuals. Difficulty of care factors been incorporated into the rate-setting model for rates. The Dept contracted with Healthcare Receivable Specialists Inc. (HRSI) to develop a methodology for the classification of individuals into Support Levels and to develop a uniform rate model that builds provider payment rates based upon those Support Levels and other underlying cost components.

An analysis of data compiled from the Supports Intensity Scales (SIS), historical funding consumption patterns, and other sources, HSRI developed a methodology that groups individuals into six Support Levels. These Support Levels are reflective of similar adaptive skills, behavioral and medical support needs, and the presence of safety risk factors individuals present to themselves or to the community. The SIS is a nationally recognized, norm-referenced, and statistically valid assessment tool endorsed and published by the American Association on Intellectual and Developmental Disabilities.

Participants may change Support Levels based upon changing needs and/or circumstances, and Support Level determinations may be disputed. Participants may submit a request for Support Level re-determination to the CCB at any time. A Department-convened review panel considers the request – along with copies of the completed SIS Interview and Profile Form, the Support Level Calculation form, the Uniform Long-Term Care 100.2 assessment, the service plan, the Level of Need (LON) checklist, and any supplemental documentation asserting that the participant’s Support Level should be re-determined. The review panel is comprised of at least three individuals with working knowledge of the SIS and of waiver services. A final decision is rendered at the conclusion of the review panel meeting. The review panel may decide that the current Support Level is appropriate, re-assign the participant to another Support Level, or request the

re-administration of the SIS Interview and/or safety risk factors. The following rates were determined by the rate-setting model and are reimbursed at a tiered, fee-for-service rate that varies by the participant’s Support Level:

• Day Habilitation: Specialized Habilitation

• Day Habilitation: Supported Community Connections

• Prevocational Services

• Supported Employment: Job Coaching (Group)

• Supported Employment: Job Development (Individual)

Non-Medical Transportation (To/From Day Program) is reimbursed at a tiered, fee-for-service rate that varies based upon the trip distance.

The following services are reimbursed on a standard, fee-for service basis but were not determined by the rate-setting model described above: Dental Services and Vision Services.

The Dept reviews IDD Dental rates regularly and utilizes the 2017 American Dental Association Survey of Dental fees to ensure sufficiency in reimbursement rates.

Vision services are reimbursed according to the Colorado Medicaid Fee Schedule for State Plan and Early Periodic Screening, Diagnosis, and Treatment (EPSDT) vision services.

CMs determine the features required in a PERS (GPS location services, wireless network capability, traditional landline capability, etc.) and the most cost-effective system required to meet the needs of the participant. Case managers must also document the systems and vendors considered and the justification for the system selected in the participant’s service plan.

The Dept requires case managers obtain at least three competitive bids for the Home Accessibility Adaptation and Vehicle Modification services. Payment is authorized to the provider with the most cost-effective bid which meets the needs of the participant.

Assistive Technology and Specialized Medical Equipment and Supplies not covered by the State Plan are reimbursed at a negotiated, manually set price. The rate methodology for Assistive Technology and Specialized Medical Equipment and Supplies is a negotiated, manually set price.

The Assistive Technology benefit requires three competitive bids when items over $2,500 are requested.

Dept guidance for the Specialized Medical Equipment and Supplies benefit suggests CMAs obtain competitive bids when costs are beyond typical for any funding level. State level approval is required for requests over $1,000, and competitive bids may be requested as part of the approval process.

Further discussion on App I-2 Rates, Billing, and Claims may be found in Main B. Optional.

Colorado Waiver# CO.0007.R08.00 

CO Developmental Disabilities (HCBS-DD)

Waiver Name:
CO Developmental Disabilities (HCBS-DD)
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Colorado Waiver# CO.0007.R08.00

Cost Neutrality

Cost Neutrality for Colorado Waiver# CO.0007.R08.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
7114 8758

Year 1 Waiver Services

List of Year 1 Waiver Services for Colorado Waiver# CO.0007.R08.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Specialized Habilitation Support Level 1 15 minutes 320 1549.19 $2.60
Specialized Habilitation Support Level 2 15 minutes 807 1866.55 $2.86
Specialized Habilitation Support Level 3 15 minutes 720 2065.39 $3.18
Specialized Habilitation Support Level 4 15 minutes 717 2111.26 $3.75
Specialized Habilitation Support Level 5 15 minutes 1024 2128.22 $4.64
Specialized Habilitation Support Level 6 15 minutes 666 2136.47 $6.66
Specialized Habilitation Support Level 7 15 minutes 172 2981.42 $10.48
Supported Community Connections Level 1 15 minutes 489 1491 $3.16
Supported Community Connections Level 2 15 minutes 1025 1815.83 $3.45
Supported Community Connections Level 3 15 minutes 815 1758.19 $3.91
Supported Community Connections Level 4 15 minutes 915 1848.72 $4.48
Supported Community Connections Level 5 15 minutes 1142 1947.48 $5.40
Supported Community Connections Level 6 15 minutes 792 1734.72 $7.10
Supported Community Connections Level 7 15 minutes 34 2091.74 $10.48
Prevocational Services Level 1 15 minutes 60 1626.7 $2.59
Prevocational Services Level 2 15 minutes 141 1851.41 $2.86
Prevocational Services Level 3 15 minutes 84 1540.42 $3.18
Prevocational Services Level 4 15 minutes 83 1862.89 $3.74
Prevocational Services Level 5 15 minutes 79 2373.69 $4.64
Prevocational Services Level 6 15 minutes 70 2066.61 $6.66
SE Job Coaching Group Level 1 15 minutes 255 2058.9 $3.47
SE Job Coaching Group Level 2 15 minutes 336 1777.12 $3.82
SE Job Coaching Group Level 3 15 minutes 206 1893.3 $4.24
SE Job Coaching Group Level 4 15 minutes 177 1431.77 $4.91
SE Job Coaching Group Level 5 15 minutes 213 1860.26 $5.85
SE Job Coaching Group Level 6 15 minutes 175 1790.99 $7.65
SE Job Coaching Individual 15 minutes 888 977.63 $14.34
SE Job Development Individual Support Level 1-2 15 minutes 15 293.38 $14.34
SE Job Development Individual Support Level 3-4 15 minutes 12 80.86 $14.34
SE Job Development Individual Support Level 5-6 15 minutes 13 23 $14.34
SE Job Development Group 15 minutes 8 408 $4.57
SE Job Placement Group Session 1 72 $1.00
SE Job Placement Individual Session 1 1 $1.00

Year 5 Waiver Services

List of Year 5 Waiver Services for Colorado Waiver# CO.0007.R08.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Specialized Habilitation Support Level 1 15 minutes 393 1939.62 $2.60
Specialized Habilitation Support Level 2 15 minutes 994 1866.55 $2.86
Specialized Habilitation Support Level 3 15 minutes 886 2145.01 $3.18
Specialized Habilitation Support Level 4 15 minutes 717 2111.26 $3.75
Specialized Habilitation Support Level 5 15 minutes 1261 2046.01 $4.64
Specialized Habilitation Support Level 6 15 minutes 819 2136.47 $6.66
Specialized Habilitation Support Level 7 15 minutes 212 2981.42 $10.48
Supported Community Connections Level 1 15 minutes 602 1626.13 $3.16
Supported Community Connections Level 2 15 minutes 1262 1859.8 $3.45
Supported Community Connections Level 3 15 minutes 1003 1635.65 $3.91
Supported Community Connections Level 4 15 minutes 1126 1848.72 $4.48
Supported Community Connections Level 5 15 minutes 1406 2042.65 $5.40
Supported Community Connections Level 6 15 minutes 975 1655.29 $7.10
Supported Community Connections Level 7 15 minutes 42 2091.74 $10.48
Prevocational Services Level 1 15 minutes 74 1626.7 $2.59
Prevocational Services Level 2 15 minutes 174 1815.41 $2.86
Prevocational Services Level 3 15 minutes 103 1540.42 $3.18
Prevocational Services Level 4 15 minutes 102 1862.89 $3.74
Prevocational Services Level 5 15 minutes 97 2874.81 $4.64
Prevocational Services Level 6 15 minutes 86 2154.36 $6.66
SE Job Coaching Group Level 1 15 minutes 314 2058.9 $3.47
SE Job Coaching Group Level 2 15 minutes 413 1777.12 $3.82
SE Job Coaching Group Level 3 15 minutes 254 1959.28 $4.24
SE Job Coaching Group Level 4 15 minutes 218 1431.77 $4.91
SE Job Coaching Group Level 5 15 minutes 262 1860.26 $5.85
SE Job Coaching Group Level 6 15 minutes 215 1790.99 $7.65
SE Job Coaching Individual 15 minutes 1093 1293.37 $14.34
SE Job Development Individual Support Level 1-2 15 minutes 30 293.38 $14.34
SE Job Development Individual Support Level 3-4 15 minutes 24 80.86 $14.34
SE Job Development Individual Support Level 5-6 15 minutes 25 23 $14.34
SE Job Development Group 15 minutes 9 408 $4.57
SE Job Placement Group session 7 72 $1.00
SE Job Placement Individual Session 1 1 $1.00

Rate Determination Methods

Rate Determination Methods for Colorado Waiver# CO.0007.R08.00

The HCBS Waiver for Persons with Developmental Disability (DD) utilizes Fee-for-Service (FFS), negotiated market price, and public pricing rate methodologies. Each rate has a unit designation and reimbursement is equal to the rate multiplied by the number of units utilized. HCBS DD FFS rate schedules are published through the Dept’s provider bulletin annually and posted to the Dept’s website. The Dept has adopted a rate methodology incorporating the following factors for all services not included in the negotiated price or public pricing methodology described below:

A. Indirect and Direct Care Requirements:

Salary expectations for direct and indirect care workers are based on the Colorado mean wage for each position, direct and indirect care hours for each position, the full-time equivalency required for the delivery of services to HCBS Medicaid clients, and necessary staffing ratios. Wages are determined by the Bureau of Labor Statistics and are updated by the Bureau every two years. Communication with stakeholders, providers, and clients aids in the determination of direct and indirect care hours required for service delivery. Finally, collaboration with policy staff ensures the salaried positions, wages, and hours required to conform to the program or service design and are in compliance with the Code of Colorado Regulations and statute.

B. Facility Expense Expectations:

Incorporates the facility type through the use of existing facility property records listing square footage and actual value. Facility expenses also include estimated repair and maintenance costs, utility expenses, and phone and internet expenses. Repair and maintenance price per square foot is determined by industry standards and vary for facilities that are leased and facilities that are owned. Utility pricing includes gas and electricity which are determined annually through the Public Utility Commission who provides summer and winter rates and thermostat conversions for appropriate pricing.

Finally, internet and phone services are determined through the use of the Build Your Own Bundle tool available through the Comcast Enterprise website.

C. Administrative Expense Expectations:

Identifies computer, software, office supply costs, and the total number of employees to determine administrative and operating costs per employee.

D. Capital Overhead Expense Expectations:

Identifies and incorporates additional capital expenses such as medical equipment, supplies, and IT equipment directly related to providing the service to Medicaid clients. Capital Overhead Expenses are rarely utilized for HCBS services but may include items such as massage tables for massage therapy or supplies for art and play therapy.

All Facility, Administrative, and Capital Overhead expenses are reduced to per employee cost and multiplied by the total FTE required to provide services per Medicaid client. To ensure rates do not exceed funds appropriated by the Colorado State Legislature, a budget neutrality adjustment is applied to the final determined rate.

Following the development of the rate, stakeholder feedback is solicited and appropriate, necessary changes may be made to the rate. HCBS DD FFS rates utilizing the methodology described above include:

1. Supported Employment: Job Coaching (Individual)

2. Supported Employment: Job Development (Group)

3. Behavioral Services: Behavioral Line Staff

4. Behavioral Services: Behavioral Counseling (Individual or Group)

5. Behavioral Services: Behavioral Plan Assessment

6. Behavioral Services: Behavioral Consultation

7. Home Delivered Meals

8. Peer Mentorship

9. Transition Setup

The HCBS DD waiver utilizes a negotiated market price methodology for services in which reimbursement will differ by client, by product, and frequency of use. The services utilizing the negotiated market price methodology include:

1. Non-Medical Transportation: Public Conveyance

2. Specialized Medical Equipment and Supplies (Disposable Supplies or Equipment)

3. Supported Employment: Job Placement (Individual)

4. Supported Employment: Job Placement (Group)

For the above services case managers coordinate with providers and determine a market price that incorporates the client's needs, products required, and frequency of use. The Dept reviews and approves the market price determined and authorized by the case manager.

After the implementation of the rate, only legislative increases or decreases are applied. These legislative rate changes are often annual and reflect inflationary increases or decreases. Rates for the HCBS DD waiver are reviewed for appropriateness every five years with the waiver renewal. The Department reviewed the rate-setting methodology and included rate-setting factors in 2018 when the rate methodology was used to rebase all waiver rates.

Rates are communicated via Dept noticing in provider bulletins, tribal notices and are made available on the Dept’s external website to be accessed by stakeholders and providers at any time.

The Department’s Waiver and Fee Schedule Rates Section is the responsible entity for rate determination. Oversight of the rate determination process is conducted internally by a review of the rates and methodology by internal staff in Policy, Budget, and members of leadership. The Department also hosts stakeholder feedback meetings in which the rates and rate determination factors are presented to external stakeholders such as providers, clients, and client advocacy groups in order to determine additional rate determination factors to be included in the rate methodology which were not captured during the initial rate-setting process.

The Dept regularly assesses rate efficiency, economy, quality of care, and sufficiency of provider populations by monitoring and analyzing paid claims utilization multiple times throughout the state fiscal year. The Dept also analyzes geographic provider density to ensure clients are able to access waiver services. In addition to these processes, the Dept regularly solicits external stakeholder feedback in order to assess whether rates are efficient, economic, allow for a high quality of care to be provided, and are sufficient to maintain the provider population.

The following services are reimbursed on a standard FFS basis but were not determined by the rate-setting model described above:

Dental Services Vision Services

Residential Habilitation: Group Residential Services and Supports (Regional Center)

Dental is reimbursed according to a specialized fee schedule. Dental rates for all IDD Adult waivers were rebased in 2015 and were based upon the American Dental Association’s (ADA) Survey of Dental Fees. Since rebasing upon the 2013 mean, the Dept has increased these rates with applicable across the board increases as approved by the Colorado legislature to assure reimbursement rates are adequate to retain a sufficient IDD Dental provider population. While the Dept has not received external stakeholder feedback to warrant a review of the current rates at this time, the Dept has reviewed IDD Dental rates regularly and utilizes the 2017 ADA Survey of Dental fees to ensure sufficiency in reimbursement rates.

Vision services are reimbursed according to the Fee Schedule for State EPSDT vision services.

Group Residential Services and Supports (GRSS) delivered at the Regional Centers in Grand Junction and Pueblo are provided by the Colorado Dept of Human Services (CDHS). Regional Center admission is limited to only those with complex mental health and/or behavioral needs, a history of a sex offense, and/or those who are medically fragile. A standard, per-diem rate was negotiated by the Dept and the CDHS Division for Regional Center Operations in order to recognize the specialized needs of this higher-risk population. As indicated in I-3.e of this waiver renewal application, no public provider receives payments that, in aggregate, exceed its reasonable costs of providing waiver services. These costs are determined by audited cost reports. A new cost-based rate for each Regional Center has been in place since July 1, 2014.

Tiered rates are used to reimburse for those services for which the level of provider effort and the intensity of service are variables based upon the differing support needs of individuals. The difficulty of care factors been incorporated into the rate-setting model for rates. The Dept contracted with Healthcare Receivable Specialists Inc. (HRSI) to develop a methodology for the classification of individuals into Support Levels and to develop a uniform rate model that builds provider payment rates based upon those Support Levels and other underlying cost components.

Through an analysis of data compiled from the Supports Intensity Scales (SIS), historical funding consumption patterns, and other sources, HSRI developed a methodology that groups individuals into 6 Support Levels. These Support Levels are reflective of similar adaptive skills, behavioral and medical support needs, and the presence of safety risk factors individuals present to themselves or to the community. The SIS is a nationally recognized, norm-referenced, and statistically valid assessment tool endorsed and published by the American Association on Intellectual and Developmental Disabilities (AAIDD).

Participants may change Support Levels based upon changing needs and/or circumstances, and Support Level determinations may be disputed. Participants may submit a request for Support Level re-determination to the CMA at any time. A Dept-convened review panel considers the request – along with copies of the completed SIS Interview and Profile Form, the Support Level Calculation form, the Uniform Long-Term Care 100.2 assessment, the service plan, the Level of Need (LON) checklist, and any supplemental documentation asserting that the participant’s Support Level should be re- determined. The review panel is comprised of at least three individuals with working knowledge of the SIS and of waiver services. A final decision is rendered at the conclusion of the review panel meeting. The review panel may decide that the current Support Level is appropriate, re-assign the participant to another Support Level, or request the re-administration of the SIS Interview and/or safety risk factors.

In rare circumstances, due to extreme behavioral or medical support needs, the needs of an individual cannot be completely captured within the 6 standard Support levels. These individuals are categorized into a 7th Support Level for which the Residential Habilitation rate is individually determined based upon the specific needs of the individual. Day Habilitation services also include Support Level seven rates to recognize increased direct-service costs for these individuals.

The following rates were determined by the rate-setting model and are reimbursed at a tiered, fee-for-service rate that varies by the participant’s Support Level:

Day Habilitation: Specialized Habilitation

Day Habilitation: Supported Community Connections Prevocational Services

Supported Employment: Job Coaching (Group) Supported Employment: Job Development (Individual) Group Residential Services and Supports

Individual Residential Services and Supports

Individual Residential Services and Supports-Host Home

Non-Medical Transportation (To/From Day Program) is reimbursed at a tiered, FFS rate that varies based upon the trip distance.

Additional information on rate determination methods located in Main B. Optional

Connecticut Waiver# CT.1085.R01.00 

CT Acquired Brain Injury II

Waiver Name:
CT Acquired Brain Injury II
Effective Date:
12/1/2019
Expiration Date:
11/30/2024

Services

List of Services for Connecticut Waiver# CT.1085.R01.00

Cost Neutrality

Cost Neutrality for Connecticut Waiver# CT.1085.R01.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
222 327

Year 1 Waiver Services

List of Year 1 Waiver Services for Connecticut Waiver# CT.1085.R01.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
ABI Group Day per hour 11 157 $16.94
Prevocational Services per hour 28 568 $38.49
Supported Employment per hour 77 477 $38.49
Independent Living Skills per hour 160 6101 $9.67

Year 5 Waiver Services

List of Year 5 Waiver Services for Connecticut Waiver# CT.1085.R01.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
ABI Group Day per hour 15 161 $18.64
Prevocational Services per hour 112 477 $42.32
Supported Employment per hour 40 565 $42.32
Independent Living Skills per hour 235 6104 $10.63

Rate Determination Methods

Rate Determination Methods for Connecticut Waiver# CT.1085.R01.00

Pursuant to Connecticut Department of Social Services Provider manual. All schedules of payment for coverable Medical Assistance Program goods and services shall be established by the commissioner and paid by the department in accordance with all applicable federal and state statutes and regulations. Waiver service rates in appendix J are based on an increase using the CPI-Medical. However, the rates are increased upon legislative action. Rates across the board were increased in by 2% across the board in January 2019.

Input on the waiver, including rates, were afforded to all parties who commented on the ABI Waiver application. This includes consumers, family, case managers, and providers. Service rate information is available as the fee schedule is posted on the DXC web site. The entire waiver application, including rates are posted for public comment as required. Consumers, provider organizations and DSS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application has been reviewed and approved by the committees of cognizance of the Connecticut state legislature after a lengthy public hearing in which stakeholders had the ability to testify and comment.

The rate setting methodology is the same for all services. Waiver service rates are based on direct and indirect costs of providing Waiver services. The rate structure for the program consists of 1) fee-for-service billing from an established fee schedule that pays uniform rates across providers; 2) usual and customary rates established individually with providers based on special provider needs such as serving hazardous urban areas which require accompaniment by security personnel. Agency-based PCA is fee-for-service billing. The agency determines the rate of pay but the maximum allowable rate for the service is established by the department in its fee schedule. Other than the self hire companion, rates do not vary for different providers of waiver services. Rates are usually prospective. If retroactive rate setting should occur, this will result in mass adjustments during a claim cycle to either compensate providers for a rate increase or recoupments if rates are decreased. During the life of this waiver, service rates may be adjusted based on legislatively approved increases or decreases to the Department's appropriation. Rates do not change unless legislatively approved. Rates were increased across the board in January 2019. At this time, fee schedules were reviewed and updated.

Oversight of the ABI rate determination method is conducted by the DSS Rate setting Unit through a review of ABI Waiver rates for reasonableness in comparison to other HCBS comparable waiver services. Additionally, DSS Fiscal Unit conducts a review of the data. When the state legislature passed increases to the state minimum wage, the fiscal unit worked with clinical staff to identify which services were most impacted by the minimum wage increase. The department had a fixed appropriation to utilize to increase rates and their analysis projected units of services impacted by the minimum wage increase. The projected units of service were divided into the allocation which resulted in a 1% rate increase to the providers. The rate setting unit works collaboratively with the Community Options unit and it was identified that the rate for Companion service was limiting provider capacity. The rate setting unit obtained cost information from some of the providers of Companion services and increased the rate by 11% in order to ensure capacity. Reviews occur at a minimum every five years to coincide with the renewal but in the case of the Companion service, it was reviewed and adjusted based on capacity concerns.

Rates for waiver services are currently under review and revision since the state legislature has passed a law increasing the state's minimum wage with the goal to raise it to $15/hour. Rates for waiver services were and are reviewed and adjusted based upon state legislative action to increasing the state's minimum wage in phases with the goal to raise it to $15/hour. Community Options staff worked closely with staff from the fiscal unit to determine which services were impacted by the minimum wage change. Newly appropriated dollars were equally distributed among the services identified as being impacted by the minimum wage increase. Rates for self directed ILST and Companion services are determined by the collective bargaining agreement.

The waiver has an adequate provider network to meet the needs of this population demonstrating sufficiency of rates. A public hearing regarding this waiver renewal was held on 8/13/19. There were no comments suggesting the rates were not sufficient.

Connecticut Waiver# 0881.R01.00 

CT Employment and Day Supports

Waiver Name:
CT Employment and Day Supports
Effective Date:
4/1/2016
Expiration Date:
3/31/2021

Services

List of Services for Connecticut Waiver# 0881.R01.00

Cost Neutrality

Cost Neutrality for Connecticut Waiver# 0881.R01.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1350 2150

Year 1 Waiver Services

List of Year 1 Waiver Services for Connecticut Waiver# 0881.R01.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Blended Supports Direct Hire/Individual 15 minutes 0 2000 $31.61
Blended Supports Agency 15 minutes 0 2000 $31.61
Group Day Supports aka Community Based Day Support Option - Per Diem per diem 413 186.09 $103.97
Group Day Supports aka Community Based Day Support Option - Per 15 minutes 15 minutes 41 675.43 $14.04
Group Day Supports aka Community Based Day Support Option - half day per half day 0 225 $53.35
Group Day Supports aka Community Based Day Support Option - Per diem medical per diem 0 225 $106.70
Group Day Supports aka Community Based Day Support Option - per 15 minutes medical 15 minutes 0 5400 $5.00
Individual Supported Employment 15 minutes 155 646.08 $11.99
Transitional Employment Services per diem per diem 0 20 $91.25
Transitional Employment Services per 15 minutes 15 minutes 0 480 $14.04
Group Supported Employment per diem 659 205.71 $91.25
Group Supported Employment per half day 0 411 $45.62
Group Supported Employment 15 minutes 65 675.43 $14.04
Individualized Day Support Individual Rate 15 minutes 280 408 $31.61
Individualized Day Support Agency Rate 15 minutes 0 0 $1.00
Customized Employment Supports per diem 0 123 $351.00
Customized Employment Supports 15 minutes 0 2950 $16.00

Year 5 Waiver Services

List of Year 5 Waiver Services for Connecticut Waiver# 0881.R01.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Health per diem 3 200 $70.59
Blended Supports Direct Hire/Individual 15 minutes 2 2000 $33.29
Blended Supports Agency 15 minutes 2 2000 $33.29
Group Day Supports aka Community Based Day Support Option - Per Diem per diem 658 186.09 $109.49
Group Day Supports aka Community Based Day Support Option - Per 15 minutes 15 minutes 65 675.43 $14.78
Group Day Supports aka Community Based Day Support Option - half day per half day 2 225 $60.00
Group Day Supports aka Community Based Day Support Option - Per diem medical per diem 2 225 $120.00
Group Day Supports aka Community Based Day Support Option - per 15 minutes medical 15 minutes 2 5400 $5.00
Individual Supported Employment 15 minutes 247 646.08 $12.63
Transitional Employment Services per diem per diem 2 20 $96.09
Transitional Employment Services per 15 minutes 15 minutes 2 480 $14.78
Group Supported Employment per diem 659 205.71 $91.25
Group Supported Employment per half day 0 411 $45.62
Group Supported Employment 15 minutes 65 675.43 $14.04
Individualized Day Support Individual Rate 15 minutes 280 408 $31.61
Individualized Day Support Agency Rate 15 minutes 0 0 $1.00
Customized Employment Supports per diem 2 123 $395.00
Customized Employment Supports 15 minutes 2 2950 $16.00

Rate Determination Methods

Rate Determination Methods for Connecticut Waiver# 0881.R01.00

DDS services are claimed based on the documented attendance in the DDS web based attendance system or through the FI billing system utilizing interim rates. Interim rates are developed based on a prior fiscal year rate. The Interim rate may include an inflation factor up to the Medical Care CPI. Final cost based replacement rates are computed by the DDS Rate Setting Unit and approved by DSS Reimbursement and CON Unit. DDS public programs are analyzed after the close of the fiscal year in an agreed-upon rate setting methodology. Contracted providers submit their Annual Reports to document the cost of providing the contracted services and the DDS Rate Setting Unit analyzes these reports minus any cost settlement of unexpended funds or unallowable costs in accordance with the State’s established cost standards to develop provider level reimbursement rates. The Fiscal Intermediaries submit cost reports for the services of the Self-directed participants to the DDS Rates Setting Unit and those cost specifics are analyzed for the “FI” rates. All rates, interim and final cost-based replacement rates are approved by DSS Reimbursement and CON.

Below is a guide as to which services are claimed based on the documented attendance in the DDS web-based attendance system and which services are claimed based on the Fiscal Intermediaries (FI) billing system utilizing interim rates.

-DDS Exclusively: Any service that is Per Diem

-FI Exclusively: Independent support broker, Peer Support, Assistive Technology, Individual Direct Goods and Services, Interpreter, Specialized Medical Equipment and Supplies and Training, Counseling and Support Services for Unpaid Caregivers.

-Every other service happens both through DDS’ attendance system and through the FI’s system.

DDS administrative costs will not be claimed as waiver services as of July 1, 2014. As of July 1, 2014, the waiver services will include a de minimis rate pursuant to 2 CFR 200.414 until an HHS approved indirect cost rate is obtained.

Payment rates paid to contracted providers and self-directed providers and staff are developed by the DDS Operations Center. The payment rates are based on a direct wage baseline with adjustments for indirect, supervision and (providers) administrative costs at the private provider level and reported on their Annual Report of Day and Residential Services.

These costs are not included in the State’s Cost Allocation Plan, as they are not direct state costs, but provider costs. However, these costs are included in the service costs in the DDS Waiver Rates as they are the provider’s costs to operate the programs. These expenses are based on information drawn from Connecticut Department of Labor wage statistics, salary surveys, and audited findings from annual provider fiscal reports. Any and all provider costs of doing business that are attributable to room and board are excluded from waiver service rates, including maintenance and upkeep, and physical plant alterations. The service rates for Group Day Supports, Supported Employment, Respite, Individualized Day Support, Independent Support Broker, and Transportation were developed based on the direct support hourly wage and the additional components of supervision, employee benefits, indirect costs, administrative and general costs at the provider level, and the number of clients per the direct care staffing ratio. There is an additional component of hours of supports for those rates calculated on a per diem basis. Payment adjustments are made to providers who experience unanticipated low attendance rates or extraordinary costs due to extreme weather conditions such as blizzards, hurricanes floods, etc., Acts of God or other unforeseen circumstance such as arson or vandalism.

DDS reviews the total revenue and expenses reported on the provider’s Annual Report of Day and Residential Services and cost settles any unexpended funds or unallowable costs in accordance with the State’s established cost standards.

The rates for, Behavioral Support Services and Interpreter were developed based on the contracts of similar supports with other DDS and State of Connecticut departments. The rate is to reimburse the provider for the wage and benefits of the behaviorist and interpreter along with any associated overhead (ie. office space, insurance, etc.). As noted above, the waiver services will include a de minimis rate pursuant to 2 CFR 200.414 until an HHS approved indirect cost rate is obtained.

Assistive Technology is individually priced and capped at $15,000 year and is paid at "up to max" rates because the services require manual pricing.

Peer Support rate is based on a review of direct and indirect costs and is paid off the department's fee schedule.

Waiver service rates are based on direct and indirect costs of providing Waiver services. Individuals, provider organizations and DDS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application has been reviewed and approved by the committees of cognizance of the Connecticut state legislature DDS has worked to connect the rates to the support needs of each person using the CT Level of Need Assessment and Risk Screening Tool (LON). The LON uses an algorithm that takes all of the assessed information on an individual to create a composite score ranging from 0-8. DDS has associated a staffing level to each of the scores from 1 through 8 to produce "need based" rates. The system also contains a separate review of extraordinary support needs that are outside the eight levels.

Data developed by DDS is formatted and sent to the Department of Social Services (the single state Medicaid agency) for review and Medicaid rate approval.

Individuals, families, provider organizations and DDS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application was also reviewed by the committees of cognizance of the Connecticut state legislature. Updated rates are posted by Fiscal Year on the DDS website and an email is sent out notifying all stakeholders of the rate changes.

Individual Day support rates are now determined by a collective bargaining agreement between the state and SEIU 1199 for the time period of 7/1/13 through 6/30/17. A renegotiation of the terms of the contract will take place beginning between September 1, 2015 and October 1, 2015 absent mutual agreement to a different time period. All applicable employer taxes are added to the pay rate to determine the Medicaid rate. In addition, as the result of the new collective bargaining agreement for personal support and IHS staff, there is a requirement for both a training and paid time off funds to be dispersed through the fiscal intermediary.( The IHS and personal support are not in the EDS waiver.)

Payment rates for Blended Supports are directly linked to the Individualized Day Support rate.

The payment rates for Customized Employment are based on the combination of the Level of Need and the specific plan that is developed for the individual.

The payment rate for transitional employment is directly linked to the group supported employment payment rate.

The payment rate for Counseling and Support Services is approved on a case by case basis, based on the cost of the service.

Group Day Supports Medical- The rate was adjusted based on a lower level of utilization. We needed to increase the rate as there will be far more days when the entire group does not meet as opposed to regular Group Day Supports.

Remote Supports Service rate is based on the monitoring agency's fee plus the amount of coverage needed for the backup agency. There will be an enhanced rate payed to providers for individuals that use Remote Supports when they previously utilized a more intensive services (Such as Individualized Home Supports) for up to two years.

Remote Supports Technology Rate will be paid based on the actual cost of the technology being used.

Environmental Modifications- Only a self-hired service. There is a cap on what they can use (depending on the modification), must obtain three quotes.

Vehicle Modifications- $15,000 cap for the modification and must obtain three bids. This service is for families not providers.

Personal emergency response system (install and monitoring) are at max fee, being that all provider costs and utilization computes the per unit cost used in the cost-based final replacement rates: personal emergency response system (install and monitoring)

Public Transportation is cost based (The cost of the Ticket, Fare and/or Pass)

Connecticut Waiver# CT.0993.R01.00 

Home and Community Supports Waiver for Persons with Autism

Waiver Name:
Home and Community Supports Waiver for Persons with Autism
Effective Date:
1/1/2018
Expiration Date:
12/31/2022

Services

List of Services for Connecticut Waiver# CT.0993.R01.00

Cost Neutrality

Cost Neutrality for Connecticut Waiver# CT.0993.R01.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
138 191

Year 1 Waiver Services

List of Year 1 Waiver Services for Connecticut Waiver# CT.0993.R01.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Mentor Direct Hire 15 minutes 23 1557 $4.34
Community Mentor Agency 15 minutes 100 1016 $6.72
Job Coach Direct Hire 15 minutes 3 573 $9.13
Job Coach Agency 15 minutes 36 600 $11.60
Social Skills Group 15 min per person 52 165 $6.18
Life Skills Coach Direct Hire 15 minutes 23 1059 $9.13
Life Skills Coach Agency 15 minutes 103 873 $11.60

Year 5 Waiver Services

List of Year 5 Waiver Services for Connecticut Waiver# CT.0993.R01.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Mentor Direct Hire 15 minutes 32 1557 $5.03
Community Mentor Agency 15 minutes 138 1016 $7.82
Job Coach Direct Hire 15 minutes 4 573 $10.60
Job Coach Agency 15 minutes 50 600 $13.47
Social Skills Group 15 min per person 72 165 $7.16
Life Skills Coach Direct Hire 15 minutes 32 1059 $10.60
Life Skills Coach Agency 15 minutes 143 873 $13.47

Rate Determination Methods

Rate Determination Methods for Connecticut Waiver# CT.0993.R01.00

Rates were determined by the Department of Developmental Services(DDS) and verified for their reasonableness by the Reimbursement & CON Unit of the Division of Health Services of the Connecticut Department of Social Services (Department).

Pursuant to the Department Provider Manual, all schedules of payment for covered Medicaid program goods and services shall be established by the Commissioner of the Connecticut Department of Social Services and paid by the Department in accordance with applicable federal and state statutes and regulations. The Autism Waiver (Waiver) service rates are based on historical rates developed by the DDS, indirect costs of 10%, Administrative add-on of 20%, and a CPI based an inflationary rate of 3%. Consumers, provider organizations and Department staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application is subject to review and approval by the committees of cognizance of the Connecticut state legislature prior to submission to CMS. The rate structure for the program consists of 1) fee-for-service billing from an established fee schedule that pays uniform rates across providers; 2) usual and customary rates established individually with providers based on special provider need; 3)”up-to-max” rates that require manual pricing. Maximum allowable rate for services are established by the Department in its fee schedule. Rates do not vary for different providers of Waiver services. Assistive Technology; Individual Goods & Services; Specialized Driving Assessment are "up to max" rates. These costs are limited to the waiver maximum over five years for Assistive Technology; one year for Individual Goods & Services; and as prescribed in the participants Individual Plan for Specialized Driving Assessment.

The historical rates developed by the DDS were based on the following assumptions:

The Clinical Behavioral Supports, Non-Medical Transportation, PERS, and Respite Rates were based on HCBS Comp and IFS Waiver rates; the Community Mentor rate was the HCBS Comp and IFS rate for Personal Supports; and Job Coach and Life skills Coach also used the HCBS Comp and IFS rates for In Home Supports for direct hire. The Social Skills Group was based on the CT Behavioral Health Partnership rate; the Specialized Driving Assessment was the CT BRS rate; and the Job Coaching and Life Skills Coaching used Department of Labor direct wage baseline and included adjustments for indirect, supervision and administrative costs. The Assistive Technology was a reasonable estimated cost of communication devices. The Individual Goods and Services were based on HCBS Comp and IFS rates, with a lower amount for this waiver. Live-in companion and interpreter rates were developed in 2013 by DDS and are both in the HCBS waiver. The live-in companion rate was based on the DDS Rental Subsidy Guidelines. Interpreter services rates are included in the HCBS Comp, IFS, and EDS waivers.

Connecticut Waiver# CT.0437.R03.00 

Comprehensive Supports

Waiver Name:
Comprehensive Supports
Effective Date:
10/1/2018
Expiration Date:
9/30/2023

Services

List of Services for Connecticut Waiver# CT.0437.R03.00

Cost Neutrality

Cost Neutrality for Connecticut Waiver# CT.0437.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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5600 5700

Year 1 Waiver Services

List of Year 1 Waiver Services for Connecticut Waiver# CT.0437.R03.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Blended Supports Direct Hire/Individual 15 minutes 8 6000 $10.42
Blended Supports Agency 15 minutes 8 6000 $10.42
Group Day Support Per Diem per diem 2711 225 $119.52
Group Day Support Per 15 minutes 15 minutes 249 5400 $4.98
Group Day Support Per half day per half day 10 225 $59.76
Group Day Support Per diem Medical per diem 2 225 $119.52
Group Day Support Per Hour Medical 15 minutes 2 5400 $4.98
Group Supported Employment per diem 1340 225 $106.41
Group Supported Employment 15 minutes 143 5400 $4.43
Group Supported Employment per half day 1 450 $53.20
Prevocational Services Per 15 minutes 15 minutes 10 5400 $4.29
Prevocational Services Per diem per diem 137 225 $103.03
Prevocational Services Per half day per half day 2 450 $51.52
Customized Employment Supports Per diem per diem 2 123 $350.82
Customized Employment Supports Per 15 minutes 15 minutes 2 2950 $14.62
Individualized Supported Employment Direct Hire/Individual 15 minutes 196 5400 $4.43
Individualized Supported Employment Agency 15 minutes 196 5400 $4.43
Individualized Day Support 15 minutes 909 2950 $5.73
Transitional Employment Services Per Diem per diem 130 20 $116.46
Transitional Employment Services Per 15 minutes 15 minutes 10 480 $4.85

Year 5 Waiver Services

List of Year 5 Waiver Services for Connecticut Waiver# CT.0437.R03.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Blended Supports Direct Hire/Individual 15 minutes 40 6000 $10.42
Blended Supports Agency 15 minutes 40 6000 $10.42
Group Day Support Per Diem per diem 2760 225 $134.54
Group Day Support Per 15 minutes 15 minutes 253 5400 $5.61
Group Day Support Per half day per half day 10 225 $67.27
Group Day Support Per diem Medical per diem 2 225 $134.54
Group Day Support Per Hour Medical 15 minutes 2 5400 $5.61
Group Supported Employment per diem 1364 225 $119.81
Group Supported Employment 15 minutes 145 5400 $4.99
Group Supported Employment per half day 1 450 $59.91
Prevocational Services Per 15 minutes 15 minutes 11 5400 $4.82
Prevocational Services Per diem per diem 139 225 $115.72
Prevocational Services Per half day per half day 2 450 $57.86
Customized Employment Supports Per diem per diem 2 123 $401.95
Customized Employment Supports Per 15 minutes 15 minutes 2 2950 $16.75
Individualized Supported Employment Direct Hire/Individual 15 minutes 200 5400 $4.57
Individualized Supported Employment Agency 15 minutes 200 5400 $4.57
Individualized Day Support 15 minutes 925 2950 $6.45
Transitional Employment Services Per Diem per diem 130 20 $133.43
Transitional Employment Services Per 15 minutes 15 minutes 10 480 $5.56

Rate Determination Methods

Rate Determination Methods for Connecticut Waiver# CT.0437.R03.00

DDS services are claimed based on the documented attendance in the DDS web based attendance system or through the FI billing system utilizing interim rates. Interim rates are developed based on a prior fiscal year rate. The Interim rate may include an inflation factor up to the Medical Care CPI. Final cost based replacement rates are computed by the DDS Rate Setting Unit and approved by DSS Reimbursement and CON Unit. DDS public programs are analyzed after the close of the fiscal year in an agreed-upon rate setting methodology. Contracted providers submit their Annual Reports to document the cost of providing the contracted services and the DDS Rate Setting Unit analyzes these reports minus any cost settlement of unexpended funds or unallowable costs in accordance with the State’s established cost standards to develop provider level reimbursement rates. The Fiscal Intermediaries submit cost reports for the services of the Self-directed participants to the DDS Rates Setting Unit and those cost specifics are analyzed for the “FI” rates. All rates, interim and final cost-based replacement rates are approved by DSS Reimbursement and CON.

DDS administrative costs will not be claimed as waiver services as of July 1, 2014. As of July 1, 2014, the waiver services will include a de minimis rate pursuant to 2 CFR 200.414 until an HHS approved indirect cost rate is obtained.

Payment rates paid to contracted providers and self-directed providers and staff are developed by the DDS Operations Center. The payment rates are based on a direct wage baseline with adjustments for indirect, supervision and (providers) administrative costs at the private provider level and reported on their Annual Report of Day and Residential Services.

These costs are not included in the State’s Cost Allocation Plan, as they are not direct state costs, but provider costs. However, these costs are included in the service costs in the DDS Waiver Rates as they are the provider’s costs to operate the programs. These expenses are based on information drawn from Connecticut Department of Labor wage statistics, salary surveys, and audited findings from annual provider fiscal reports. Any and all provider costs of doing business that are attributable to room and board are excluded from waiver service rates, including maintenance and upkeep, and physical plant alterations. The service rates for Prevocational, Group Day Supports, Supported Employment, Respite, Individualized Day Support, Independent Support Broker, and Transportation were developed based on the direct support hourly wage and the additional components of supervision, employee benefits, indirect costs, administrative and general costs at the provider level, and the number of clients per the direct care staffing ratio. There is an additional component of hours of supports for those rates calculated on a per diem basis. Payment adjustments are made to providers who experience unanticipated low attendance rates or extraordinary costs due to extreme weather conditions such as blizzards, hurricanes floods, etc., Acts of God or other unforeseen circumstance such as arson or vandalism. DDS reviews the total revenue and expenses reported on the provider’s Annual Report of Day and Residential Services and cost settles any unexpended funds or unallowable costs in accordance with the State’s established cost standards.

The rates for Training and Counseling for unpaid caregivers, Behavioral Support Services and Interpreter were developed based on the contracts of similar supports with other DDS and State of Connecticut departments. The rate is to reimburse the provider for the wage and benefits of the behaviorist and interpreter along with any associated overhead (ie. office space, insurance, etc.). As noted above, the waiver services will include a de minimis rate pursuant to 2 CFR

200.414 until an HHS approved indirect cost rate is obtained.

Assistive Technology is individually priced and capped at $10,000 year and is paid at "up to max" rates because the services require manual pricing.

Peer Support rate is based on a review of direct and indirect costs and is paid off the department's fee schedule.

Waiver service rates are based on direct and indirect costs of providing Waiver services. Individuals, provider organizations and DDS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application has been reviewed and approved by the committees of cognizance of the Connecticut state legislature

The following services are at max fee, being that all provider costs and utilization computes the per unit cost used in the cost-based final replacement rates: personal emergency response system (install and monitoring), community companion homes, individualized home supports, individualized day supports, behavioral support services, transportation, health care coordination, companion supports, respite, interpreter services, personal supports, supported employment, group day supports, nutrition, live in care giver, senior supports, parenting supports, assisted living, and independent support broker. The service for adult day health utilizes the DSS promulgated rates. Continuous Residential Supports, and Share Living are provider level rates based on the providers service costs as reported in the Annual Report, with the exclusion of any room and board costs to the waiver service rates.

DDS has worked to connect the rates to the support needs of each person using the CT Level of Need Assessment and Risk Screening Tool (LON). The LON uses an algorithm that takes all of the assessed information on an individual to create a composite score ranging from 0-8. DDS has associated a staffing level to each of the scores from 1 through 8 to produce "need based" rates. The system also contains a separate review of extraordinary support needs that are outside the eight levels.

Data developed by DDS is formatted and sent to the Department of Social Services (the single state Medicaid agency) for review and Medicaid rate approval.

Individuals, families, provider organizations and DDS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application was also reviewed by the committees of cognizance of the Connecticut state legislature. Updated rates are posted by Fiscal Year on the DDS website and an email is sent out notifying all stakeholders of the rate changes.

The rates are reviewed annually for each waiver service. The primary factor considered regarding the sufficiency of the rates is the cost on the provider’s annual reports. From the annual reports we are able to see the number of providers that report costs higher than the rates, as well as those providers with costs lower than the rates. All contracted services are on the annual reports so we are able to review each services average cost vs rate.

1. Blended Supports- This rate is based on the individualized day supports rate, The key difference is that funding can come from either Day or Residential money (Which the State of CT funds out of two separate budget lines)

2. Live-in Caregiver- Rate is based on each individual’s needs, budget and expenses of the living situation. The information is inputted into the CT Rent subsidy formula to determine the actual rate paid.

3. Community Living Arrangements- The methodology was based on direct care staff salary with adjustments for supervision, benefits, indirect expense and A and G costs

4. Customized Employment Supports- DDS is currently working with other departments to set the rate. The vast majority of the rate methodology will mimic Individualized Supported Employment.

5. Environmental Modifications- Only a self-hired service. There is a cap on what they can use (depending on the modification), must obtain three quotes.

6. Individual Directed Goods and Services- Each payment rate is negotiated with the provider based on the service.

7. Shared Living- Negotiated rate with a cap of $299 per day determined by amount of staffing and supports that the individual needs.

8. Specialized Medical Equipment and Supplies- Only a self-hired service, negotiated depending on the needs of the individual

9. Transitional Services- Set based on the Group Supported Employment rate. Currently using an interim payment rate as DDS is still evaluating cost of the service.

10. Vehicle Modifications- $15,000 cap for the modification and must obtain three bids. This service is for families not providers.

11. Remote Supports Service rate is based on the monitoring agency's fee plus the amount of coverage needed for the backup agency. There will be an enhanced rate payed to providers for individuals that use Remote Supports when they previously utilized a more intensive services (Such as Individualized Home Supports) for up to two years.

12. Remote Supports Technology Rate will be paid based on the actual cost of the technology being used.

Connecticut Waiver# CT.0426.R03.00 

CT Individual and Family Support

Waiver Name:
CT Individual and Family Support
Effective Date:
2/1/2018
Expiration Date:
1/31/2023

Services

List of Services for Connecticut Waiver# CT.0426.R03.00

Cost Neutrality

Cost Neutrality for Connecticut Waiver# CT.0426.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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4500 4500

Year 1 Waiver Services

List of Year 1 Waiver Services for Connecticut Waiver# CT.0426.R03.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Blended Supports Direct Hire/Individual 15 minutes 2 2000 $10.00
Blended Supports Agency 15 minutes 2 2000 $10.00
Group Day Support Per Diem per diem 756 352 $56.75
Group Day Support Per 15 minutes 15 minutes 713 3900 $5.12
Group Day Support Per half day per half day 2 75 $28.50
Group Day Support Per diem Medical per diem 2 75 $106.70
Group Day Support Per Hour Medical 15 minutes 2 1800 $5.00
Group Supported Employment per diem 900 352 $46.49
Group Supported Employment 15 minutes 359 4000 $4.09
Group Supported Employment per half day 1 704 $23.25
Prevocational Services Per 15 minutes 15 minutes 31 3900 $5.11
Prevocational Services Per diem per diem 65 352 $56.65
Prevocational Services Per half day per half day 2 6.67 $28.30
Customized Employment Supports Per diem per diem 2 41 $351.00
Customized Employment Supports Per 15 minutes 15 minutes 2 983.33 $15.00
Individualized Supported Employment Direct Hire/Individual 15 minutes 184 1400 $11.69
Individualized Supported Employment Agency 15 minutes 647 1400 $11.69
Individualized Day Support - Direct Hire 15 minutes 111 1350 $16.27
Individualized Day Support Agency 15 minutes 627 1350 $16.27
Transitional Employment Services Per Diem per diem 130 352 $46.49
Transitional Employment Services Per 15 minutes 15 minutes 10 4000 $4.09

Year 5 Waiver Services

List of Year 5 Waiver Services for Connecticut Waiver# CT.0426.R03.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Blended Supports Direct Hire/Individual 15 minutes 2 6000 $10.00
Blended Supports Agency 15 minutes 2 6000 $10.00
Group Day Support Per Diem per diem 756 352 $65.88
Group Day Support Per 15 minutes 15 minutes 713 3900 $5.94
Group Day Support Per half day per half day 2 225 $32.94
Group Day Support Per diem Medical per diem 2 225 $120.00
Group Day Support Per Hour Medical 15 minutes 2 5400 $4.45
Group Supported Employment per diem 900 352 $53.97
Group Supported Employment 15 minutes 359 4000 $4.75
Group Supported Employment per half day 1 704 $26.99
Prevocational Services Per 15 minutes 15 minutes 31 3900 $5.93
Prevocational Services Per diem per diem 65 352 $65.76
Prevocational Services Per half day per half day 2 20 $32.88
Customized Employment Supports Per diem per diem 2 123 $395.00
Customized Employment Supports Per 15 minutes 15 minutes 2 2950 $16.00
Individualized Supported Employment Direct Hire/Individual 15 minutes 184 1400 $13.57
Individualized Supported Employment Agency 15 minutes 647 1400 $13.57
Individualized Day Support - Direct Hire/Individual 15 minutes 111 1350 $18.89
Individualized Day Support - Agency 15 minutes 627 1350 $18.89
Transitional Employment Services Per Diem per diem 130 352 $53.97
Transitional Employment Services Per 15 minutes 15 minutes 10 4000 $4.75

Rate Determination Methods

Rate Determination Methods for Connecticut Waiver# CT.0426.R03.00

DDS services are claimed based on the documented attendance in the DDS web based attendance system or through the FI billing system utilizing interim rates. Interim rates are developed based on a prior fiscal year rate. The Interim rate may include an inflation factor up to the Medical Care CPI. Final cost based replacement rates are computed by the DDS Rate Setting Unit and approved by DSS Reimbursement and CON Unit. DDS public programs are analyzed after the close of the fiscal year in an agreed-upon rate setting methodology. Contracted providers submit their Annual Reports to document the cost of providing the contracted services and the DDS Rate Setting Unit analyzes these reports minus any cost settlement of unexpended funds or unallowable costs in accordance with the State’s established cost standards to develop provider level reimbursement rates. The Fiscal Intermediaries submit cost reports for the services of the Self-directed participants to the DDS Rates Setting Unit and those cost specifics are analyzed for the “FI” rates. All rates, interim and final cost-based replacement rates are approved by DSS Reimbursement and CON.

DDS administrative costs will not be claimed as waiver services as of July 1, 2014. As of July 1, 2014, the waiver services will include a de minimis rate pursuant to 2 CFR 200.414 until an HHS approved indirect cost rate is obtained.

Payment rates paid to contracted providers and self-directed providers and staff are developed by the DDS Operations Center. The payment rates are based on a direct wage baseline with adjustments for indirect, supervision and (providers) administrative costs at the private provider level and reported on their Annual Report of Day and Residential Services.

These costs are not included in the State’s Cost Allocation Plan, as they are not direct state costs, but provider costs. However, these costs are included in the service costs in the DDS Waiver Rates as they are the provider’s costs to operate the programs. These expenses are based on information drawn from Connecticut Department of Labor wage statistics, salary surveys, and audited findings from annual provider fiscal reports. Any and all provider costs of doing business that are attributable to room and board are excluded from waiver service rates, including maintenance and upkeep, and physical plant alterations. The service rates for Prevocational, Group Day Supports, Supported Employment, Respite, Individualized Day Support, Independent Support Broker, and Transportation were developed based on the direct support hourly wage and the additional components of supervision, employee benefits, indirect costs, administrative and general costs at the provider level, and the number of clients per the direct care staffing ratio. There is an additional component of hours of supports for those rates calculated on a per diem basis. Payment adjustments are made to providers who experience unanticipated low attendance rates or extraordinary costs due to extreme weather conditions such as blizzards, hurricanes floods, etc., Acts of God or other unforeseen circumstance such as arson or vandalism. DDS reviews the total revenue and expenses reported on the provider’s Annual Report of Day and Residential Services and cost settles any unexpended funds or unallowable costs in accordance with the State’s established cost standards.

The rates for Training and Counseling for unpaid caregivers, Behavioral Support Services and Interpreter were developed based on the contracts of similar supports with other DDS and State of Connecticut departments. The rate is to reimburse the provider for the wage and benefits of the behaviorist and interpreter along with any associated overhead (ie. office space, insurance, etc.). As noted above, the waiver services will include a de minimis rate pursuant to 2 CFR

200.414 until an HHS approved indirect cost rate is obtained.

Assistive Technology is individually priced and capped at $15,000 year and is paid at "up to max" rates because the services require manual pricing.

Peer Support rate is based on a review of direct and indirect costs and is paid off the department's fee schedule.

Waiver service rates are based on direct and indirect costs of providing Waiver services. Individuals, provider organizations and DDS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application has been reviewed and approved by the committees of cognizance of the Connecticut state legislature

The following services are at max fee, being that all provider costs and utilization computes the per unit cost used in the cost-based final replacement rates: personal emergency response system (install and monitoring), community companion homes, individualized home supports, individualized day supports, behavioral support services, transportation, health care coordination, companion supports, respite, interpreter services, personal supports, supported employment, group day supports, nutrition, live in care giver, senior supports, parenting supports, assisted living, and independent support broker. The service for adult day health utilizes the DSS promulgated rates. Continuous Residential Supports, and Share Living are provider level rates based on the providers service costs as reported in the Annual Report, with the exclusion of any room and board costs to the waiver service rates.

DDS has worked to connect the rates to the support needs of each person using the CT Level of Need Assessment and Risk Screening Tool (LON). The LON uses an algorithm that takes all of the assessed information on an individual to create a composite score ranging from 0-8. DDS has associated a staffing level to each of the scores from 1 through 8 to produce "need based" rates. The system also contains a separate review of extraordinary support needs that are outside the eight levels.

Data developed by DDS is formatted and sent to the Department of Social Services (the single state Medicaid agency) for review and Medicaid rate approval.

Individuals, families, provider organizations and DDS staff have had the opportunity to review the Waiver application and rates pursuant to the public notice. The Waiver application was also reviewed by the committees of cognizance of the Connecticut state legislature. Updated rates are posted by Fiscal Year on the DDS website and an email is sent out notifying all stakeholders of the rate changes.

The rates are reviewed annually for each waiver service. The primary factor considered regarding the sufficiency of the rates is the cost on the provider’s annual reports. From the annual reports we are able to see the number of providers that report costs higher than the rates, as well as those providers with costs lower than the rates. All contracted services are on the annual reports so we are able to review each services average cost vs rate.

1. Blended Supports- This rate is based on the individualized day supports rate, The key difference is that funding can come from either Day or Residential money (Which the State of CT funds out of two separate budget lines)

2. Live-in Caregiver- Rate is based on each individual’s needs, budget and expenses of the living situation. The information is inputted into the CT Rent subsidy formula to determine the actual rate paid.

3. Community Companion Homes- Rate is based on the CT Level Of Need assessment.

4. Customized Employment Supports- The payment rates for Customized Employment are based on the combination of the Level of Need and the specific plan that is developed for the individual.

5. Environmental Modifications- Only a self-hired service. There is a cap on what they can use (depending on the modification), must obtain three quotes.

6. Individual Directed Goods and Services- Each payment rate is negotiated with the provider based on the service.

7. Shared Living- Negotiated rate with a cap of $299 per day determined by amount of staffing and supports that the individual needs.

8. Specialized Medical Equipment and Supplies- Only a self-hired service, negotiated depending on the needs of the individual

9. Transitional Employment Services- Set based on the Group Supported Employment rate as it closely mimics the type of staffing ratio that group supported employment provides. Currently using an interim payment rate as DDS is still evaluating cost of the service. To be set during FY 2020 based on actual cost data.

10. Vehicle Modifications- $15,000 cap for the modification and must obtain three bids. This service is for families not providers.

11. Rates paid for supported employment are based on three main factors:

1. The Level of need of the individuals being served. The level of need helps to determine the average staffing ratio needed for the various employment groups throughout the state.

2. Average salary and fringe cost of the job classes working with the group.

3. Average Utilization- Example(In a 1 to 4 ratio group, staffing costs do not diminish if a member of a group of 4 does not show up)

12. Group Day Supports Medical- The rate was adjusted based on a lower level of utilization. We needed to increase the rate as there will be far more days when the entire group does not meet as opposed to regular Group Day Supports.

13. Remote Supports Service rate is based on the monitoring agency's fee plus the amount of coverage needed for the backup agency. There will be an enhanced rate payed to providers for individuals that use Remote Supports when they previously utilized a more intensive services (Such as Individualized Home Supports) for up to two years.

14. Remote Supports Technology Rate will be paid based on the actual cost of the technology being used.

Delaware Waiver# DE.0009.R08.00 

DE DDDS Lifespan Waiver

Waiver Name:
DE DDDS Lifespan Waiver
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Delaware Waiver# DE.0009.R08.00

Cost Neutrality

Cost Neutrality for Delaware Waiver# DE.0009.R08.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2600 3136

Year 1 Waiver Services

List of Year 1 Waiver Services for Delaware Waiver# DE.0009.R08.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Community Participation 15 minutes 51 1250 $8.08
Day Habilitation non facility 15 minutes 70 1250 $7.98
Day Habilitation Facility 15 minutes 40 1250 $7.88
Day Habilitation Facility Day 1189 220 $93.96
Prevocational Services Facility Day 665 220 $77.80
Prevocational Services Non Facility 15 minutes 20 1250 $7.98
Prevocational Services Facility 15 minutes 166 710 $7.88
Supported Employment Individual 15 minutes 517 730 $13.55
Supported Employment Small Group 15 minutes 195 1758 $4.63

Year 5 Waiver Services

List of Year 5 Waiver Services for Delaware Waiver# DE.0009.R08.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Community Participation 15 minutes 131 1250 $8.08
Day Habilitation non facility 15 minutes 130 1250 $7.98
Day Habilitation Facility 15 minutes 20 1250 $7.88
Day Habilitation Facility Day 1309 220 $114.68
Prevocational Services Facility Day 605 220 $98.52
Prevocational Services Non Facility 15 minutes 60 1250 $7.98
Prevocational Services Facility 15 minutes 200 710 $7.88
Supported Employment Individual 15 minutes 637 890 $13.55
Supported Employment Small Group 15 minutes 265 1758 $463.00

Rate Determination Methods

Rate Determination Methods for Delaware Waiver# DE.0009.R08.00

DDDS is responsible for the development of statewide rates for waiver services through an MOU with DMMA. DMMA is responsible for the final review & approval of all rates and for ensuring that rates are computed consistent with the approved methodology.

Rates for most Lifespan waiver services are based on a “market basket” methodology initially established in 2004. The market basket methodology, also commonly referred to as the “brick” methodology, replaced a process of negotiated rates that DDDS used prior to 2004. DDDS rebased the benchmark rates in January 2014 and then again in January 2019 as directed by the Delaware legislature. DDDS completed the DSP rate rebase and published the results in January 2019. The 2019 rate study included the following services: residential habilitation, facility-based and non-facility based day habilitation, community participation, facility-based and non-facility based pre-vocational services, supported employment individual & group and supported living. DDDS also used the market basket methodology to compute an hourly rate for the new service of Medical Residential Habilitation and for Behavior Consultation and Nurse Consultation, although they were not included in the rate study.

A market basket is a set of goods and services that together indicate the cost of a product or a service. The Consumer Price Index is an example of a market basket. A market basket is often described as a fixed-weight index because it centers on how much more or less it would cost, at a later time, to purchase the same mix of goods or services that was purchased in a base period.

As with the 2014 rebase, in the 2019 rebase, DDDS reviewed and made revisions to the composition of the market basket and to the assumptions for all of the rate components based on observed and anticipated changes in service delivery. In the 2019 study, DDDS re-evaluated and refreshed the DSP wages and the other components of the “market basket” used to create the DSP rates to address changes in operating costs, additional types of expenses, and the relationship between costs to the wage. The 2019 rate study reflects changes in service delivery in response to the CMS HCBS Settings Rule published in January 2014.

DDDS shared the 2019 rate study and benchmark rates with the provider agencies, advocates and other key stakeholders while in draft. DDDS incorporated their feedback into the final rates and was documented in the rate study. DDDS worked closely with the Delaware provider association representing most of the DDDS waiver providers on the study.

The Direct Support Professional (DSP) rates are made up of four components: DSP Wage, employment related expenses, program indirect expenses, administrative expenses.

DSP Wage Rate: The methodology requires the selection of a wage proxy for each type of Direct Support Professional

• employment related expenses (%)

• program indirect expenses (%)

• administrative expenses (%)

Employment Related Expenses: include benefits paid to or for workers above salary and wages. They include expenses such as health insurance, workers comp, unemployment compensation, state/federal payroll taxes, criminal background checks and training.

Program Related Expenses: support the delivery of the service but are either non-salary expenses or are a step removed from the direct delivery of the service. These include program management, program rent, utilities, program supplies, technology expenses (phones, laptops, network, software licenses), vehicle costs for staff, quality assurance, staff recruitment costs & DSP staff time spent in allowable but not billable activities.

General and Administrative Expenses include functions that are necessary for the operation of the organization but cannot be directly related to a good or service produced by the organization. This includes: payroll and accounting, legal counsel, outside audit fees, general liability insurance, managerial salaries, corporate overhead, rent, utilities, office equipment and subscriptions.

Whereas the 2014 study used a survey tool provided by the consultant to collect and analyze provider financial data, the 2019 study used the provider General Ledgers from the providers as the source of provider cost data for the non-wage components of the market basket: Employment Related Expenses (ERE), Program Indirect Expenses (PI), and General and Administrative Expenses (G&A). The Provider General Ledgers and chart of accounts were used to code expenses as ERE, PI or G&A or unallowable (such as room and board expenses for residential settings). The analysis of expense data did not reflect any significant difference in provider cost profiles for ERE or G&A expenses, thus, the percentages assigned for ERE and G&A do not differ among service type. However, the expense data did demonstrate a need to assign a different percentage for PI costs; therefore, each service has a distinct PI percentage included in the calculation of the rate.

The costs for ERE, PI and G&A are converted to percentages that are multiplied by the direct support hourly wage rate as a set of recursive percentages in order to develop an hourly provider DSP benchmark rate for each service.

The formula to compute the hourly rate for each service using the rate components (expressed as a percentage) is as follows:

(DSP wage+(DSP*(1+ERE))/(1-PI)/(1-GA)

Impact of State Funding on Provider Rates: The legislature determines the level of funding that is available for services and rate increases each year based on the approved Benchmark rates as the standard. The goal is to use available funding to “level up” the rates to the same % of the benchmark and to reach the benchmark over time. As of July 1, 2019, all rates included in the 2014 DSP rebasing study were at a minimum of 81.2% of the benchmark. The legislature has not yet voted on the Operating Budget bill for SFY2020 so the percent of the new benchmark rates from the 2019 rebasing study is not yet known.

The DSP rates are periodically re-based using cost data from the most current period available. The Epilogue of the Budget Act enacted by the Delaware General Assembly indicates that DDDS “may rebase, once every one to three years” its Direct Support Professional rates. DDDS publishes waiver rates on the DDDS website for each year.

Transportation to and from the service setting is a component part of the service for residential habilitation, day habilitation and prevocational service and is paid as an add-on to the direct support unit cost rate. Rates for residential services do not include any costs associated with room and board.

State-Operated Day Habilitation: The rate for the day habilitation program operated by DDDS is computed on an annual basis using prior year actual annual costs, including personnel, benefits, program related expenses such as rent, utilities and supplies, and administration (using the indirect cost rate approved by the Division of Cost Allocation (DCA), U.S. DHHS). The total actual costs are divided by actual units of service to calculate a daily rate for this service.

The rate for the new service called “Medical Residential Habilitation” is computed in hourly units of service. DDDS computed the rate by defining a nursing wage for RN and LPN from BLS data and adding the same factors for Employee-Related Expenses (ERE), Program Indirect Expenses (PI), and General Administrative Expenses (GA) as for Residential Habilitation from the 2019 rate study.

The baseline Medical Residential Habilitation rate represents services provided by one RN to one individual. An adjusted reimbursement rate per individual is computed to allow Medical Residential Habilitation to be provided by a single RN for up to three (3) clients residing in a Neighborhood Group Home or Staffed Apartment or up to two (2) (DSP). DDDS obtained wage data from the U.S. DOL Bureau of Labor Statistics and job postings from national internet employment sites for job classifications with similar requirements & duties. DDDS identified the need for three distinct categories of Direct Support Professionals with three different wage rates. The three categories and wages are: DSP Residential Habilitation and Facility-Based Day Services $14.11/hr, DSP Non-Facility Based Day Services $15.06/hr and Supported Employment, Community Participation and Supported Living $18.84. DDDS adopted this different approach to acknowledge the different qualifications required for DSPs who provide support in integrated community settings versus facility-based settings. The DSPs who perform their work in the broader community are required to perform their duties without the close support of a supervisor. Since these staff must be able to act in a more independent manner, the staff must have different competencies. Thus, the qualifications for this type of staff are more rigorous.

The “market basket” or brick approach adds the following components on top of the wage and are expressed as percentages. These components can vary between types of service: clients living with a Shared Living provider.

Rates for nurse to client ratios greater than 1:1 are computed using the same methodology as individual PDN rates are computed under the State Plan as follows:

Two individuals: Rate for Each = 50% of 143% of baseline rate

Three individuals: Rate for Each = 33% of 214% of baseline rate

This is consistent with the methodology used by DMMA for fee for service rates for Private Duty Nursing.

Determining the number of hours of direct support: DDDS uses a standardized assessment tool to determine the number of direct support hours needed for each waiver member for residential, day, employment and nurse and behavioral consultation services as part of the person centered planning process.

While all rates are initially computed as hourly rate, they may be billed as 15 minute unit, hourly or per diem rates as specified in Appendix J. Per diem rates are computed by multiplying the hourly rate for the service by the number of hours of support needed per day. 15 minute unit rates are computed by dividing the computed hourly rate by four.

When it is necessary to provide Residential Habilitation services out-of-state (i.e. out of network), the payment shall be the lesser of: the State Medicaid rate for the provider/service in that state, the provider’s usual and customary rate or a negotiated rate that is lower than the Medicaid or usual and customary rate.

Supported Employment - Small Group: The hourly rate for Group Supported Employment is computed as part of the

“market basket” methodology described above. DDDS must perform additional computations to the rate for this service to account for the number of waiver members in the group. The unit cost rate is then divided by the number of waiver members in the group from 2 – 8.

Community Participation service 1:2 staff ratio: The rate for Community Participation 1:1 is computed as part of the “market basket” methodology described above. Community Participation may be provided to no more than two individuals supported by a single staff person. Before the base rate is divided by 2 to compute the 1:2 ratio rate, a gross up factor is applied to the base rate for the service. This is to ensure that overhead costs are properly captured, based on the assumption that simply dividing the base rate by the 2 individuals supported by a single DSP would not adequately capture an agency's incremental costs in delivering the service.

Community Transition: Goods and services will be reimbursed at cost. The provider of will submit an invoice with applicable receipts to DDDS for reimbursement. Invoices must be approved by DDDS before payment is made.

See Main - "Additional Needed Information (Optional) text box for the continuation of the Rate Determination Methods.

District of Columbia Waiver# DC.0307.R04.00 

DC People with Intellectual and Developmental Disabilities

Waiver Name:
DC People with Intellectual and Developmental Disabilities
Effective Date:
11/20/2017
Expiration Date:
11/19/2022

Services

List of Services for District of Columbia Waiver# DC.0307.R04.00

Cost Neutrality

Cost Neutrality for District of Columbia Waiver# DC.0307.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1822 1962

Year 1 Waiver Services

List of Year 1 Waiver Services for District of Columbia Waiver# DC.0307.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Individual 15 minutes 550 4368 $5.63
Day Habilitation 1:1 15 minutes 153 3706.69 $10.66
Day Habilitation Small Group 15 minutes 10 13 $8.50
Day Habilitation with Meals (1:1 Meal Delivered) 1 day 5 156 $7.56
Day Habilitation w/ Meals (1:1 Meal including Preparation/Packaged) 1 day 3 156 $5.19
Day Habilitation w/ Meals (1:4 Meal Delivered) 1 day 64 156 $7.56
Day Habilitation w/ Meals (1:4 Meal including Preparation/Packaged) 1 day 102 156 $5.19
Employment Readiness 15 minutes 560 2011.36 $4.86
Supported Employment - Assessment Prof 15 minutes 7 152.35 $12.29
Supported Employment Assessment Paraprof 15 minutes 4 80 $6.74
Supported Employment Placement Prof 15 minutes 93 735.58 $12.29
Supported Employment Placement Paraprof 15 minutes 56 434.49 $6.74
Supported Employment - Training Prof 15 minutes 68 1396.27 $12.29
Supported Employment - Training Paraprof. 15 minutes 71 845.37 $6.74
Long-Term Supported Employment - Follow Along 15 minutes 0 640 $6.74
Long-Term Supported Employment - Follow Along Group 15 minutes 4 2816 $3.26
Individualized Day Support 1:1 15 minutes 35 750 $8.66
Individualized Day Support 1:2 15 minutes 338 1087.26 $5.97
Individualized Day Support Meal Modifier 1 day 24 156 $7.56
Small Group Supported Employment 15 minutes 10 799.67 $3.26

Year 5 Waiver Services

List of Year 5 Waiver Services for District of Columbia Waiver# DC.0307.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Individual 15 minutes 560 4368 $6.24
Day Habilitation 1:1 15 minutes 166 4237.91 $11.81
Day Habilitation Small Group 15 minutes 100 13 $9.41
Day Habilitation with Meals (1:1 Meal Delivered) 1 day 5 156 $8.38
Day Habilitation w/ Meals (1:1 Meal including Preparation/Packaged) 1 day 3 156 $5.75
Day Habilitation w/ Meals (1:4 Meal Delivered) 1 day 71 156 $8.38
Day Habilitation w/ Meals (1:4 Meal including Preparation/Packaged) 114 156 $5.75
Employment Readiness 15 minutes 150 1648.97 $5.38
Supported Employment - Assessment Prof 15 minutes 7 128.89 $13.62
Supported Employment Assessment Paraprof 15 minutes 4 80 $7.47
Supported Employment Placement Prof 15 minutes 183 1052.17 $13.62
Supported Employment Placement Paraprof 15 minutes 134 621.13 $7.47
Supported Employment - Training Prof 15 minutes 29 1769 $13.62
Supported Employment - Training Paraprof. 15 minutes 20 976.27 $7.47
Long-Term Supported Employment - Follow Along 15 minutes 156 640 $7.47
Long-Term Supported Employment - Follow Along Group 15 minutes 4 2816 $3.61
Individualized Day Support 1:1 15 minutes 95 678 $9.60
Individualized Day Support 1:2 15 minutes 451 1087.26 $6.62
Individualized Day Support Meal Modifier 1 day 27 156 $8.38
Small Group Supported Employment 15 minutes 10 848.11 $3.61

Rate Determination Methods

Rate Determination Methods for District of Columbia Waiver# DC.0307.R04.00

Provider payment rates are uniform for every provider. DHCF & DDS elicit public comments through DC rule-making process. Information about payment rates is available to participants via publication of proposed & ratified rules & from their service coordinator. DDS is responsible for the rate development with oversight by DHCF.

Rate information including public comment is available upon request, on DHCF website at http://dhcf.dc.gov & DDS website at http://dds.dc.gov. Rate structures are based on geographic market analysis in DC & surrounding jurisdictions. All residential services are covered by the DC Living Wage Act of 2006 which is tied to the Consumer Price Index (CPI), which is the source of the trend used for projecting all rates with Direct Support Professional (DSPs) in future waiver years. Additional details on the rate setting method & each rate are available at: https://dds.dc.gov/publication/public-notice-waiver-renewal-april-2017. DC requests authority to inflate clinical & wellness services annually by the CPI or the CMS Skilled Nursing Facility Market Basket Index (MBI), whichever is lower.

Residential Habilitation (Res Hab) & Supported Living (SL) services rates were established using cost reporting & feedback with the DC provider community re: ICF/IID rates, and match the Administrative Rate (13%), Support Service Wages (House Manager, QDDP, RN, LPN) & Paid Time Off factor as approved in the State Plan. The Res Hab & SL services exclude capital, room, board, medical & clinical services. The daily rate includes: DSP Living Wage rate + overtime & time off; LPN staffing + overtime & time off to address DC Medication Administration rules;. RN oversight for medication administration & health assessments at 1:12 waiver individuals per DC policy; House Manager for DSP supervision at 1:12;. QIDP for programming responsibilities at 1:12; 20% fringe benefit rate which reflects actual costs; a general & administrative rate of 13% is applied to the total costs of all services, based on reasonable comparison with other comparable residential care provider categories; & a 95% occupancy rate (based on 2015 utilization review) applied to the rate to account for hospitalization, LTC, & vacation time that is not billable to the waiver.

The Res Hab & Daily SL methodology establish rates based on the intensity of direct support provided for all people living in the setting on a daily basis and shares the costs of direct support services across all people living in the setting. All rates have been inflated since 2015 by the CPI per the approved waiver. The rate methodology will be reviewed after the 2017 ICF/IID rebasing of rates is completed. For Day Habilitation & Employment Readiness the waiver amendment approved in Sept. 2015 based facility costs on the average price per square foot for typical commercial space in the DC area of $30-35/ sq ft. & provides $7,000 per 25 participants per month + utilities ($800), phones/cable/internet ($600) & maintenance ($2,000). Small Group day services (no more than 15 persons) reduces the facility expenses to account for the smaller size to $5,000 for space, $500 for utilities, $500 for phones/cable/internet & $1,500 for maintenance. The daily rate also includes: DSP wage of $13.09 for 1:4 staff person to waiver participants in Day Hab & 1:3 waiver participants in small group + overtime & time off calculations;. RN oversight for medication administration & health assessments per DC policy of 1:25 HCBS individuals for Day Hab & 1:15 for small group; Program Manager for DSP supervision at 1:25 for Day Hab & 1:15 for small group; QIDP for programming responsibilities at 1:25 for Day Hab & 1:15 in small group; 20% fringe benefit rate applied to reflect actual costs in DC; an indirect percentage of 25% for transportation, program supplies & quality assurance responsibilities required by DC policy; a general & administrative percentage of 13% applied based on the total costs of all services, based on reasonable comparison with other provider categories; & an 85% occupancy rate (based on 2015 utlzn. review) applied to the rate to account for hospitalization, LTC, & vacation time that is not billable to the waiver program in Day Hab & 80% for small group, based on expectations that the acuity of the waiver participants in that program will have a higher absence rate.

The rates have been inflated since 2015 by the CPI. The Day Habilitation Rate shall be reimbursed at $5.63 per 1/4 hour or $135.12 per day, & is reasonable as compared to the EPD HCBS waiver rate for ADHP as approved under the 1915(i) State Plan reimbursement rate for acuity 2 at $125.78 per day. Day Habilitation Small Group shall be reimbursed at $8.50 per 1/4 hour. Employment readiness service shall be reimbursed at $4.85 per 1/4 hour and does not include reimbursement for RN oversight. The rates have remained sufficient to maintain an adequate provider network.

The methodology is scheduled for review in late 2017 following submission of provider costs reports & will be reevaluated at that time. In-home Support (IHS); Periodic Supported Living & Periodic Supported Living with transportation (SL/P, SLT/P); Hourly Respite (HR); Supported Employment; Group Supported Employment; Individualized Day services (IDS): For these hourly based rates, the following methodology has been used to update the rates following CMS guidance & methodologies employed by other states for fee-for-service rates. Rates include DSP wages, productivity factors, employment related taxes, benefits, indirect or program related support, & administrative overhead expenses. Indirect expenses are calculated based on each service definition & DDA quality requirements. Due to public comment: the DSP base for HR was raised to the Living Wage; the front-line supervisor hours for IDS increased to 75; Q hours for SL/P & SLT/P increased to 52; a new high acuity IHS was added with 52 hours for the Q and RN. Details for productivity factors, indirect & each rate methodology can be found at https://dds.dc.gov/publication/public-notice-waiver-renewal-april-2017.

Each hourly rate follows the same methodology with variances in the base wage based on the qualification requirements of the DSP, aligned with the 2015 BLS data for District of Columbia metropolitan area if appropriate, productivity assumptions & indirect requirements of the service. As an example, In-home Support reimbursement methodology is calculated using the living wage of $13.95 as the base, productivity factor of 1.10 for a billable hour of $15.35, an addition of 20% for employee related taxes & benefits for a total staff cost of $18.41. An addition of 17% for indirect & 13% administrative overhead is added to the staff cost. The rate will be inflated annually by the CPI for these hourly rates beginning with FY18.

Clinical Services/ Physical Therapy, Speech Therapy & Occupational Therapy: The waiver program has adopted rates for these clinical services similar to those in use for the DC EPSDT program, which uses the same qualifications for professional personnel to deliver these services & the same method of service delivery. The rates were aligned to expand the number of qualified providers & increase access to this service under the waiver amendment # DC.0307.R03.02 at $100.00 per hour for all services in this category & has since been inflated per the approved cost of living adjustments to $101.04 in FY17, inflated to $103.68 in FY18. Future inflation increases are tied to the CPI or Skilled Nursing Facility MBI whichever is lower beginning in FY18. Family Training is currently $61.44 hourly, inflated to $63.04 for FY18 and is compared to State Plan clinical therapies & counseling services. This renewal application adds a new option for Family Training to be delivered by a peer as a method to increase access to the service. A new service, Parenting Support, is introduced to provide support to people with I/DD who are raising children and will be delivered by Parenting Support professionals, or, a qualified peer.

The Family Training Professional & Parenting Support Professional services are delivered by similarly trained staff, e.g. teachers, counselors & therapists. As such, the rate for Parenting Support Professional has been set at the same rate in use for Family Training. The Peer rate for both services is calculated using the base wage of $18.40 (BLS 2015 Social & Human Service Assistants median) + productivity factor of 1.3% + employee benefits factor of 22% for a total staff cost of $27.97. Program support & administrative overhead percentage of 23% is added for a final rate of $34.40. Behavior Support services methodology have not changed in this renewal. The rates have been reviewed relative to the DC State Plan, DC Behavioral Health system, DC Early Intervention Program & MD DD waiver program & remain appropriate. Access to services is also sufficient. Wellness Services/ Fitness; Nutrition; Bereavement Counseling & Massage Therapy were reviewed & adjusted as part of the Sept. 2015 waiver amendment & compared to a variety of competitive DC sources to ensure geographic market equity.

The Host Home rate methodology was revised for FY15 & reviewed by CMS in the Sept. 2015 amendment of this waiver. Host Home services rates are based on the waiver participant’s level of need as determined by the DC Level of Need & Risk Assessment Tool. The Host Home rates have been inflated for associated cost of living increases aligned with the DC living wage, & a review of the methodology indicates that all assumptions remain the same for this renewal. The rates include host home recruitment, direct support & supervision costs, employee benefits, respite & program & administrative overhead consistent with factors used throughout the DDA HCBS program. The Daily Respite rate methodology was revised for FY15 & reviewed by CMS in the Sept. 2015 amendment of this waiver. The Daily Respite rate has been inflated for associated by the CPI to a FY17 rate of $404.10, & a review of the methodology indicates that all assumptions remain the same for this renewal. The rate will be inflated by the CPI to $414.61 per day for FY18. Assistive Technology (AT) is capped at $10,000 for the 5 year waiver period based upon a review of other state waivers who offer this service. Costs for AT purchases & maintenance will be comparable with costs in the DC Vocational Rehabilitation program, as well as past experience with services like Personal Emergency Response Systems. One Time Transitional Services rate for this service is set as up to $5000 to match Community Transition, the DC EPD HCBS waiver equivalent service and the rate through the Money Follows the Person Demonstration project. Skilled Nursing & Personal Care are extended State Plan & match the State Plan rates.

Companion services match the State Plan rate for Personal Care. Meals were added to the waiver in the Sept. 2015 amendment for people who live independently or with families & attend Day Habilitation or IDS. The rate was built at the time of the amendment based upon actual cost of services from local vendors & have been inflated using the CPI to a rate of $5.99 per meal for FY18. The rates for Creative Arts Therapies were adjusted at the time of the Sept. 2015 waiver amendment, based upon market research that compared the IDD waiver rates with state plan rates for seniors, rates for therapies offered by the DC Department of Behavioral Health & private rates. They have since been adjusted by the CPI to a rate of $77.74 for FY18. The research completed in 2015, which forms the basis for these rates is available upon request. Dental rates are established by DHCF based on an average of all procedure codes. The Dental rate is an enhancement to the State Plan rate that was developed through a collaborative process that involved DHCF, DDS, providers, & other stakeholders, with any inflation guided by the State Plan.

Florida Waiver# FL.0867.R02.00 

Developmental Disabilities Individual Budgeting

Waiver Name:
Developmental Disabilities Individual Budgeting
Effective Date:
4/1/2019
Expiration Date:
3/31/2024

Services

List of Services for Florida Waiver# FL.0867.R02.00

Cost Neutrality

Cost Neutrality for Florida Waiver# FL.0867.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
34742 40742

Year 1 Waiver Services

List of Year 1 Waiver Services for Florida Waiver# FL.0867.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Life Skills Level 1 15 minutes 5282 2700.7 $2.61
Life Skills Level 2 15 minutes 2013 356.9 $8.31
Life Skills Level 3 hour 14514 40.6 $6.02

Year 5 Waiver Services

List of Year 5 Waiver Services for Florida Waiver# FL.0867.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Life Skills Level 1 15 minutes 6194 2700.7 $3.09
Life Skills Level 2 15 minutes 2361 356.9 $9.88
Life Skills Level 3 hour 17021 1040.6 $7.15

Rate Determination Methods

Rate Determination Methods for Florida Waiver# FL.0867.R02.00

The rate model for all waiver services included calculating the direct care staff wages, employment-related expenditures, program-related expenditures, and general and administrative expenditures. In addition to calculating the four rate components, the actuaries developed geographical factors based upon their survey of a sample of provider costs, audited financial reports, and a market analysis of Bureau of Labor statistics for wages and compensation practices, housing rent and lease costs, uninsured workers, crime statistics, and cost of living indices.

Provider rates are subject to the availability of funding provided by the Florida Legislature. Rates may be adjusted upon the direction of the legislature. The State employs the services of actuarial firms to examine rate setting assumptions and methods for establishing provider service rates.

Provider service rate models were developed separately for the three following service groups:

Group One: life skills development level two – supported employment, life skills development level three – adult day training, consumable medical supplies, durable medical equipment and supplies, environmental accessibility adaptations, personal emergency response systems, residential habilitation general information, residential habilitation (standard), residential habilitation (behavior focused), residential habilitation (intensive behavior), special medical home care, supported living coaching, supported coordination, behavior analysis services, behavior assistant services, dietitian services, private duty nursing, residential nursing services, skilled nursing, specialized mental health counseling, transportation services, and dental services. Rates for physical therapy, occupational therapy, speech therapy, respiratory therapy, behavioral analysis services assessment, physical therapy assessment, occupational therapy assessment, speech therapy assessment, psychological assessment, respiratory therapy assessment, therapeutic massage assessment, specialized mental health therapy assessment, and special medical home care relied on the same data and hourly therapy rates which did not exceed the home and community based services maximum allowable rates at the time.

Group Two: personal support services, respite services, residential habilitation services (live-in), and life skills development level one - companion services.

Group Three: enhanced intensive behavior services.

To ensure the Group Two payment rates were compliant with the Fair Labor Standards Act (FLSA) and included wages comparable to current industry standards, the actuaries surveyed waiver providers who provided waiver services in calendar year 2014, to collect financial and other information related to the provision of those services and associated costs. Additionally, they collected and reviewed publicly available data on wages for workers in the industry based on the North American Industry Classification System for “Services for the Elderly and Persons with Disabilities” category in the “Health Care and Social Assistance” sector. The actuaries also collected and reviewed industry worker’s compensation information and public information on taxes and benefits. To address the enhanced intensive behavioral (EIB) needs for some waiver recipients, the APD worked with actuaries to develop a rate for Group Three services that required higher staffing ratios for direct care professionals. The staffing ratio assumption for the new enhanced rate is one-to-one coverage during awake hours and one staff to two recipient coverage during asleep hours.

Rates are promulgated into rule. During the rule promulgation process, the Medicaid agency publishes a notice in the Florida Administrative Register (FAR) alerting the public of scheduled workshops and hearings where input may be provided. Written comments may also be submitted in lieu of oral comments at the public meeting. Providers have the opportunity to provide input on rates through the administrative rule-making process. The AHCA has rule-making authority including promulgation of the Coverage and Limitations Handbook and rate rules.

Rates are posted on the Internet by AHCA and APD and available to waiver participants at the following websites: https://www.flrules.org/gateway/ruleno.asp?id=59G-13.081

http://apd.myflorida.com/docs/Rate%20Changes%20Effective%2007012016.pdf (APD)

http://apd.myflorida.com/providers/rates-billing/docs/procedure-code-table.pdf (APD)

When changes occur, the public is generally notified through a healthcare alert. The public can enroll to receive healthcare alerts at the following website: http://ahca.myflorida.com/MCHQ/alerts/alerts.shtml

Waiver participants have the option to sign up for notices in the FAR, alerting the public of any new rules at the following website: https://www.flrules.org/Default.asp

Florida Waiver# FL.0342.R04.00 

Traumatic Brain and Spinal Cord Injury

Waiver Name:
Traumatic Brain and Spinal Cord Injury
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for Florida Waiver# FL.0342.R04.00

Cost Neutrality

Cost Neutrality for Florida Waiver# FL.0342.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
468 1

Year 1 Waiver Services

List of Year 1 Waiver Services for Florida Waiver# FL.0342.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Life Skills 15 minutes 26 598.1 $7.87

Year 5 Waiver Services

List of Year 5 Waiver Services for Florida Waiver# FL.0342.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Life Skills 15 minutes 0 0 $0.01

Rate Determination Methods

Rate Determination Methods for Florida Waiver# FL.0342.R04.00

DOH BSCIP is responsible for ensuring that all rates paid under this waiver do not exceed fair market value yet are adequate to ensure sufficient provider capacity. The provider rates are comparable to similar or same services reimbursed through Medicaid State Plan or other home and community-based waivers. A cross waiver analysis of rates was conducted when rate determinations were made.

The Fee Schedule for the waiver is established in the Florida Administrative Code through the state of Florida rulemaking process. The rulemaking process includes an opportunity for providers and other members of the general public to attend public meetings announced though public advertisements. During these meetings, participants have the opportunity to comment on the proposed rates and provide feedback.

Georgia Waiver# GA.0323.R04.00 

Comprehensive Supports Waiver Program

Waiver Name:
Comprehensive Supports Waiver Program
Effective Date:
4/1/2016
Expiration Date:
3/31/2021

Services

List of Services for Georgia Waiver# GA.0323.R04.00

Cost Neutrality

Cost Neutrality for Georgia Waiver# GA.0323.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
8056 8600

Year 1 Waiver Services

List of Year 1 Waiver Services for Georgia Waiver# GA.0323.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Access Group 15 minutes 5370 3885 $3.10
Community Access 15 minutes 2407 591 $7.41
Prevocational Services 15 minutes 1019 1961 $3.10
Supported Employment Group 15 minutes 259 2178 $1.84
Supported Employment 15 minutes 375 355 $7.41
Community Guide 15 minutes 3 184 $8.93

Year 5 Waiver Services

List of Year 5 Waiver Services for Georgia Waiver# GA.0323.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Access Group 15 minutes 6113 5083 $3.10
Community Access 15 minutes 2477 1495 $7.41
Prevocational Services 15 minutes 8.19 2485 $3.10
Supported Employment Group 15 minutes 201 1440 $2.02
Supported Employment 15 minutes 501 1440 $8.15
Community Guide 15 minutes 18 263 $8.93

Rate Determination Methods

Rate Determination Methods for Georgia Waiver# GA.0323.R04.00

Waiver services are reimbursed on a fee-for-service basis, with the exceptions discussed below. Rate determination and oversight is a responsibility of the Department of Community Health (DCH).

Service rates are published with 30-day public comment prior to submission to CMS. Approved rates are published in the Medicaid policy manuals available at

https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/54/Default.aspx.

Rate Changes or additions made through this amendment:

Rates for Supported Employment - Individual and Group were changed for Waiver Years 4 and 5 to reflect a 5% increase approved by the Georgia General Assembly and the Governor during the 2019 Legislative Session.

The rate methodology for Transportation Services was changed to allow greater flexibility in use of transportation funds through a $1 = 1 unit methodology. This option will provide greater access to waiver participants in rural areas where a trip-based unit was not feasible or successful in recruiting transportation providers. There is no change to the maximum allocation amount for the service which can be authorized for transit needs related to community activities but may not duplicate non-emergency medical transportation available through Georgia's Medicaid State Plan.

There are no other rate changes proposed through this amendment. Consumer-directed services are reimbursed on a ‘one dollar equals one unit’ basis. Members who choose consumer-direction are subject to the same annual budget limits as those members who choose agency-directed services, but are empowered to negotiate hourly rates with their care providers. Reimbursement is made based on these negotiated amounts. Rates do not vary by geography or by provider type.

Public Comment: DCH Board Meetings are open to the public, recorded and transcribed for public availability.

Following initial adoption is public notice of the waiver amendment in each county DFCS office and on the DCH website found at

https://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/Public%20Notice%20NOW%20and%20COMP.pdf. One comment was received in response to the public notice and was received by U.S. Postal mail. The comments were compiled and presented to the board for consideration before final adoption. A full list of the comments and DCH responses has been added to the Main Section of this amendment in Item 6. Please refer to that section for a summary of

the one public comment received and the general solicitation process

Georgia Waiver# GA.0175.R06.00 

Georgia New Options Waiver

Waiver Name:
Georgia New Options Waiver
Effective Date:
11/9/2017
Expiration Date:
11/8/2022

Services

List of Services for Georgia Waiver# GA.0175.R06.00

Cost Neutrality

Cost Neutrality for Georgia Waiver# GA.0175.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4792 5358

Year 1 Waiver Services

List of Year 1 Waiver Services for Georgia Waiver# GA.0175.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Access Group 15 minutes 3535 4896 $3.10
Community Access 15 minutes 1625 1440 $7.41
Prevocational Services 15 minutes 1203 3168 $3.10
Supported Employment Group 15 minutes 282 5337 $1.84
Supported Employment Individual 15 minutes 577 2048 $7.41
Community Guide 15 minutes 1 123 $8.93

Year 5 Waiver Services

List of Year 5 Waiver Services for Georgia Waiver# GA.0175.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Access Group 15 minutes 3894 3386 $3.10
Community Access 15 minutes 1615 591 $7.41
Prevocational Services 15 minutes 1262 3322 $3.10
Supported Employment Group 15 minutes 310 2027 $2.02
Supported Employment Individual 15 minutes 491 300 $8.15
Community Guide 15 minutes 7 224 $8.93

Rate Determination Methods

Rate Determination Methods for Georgia Waiver# GA.0175.R06.00

Waiver services are reimbursed on a fee-for-service basis, with description of rate-setting methods for the new services discussed below by service type. Other waiver rates are historical with periodic rate increases submitted to CMS following legislated and budgeted increases. Rate determination and oversight is a responsibility of the Department of Community Health (DCH).

Service rates are published with 30-day public comment prior to submission to CMS. Approved rates are published in the Medicaid policy manuals available at

https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/54/Default.aspx.

Rate Changes or additions made through this amendment:

- Interpreter Services: DCH reviewed waiver programs that offered the same or similar Interpreter Services both for service description and rates using a nationwide search. DCH then modeled the definition of Interpreter Services using similar state waiver services and then verified the definition, provider qualifications, and service rate with the DBHDD Office of Deaf Services.

DCH will review rates to ensure payments are consistent with economy, efficiency, and quality of care. Further, DCH will determine whether rates are satisfactory to enlist enough providers at six months after waiver approval and semiannually thereafter. DCH will track provider network adequacy through its Provider Enrollment Unit. If needed, DCH will amend the waiver to adjust rates to ensure network adequacy.

Transition Services (Transition Community Integration Services and Transition Services and Supports):

Georgia used Money Follows the Person data analysis by the Georgia Health Policy Center, its independent evaluator for the MFP, to review utilization of both services.

Transition Community Integration Services and Transition Supports are proposed in the same format used in MFP to allow sustainability of the nursing home transition efforts begun through MFP. Adjustment was made to the maximum allowable units based on average utilization through MFP and the$1 = 1 unit rate allows flexibility in reimbursement of services and allowable goods needed to achieve successful transition.

Supported Employment Service rates have been adjusted in Appendix J of this amendment to reflect a legislated rate increase for both group and individual supported employment rates during the 2019 Georgia General Assembly.

Behavior Support Services Levels 1 and 2:

Changes to Behavior Support Services apply to service names and structure only and do not impact rates. There is no change in the rate as Behavior Support Consultation changes naming configuration to Behavior Support Services - Level 2.

Transportation rate methodology change: Transportation rates have been changed to reflect maximum flexibility within the annual cost maximum. This change does not impact the maximum allocation, rather moves a flat per-trip rate to a flexible $1 - 1 unit rate. The methodology adjustment was determined through discussion with members and informal supporters living in Georgia rural areas.

Note: There is no change in respite service, rate, or unit designation. Respite Service has been renamed and unbundled to clearly describe the service unit and delivery setting.

Consumer-directed services are reimbursed on a ‘one dollar equals one unit’ basis. Members who choose consumer direction are subject to the same annual budget limits as those members who choose agency-directed services, but are empowered to negotiate hourly rates with their care providers. Reimbursement is made based on these negotiated amounts. Rates do not vary by geography or by provider type.

Public Comment: DCH Board Meetings are open to the public, recorded and transcribed for public availability.

Following initial adoption is public notice of the waiver amendment in each county DFCS office and on the DCH website found at

https://dch.georgia.gov/sites/dch.georgia.gov/files/related_files/document/Public%20Notice%20NOW%20and%20COMP.pdf.

One comment was received in response to the public notice and was received by U.S. Postal mail. The comments were compiled and presented to the board for consideration before final adoption. A full list of the comments and DCH responses has been added to the Main Section of this amendment in Item 6. Please refer to that section for a summary of the one public comment received and the general solicitation process.

Hawaii Waiver# HI.0013.R07.00 

HCB Services for People with Intellectual and Developmental Disabilities (I/DD Waiver)

Waiver Name:
HCB Services for People with Intellectual and Developmental Disabilities (I/DD Waiver)
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Hawaii Waiver# HI.0013.R07.00

Cost Neutrality

Cost Neutrality for Hawaii Waiver# HI.0013.R07.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2735 2863

Year 1 Waiver Services

List of Year 1 Waiver Services for Hawaii Waiver# HI.0013.R07.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Discovery & Career Planning 15 minutes 30 1512.6 $7.24
Individual Employment Supports 15 minutes 11 741.8 $13.18
Community Learning Services Individual 15 minutes 0 0 $0.01
Community Learning Service- Group 15 minutes 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Hawaii Waiver# HI.0013.R07.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Discovery & Career Planning 15 minutes 31 1512.6 $12.48
Individual Employment Supports 15 minutes 12 741.8 $11.33
Community Learning Services Individual 15 minutes 2412 284.1 $8.49
Community Learning Service- Group 15 minutes 1642 449.8 $4.83

Rate Determination Methods

Rate Determination Methods for Hawaii Waiver# HI.0013.R07.00

Rate determination and oversight is a joint responsibility between the Department of Health’s Developmental Disabilities Division (DDD) and the Department of Human Services’ Med-QUEST Division.

Waiver services are reimbursed on a prospective, fee-for-service basis, with the exceptions noted below for items and services that are procured and manually priced. With the assistance of Burns & Associates, Inc., a national consultant experienced in developing provider reimbursement rates for HCBS waivers, DDD has recently completed a comprehensive review of payment rates.

The rate study considered both existing services and new services being added to the waiver in order to enhance participants’ supports for full community integration. The State will begin phasing in the resultant new fee schedule on July 1, 2017.

The rate study included:

- A series of meetings with a Provider Advisory Group. The group was comprised of a diverse cross-section of providers in terms of services delivered, size, and location. The group was convened at key milestones in the study, including development of a draft provider survey and consideration of survey results.

- Development and administration of a provider survey related to service design and costs. All providers were sent the survey and given an opportunity to participate.

Burns & Associates provided technical assistance throughout the survey period, including drafting detailed instructions for completing the survey, recording and posting online a webinar to walk-through the survey, responding to questions via phone calls and emails, reviewing each submitted survey and working with providers to resolve potential errors. The provider survey informed the rates for both existing and ‘new’ services because most of the new services are spin-offs of existing services (for example, Community Learning Service is essentially Personal Assistance/ Habilitation and Adult Day Health services provided in the community; Residential Habilitation is PAB being delivered in a licensed or certified settings).

-Identification of benchmark data, including Bureau of Labor Statistics cross-industry wage and benefit data as well as rates for comparable services in similar programs.

-Development of rate models for each service that include specific assumptions related to the various costs associated with delivering each service, including direct care worker wages, benefits, and ‘productivity’ (i.e., billable time); staffing ratios; mileage; facility expenses; and agency program support and administration. Development of rate models for participant-directed services followed the same approach although individual assumptions may differ (for example, the participant-directed rate models include lesser amounts for employee benefits and do not include agency overhead costs) and the rates are based on an allowable range of wages the employer can pay the employee.

-Incorporation of Supports Intensity Scale (SIS) assessment data to create ‘tiered’ rates for Residential Habilitation, Adult Day Health, and Community Learning Service-Group to recognize the need for more intensive staffing for individuals with more significant needs. In particular, the State has adopted a SIS-based seven level framework using assessment criteria employed in several other states. These seven assessment levels were grouped into three rate tiers. The models for each tier incorporate different staffing ratios (with more intensive staffing necessitating a higher rate), reflecting the DDD’s expectations for support.

-Analysis of travel distances across the islands, which resulted in the new fee schedule incorporating generally higher rates for services delivered on the Big Island in order to account for greater travel-related expenses in terms of both mileage and staff time.

-A public comment process through which proposed rate models were emailed to providers and other stakeholders, and posted online. Interested parties were given several weeks to submit written comments. DDD prepared written responses to all comments received and revised the rates as appropriate. DDD oversaw the work of the consultant and assumed ownership of the rate models so that they can be periodically reviewed and updated as necessary.

Rate models were developed for all waiver services with a few exceptions. The waiver rate schedule is available on DOH/DDD’s website. Rate models for the new Private Duty Nursing and Nursing Respite services were derived from the Skilled Nursing rate models established as part of the rate study with adjustments to account for expected differences in encounter lengths. Specifically, the Private Duty Nursing and Nursing respite rate models incorporate the same wage, benefit, and overhead assumptions as in the Skilled Nursing rate models, but less travel and more billable hours based on longer encounters

(resulting in less travel and downtime).

For services provided by licensed behavior analysts and registered behavior technicians, the State benchmarked the rates for licensed behavior analysts and registered behavior technicians against those paid by TRICARE and Med-QUEST (the two systems pay the same rates for these services). Services in these programs are more likely to be clinic-based whereas waiver services will primarily be home- and community-based. Given the travel associated with home- and community-based services, professionals delivering waiver services will have fewer billable hours per day. Thus, the rates from these other programs were increased by 20 percent to account for fewer billable encounters, effectively assuming that clinic-based providers can deliver an average of six billable hours of service per day while home- and community-based providers can deliver only five hours.

Specialized Medical Equipment and Supplies, Vehicular Modifications, Personal Emergency Response Systems and Assistive Technology services are reimbursed through manual pricing, up to the limits specified in the service description.

PERS has established rates that is based on the market costs for the installation and monthly monitoring services. The rate has remained the same for several years and the provider has not indicated a need to increase the rate.

Assistive Technology, Specialized Medical Equipment and Supplies, Vehicular Modifications, and Environmental Accessibility Adaptations are purchased following state of Hawaii procurement rules.

1. Purchase amount is less than $5,000, three (3) quotes required, award to the lowest bidder. If amount is $2,500 or more, bidder must present Certificate of Vendor Compliance (CVC) prior to awarding the contract;

2. Purchase amount is $5,000 but less than $15,000, three (3) written quotes required by using the State Procurement Office Form, small purchase, upon approval from the procurement officer, contract will be awarded to the lowest bidder who is required to present the CVC;

3. Purchase amount is $15,000 or more, HIePRO solicitation is required, award to the lowest bidder who present CVC prior to award the contract.

Once an award is made, the case manager enters the authorization for the lowest bid amount into the DOH/DDD system that is transmitted to the DHS/MQD fiscal agent. If the supplier is a waiver provider, the provider submits a claim through the DHS/MQD fiscal agent for payment after the item is delivered. This ensures that the lowest bid is the authorized amount and cannot be exceeded. If the supplier is not a waiver provider, reimbursement is processed by purchase order through the DOH/DDD fiscal office. The fiscal office ensures that the billed amount does not exceed the approved amount per the procurement rules. The DOH/DDD fiscal office then works with DHS/MQD for reimbursement of the FFP.

Idaho Waiver# ID.0076.R06.00 

Idaho Developmental Disabilities Waiver

Waiver Name:
Idaho Developmental Disabilities Waiver
Effective Date:
10/1/2017
Expiration Date:
9/30/2022

Services

List of Services for Idaho Waiver# ID.0076.R06.00

Cost Neutrality

Cost Neutrality for Idaho Waiver# ID.0076.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5094 7458

Year 1 Waiver Services

List of Year 1 Waiver Services for Idaho Waiver# ID.0076.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 684 1153 $5.25
Community Support Services (Participant Direction) Per week 1334 52 $1020.52

Year 5 Waiver Services

List of Year 5 Waiver Services for Idaho Waiver# ID.0076.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 1565 1150 $6.16
Community Support Services (Participant Direction) Per week 2699 52 $1254.25

Rate Determination Methods

Rate Determination Methods for Idaho Waiver# ID.0076.R06.00

The Department provides public notice of significant reimbursement changes in accordance with 42 CFR § 447.205

(made applicable to waivers through 42 CFR § 441.304(e)). The Department publishes public notice of proposed reimbursement changes in multiple newspapers throughout the State and on the Department’s website at www.healthandwelfare.idaho.gov.

Copies of public notices and text of proposed significant reimbursement changes are made available for public review on Department's website and during regular business hours at agency locations in each Idaho county as identified in each public notice. Additionally, payment rates are published on our website at

www.healthandwelfare.idaho.gov for the public to access.

The Department provides opportunity for meaningful public input related to proposed reimbursement changes in accordance with 42 CFR § 441.304(f). The Department solicits comments from the public (including beneficiaries, providers and other stakeholders) through its public notice process and through public hearings related to the proposed reimbursement changes. The public is given the opportunity to comment on the proposed reimbursement changes for at least 30 days prior to the submission of a waiver amendment to CMS. Additionally, when administrative rules are promulgated in connection with reimbursement changes, the proposed rules are published in the Idaho Administrative Bulletin and the public is given the opportunity to comment.

Waiver service providers will be paid on a fee for service basis as established by the Department depending on the type of service provided. The Bureau of Financial Operations is responsible for rate determinations.

Please see below for services and Reimbursement Methodology information:

Adult Day Health:

The rate was derived by using Bureau of Labor Statistics mean wage for the direct care staff providing the service adjusted for employment related expenditures and indirect general and administrative costs which includes program related costs and are based on surveyed data. The rate for this service is set at a percentage of the statewide target reimbursement rate.

Behavioral Consultation/Crisis Management:

The rate was derived by using Bureau of Labor Statistics mean wage for the direct care staff providing the service adjusted for employment related expenditures and indirect general and administrative costs which includes program related costs and are based on surveyed data. The rate for this service is set at a percentage of the statewide target reimbursement rate.

Chore Services:

These items are manually priced based on the submitted invoice price which cannot exceed $8.00 an hour.

Environmental Accessibility Adaptations:

For adaptations over $500, three bids are required if it is possible to obtain three bids. The lowest bid which meets the participant's needs is selected.

Home Delivered Meals:

The rate is set based on Personal Care Service rates and then increased or decreased based on the qualifications to provide the waiver service, what sort of supervision was required, and agency costs associated with delivering the services.

Non-Medical Transportation

A study is conducted that evaluates the actual costs of fuel reasonably incurred by the typical non-commercial transportation provider whose personal vehicle averages fifteen (15) miles per gallon.

Personal Emergency Response System:

The rate is developed by surveying Personal Emergency Response System vendors in all seven regions of the State to calculate a state-wide average. The state-wide average is the rate paid for this service.

Residential Habilitation:

The rate model used to develop Residential Habilitation rates is described in Idaho Administrative Code (IDAPA) 16.03.10.037.04. The Department will survey current residential habilitation providers to identify the actual cost of providing residential habilitation services (Cost Survey). Reimbursement rates will be based on surveyed data and derived using a combination of four cost components – direct care staff wages, employer related expenditures, program related costs, and indirect general and administrative costs.

The individual components of the rate will be determined as follows: (1) the direct care staff wage component will be determined using either the wage for a comparable Bureau of Labor Statistics (BLS) occupation title, or the weighted average hourly rate from surveyed data if there is no comparable BLS occupation title; (2) the employer related expenditure component will be determined by multiplying the direct care staff wage by the cumulative percentage of employer costs for employee compensation identified by BLS for the West Region, Mountain Division and the internal revenue service employer cost for social security benefit and Medicare benefit; (3) the program related cost component will be determined by identifying the 75th percentile of the ranked program related costs from the surveyed data; and (4) the indirect general and administrative cost component will be determined by identifying the 75th percentile of the ranked general and administrative costs from the surveyed data.

Respite:

The rate is set based on Personal Care Service rates and then increased or decreased based on the qualifications to provide the waiver service, what sort of supervision was required, and agency costs associated with delivering the services.

Skilled Nursing:

These services are paid on a uniform reimbursement rate based on an annual survey conducted by the Department.

Specialized Medical Equipment and Supplies:

For equipment and supplies that are manually priced, including miscellaneous codes, a copy of the manufacturer's suggested retail pricing (MSRP) or an invoice or quote from the manufacturer is required. Reimbursement will be seventy-five percent (75%) of MSRP. If pricing documentation is the invoice, reimbursement will be at cost plus ten percent (10%), plus shipping (if that documentation is provided). For equipment and supplies that are not manually priced, the rate is based on the

Medicaid fee schedule price.

Transition Services:

The benefit limit of $2,000 was recommended by Federal partners and validated by an informal cost analysis conducted in 2013. Additionally, the State opted to align with other states with approved Transition Services in their waivers. These states include Colorado, Georgia, Ohio, and Tennessee. The analysis included sample shopping at multiple retailers to procure essential household furnishings, appliances and supplies. Additionally, the State regularly reaches out to existing providers and agencies to raise interest and participation in Transition Management training to increase the provider pool.

Supported Employment:

The rate was derived by using Bureau of Labor Statistics mean wage for the direct care staff providing the service adjusted for employment related expenditures and indirect general and administrative costs which includes program related costs and are based on surveyed data. The rate for this service is set at a percentage of the statewide target reimbursement rate.

Self-Directed Services (Support Broker Services and Community Support Services):

Rates are set by the participant based on the specific needs of the participant through negotiation with the worker. The identified rates may not exceed prevailing market rates. The Department provides training and resource materials to assist the participant, support broker, and circle of supports to make this determination. The participant and the support broker monitor this requirement each time the participant enters into an employment agreement. The Department ensures that the proposed plan of service does not exceed the overall budget at the time of plan review and approval. The Department also reviews a statistically valid sample of participant employment agreements during the annual retrospective quality assurance reviews.

Financial Management Services:

Reimbursement methodology for FMS is based on a market study of other state Medicaid program rates for FMS to gather a range which allows the Department to accept a Per Member Per Month (PMPM) rate within the range determined from the market study. The established PMPM payment rates for each Department approved qualified FMS provider will be published on a fee schedule by the Department. This fee schedule will be updated at least yearly, and when new providers are approved. This information will be published for consumer convenience to the IDHW Medicaid website, and by request.

Waiver Name:
Aged and Disabled
Effective Date:
10/1/2017
Expiration Date:
9/30/2022

Services

List of Services for Idaho Waiver# ID.1076.R06.00

Cost Neutrality

Cost Neutrality for Idaho Waiver# ID.1076.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
11485 13436

Year 1 Waiver Services

List of Year 1 Waiver Services for Idaho Waiver# ID.1076.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 2 3020 $4.53
Day Habilitation MMCP Per Member Per Month 0 12 $0.01
Day Habilitation Idaho Medicaid Plus Per Member Per Month 0 0 $0.01
Supported Employment MMCP Per Member Per Month 1 12 $0.01
Supported Employment 15 minutes 8 902 $5.25
Supported Employment Idaho Medicaid Plus per member per month 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Idaho Waiver# ID.1076.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 1 3020 $4.53
Day Habilitation MMCP 15 minutes 1 3020 $4.53
Day Habilitation Idaho Medicaid Plus 15 minutes 1 3020 $4.53
Supported Employment MMCP 15 minutes 4 902 $5.25
Supported Employment 15 minutes 2 902 $5.25
Supported Employment Idaho Medicaid Plus per member per month 5 902 $5.25

Rate Determination Methods

Rate Determination Methods for Idaho Waiver# ID.1076.R06.00

The Department provides public notice of significant reimbursement changes in accordance with 42 CFR § 447.205 16.03.10.037.02 requires the Department to conduct a survey when there are identified access issues. As a result, the rate was developed from a cost survey conducted in 2016. The surveyed results of four cost components were combined to arrive at an hourly unit rate. Since these services are identified as personal care service, section 16.03.10.307 followed. The hourly rate calculation was determined using the following reimbursement methodology. The Department followed IDAPA 16.03.10.307.04.a in calculating a direct care wage. This section states the Department will establish Personal Assistance Agency rates for personal assistance services based on the WAHR. The Department followed IDAPA 16.03.10.307.04.b in calculating a supplemental component. This section states the Department will calculate a supplemental component using costs reported for travel, administration, training, and payroll taxes and fringe benefits (employment related expenditures, program related costs, and indirect general and administrative costs).

Adult Residential Care - This service is paid on a per diem basis based on the number of hours and types of assistance required by the participant as identified in the Uniform Assessment Instrument.

Non-medical Transportation - A study is conducted that evaluates the actual costs of fuel reasonably incurred by the typical non-commercial transportation provider whose personal vehicle averages fifteen (15) miles per gallon.

Specialized Medical Equipment & Supplies - For codes that are manually priced, including miscellaneous codes, a copy of the manufacturer's suggested retail pricing (MSRP) or an invoice or quote from the manufacturer is required. Reimbursement will be seventy-five percent (75%) of MSRP. If pricing documentation is the invoice, reimbursement will be at cost plus ten percent (10%), plus shipping (if that documentation is provided). For codes that are not manually priced, the rate is based on the Medicaid fee schedule price.

Environmental Accessibility Adaptations - For adaptations over $500, three bids are required if it is possible to obtain three bids. The lowest bid which meets the participant's needs is selected.

Nursing Services - These services are paid on a uniform reimbursement rate based on an annual survey conducted by the Department.

The contract between the Department and the MCE shall be a firm fixed fee, indefinite quantity contract for services specified in the Scope of Work. For payment purposes, a capitated payment is calculated based on the current eligible MMCP or Idaho Medicaid Plus participant count multiplied by the per member per month (PMPM) figure and is intended to be adequate to support participant access to, and utilization of covered services, including administrative costs. The total PMPM payment is comprised of two (2) components; the Medical capitation and the blended Long Term Services and Supports (LTSS). Once the eligible Enrollee count by enrollment status is determined for the contract, the blended LTSS rate will remain in effect through the contract period.

Transition Services - The benefit limit of $2,000 was recommended by Federal partners and validated by an informal cost analysis conducted in 2013. The analysis included sample shopping at multiple retailers to procure essential household furnishings, appliances, and supplies.

In addition, Idaho chose to align the $2,000 benefit limit to several other states with approved Transition Services benefits (Colorado, Georgia, Ohio, and Tennessee). The analysis results concluded that this is a reasonable amount. To ensure that there are enough providers to render Transition Services, the State regularly reaches out to existing providers and agencies to raise interest and participation in Transition Management training to increase the provider pool. The participant-directed rate methodology does not differ from the methodology utilized when the service is provider-managed. (made applicable to waivers through 42 CFR § 441.304(e)). The Department publishes public notice of proposed reimbursement changes in multiple newspapers throughout the State and on the Department’s website at www.healthandwelfare.idaho.gov. Copies of public notices and text of proposed significant reimbursement changes are made available for public review on Department’s website and during regular business hours at agency locations in each Idaho county as identified in each public notice. Additionally, payment rates are published on our website at www.healthandwelfare.idaho.gov for the public to access.

The Department provides opportunity for meaningful public input related to proposed reimbursement changes in accordance with 42 CFR § 441.304(f). The Department solicits comments from the public (including beneficiaries, providers and other stakeholders) through its public notice process and through public hearings related to the proposed reimbursement changes. The public is given the opportunity to comment on the proposed reimbursement changes for at least 30 days prior to the submission of a waiver amendment to CMS. Additionally, when administrative rules are promulgated in connection with reimbursement changes, the proposed rules are published in the Idaho Administrative Bulletin and the public is given the opportunity to comment.

Waiver service providers will be paid on a fee-for-service basis as established by the Department depending on the type of service provided. The Bureau of Financial Operations is responsible for rate determinations. The Department will ensure that the MCE reimburses providers at a rate no less than the current Medicaid Provider rates.

The Department solicits comments at public hearings when administrative rules related to rate determination methods are promulgated. Administrative rules are published when there are changes to rate determination methods. The public may submit comments on these rules for 21 days after the date of publishing.

Pursuant to 42 CFR §447.205, the Department gives notice of its proposed reimbursement changes by publishing legal notices throughout the State to inform providers about any change. Additionally, payment rates are published on our website at www.healthandwelfare.idaho.gov for participants to access.

Please see below for services and reimbursement methodology information:

Adult Day Health and Home Delivered Meal Services. The initial rate was set in 1999 based on time studies in nursing facilities.

Residential Habilitation. The rate model used to develop Residential Habilitation rates is described in Idaho Administrative Code (IDAPA) 16.03.10.037.04. The Department surveyed residential habilitation providers to identify the actual cost of providing residential habilitation services (Cost Survey). Reimbursement rates are based on surveyed data and derived using a combination of four cost components – direct care staff wages, employer related expenditures, program related costs, and indirect general and administrative costs.

The individual components of the rate are determined as follows: (1) the direct care staff wage component is determined using either the wage for a comparable Bureau of Labor Statistics (BLS) occupation title, or the weighted average hourly rate from surveyed data if there is no comparable BLS occupation title; (2) the employer related expenditure component is determined by multiplying the direct care staff wage by the cumulative percentage of employer costs for employee compensation identified by BLS for the West Region, Mountain Division and the internal revenue service employer cost for social security benefit and Medicare benefit; (3) the program related cost component is determined by identifying the 75th percentile of the ranked program related costs from the surveyed data; and (4) the indirect general and administrative cost component is determined by identifying the 75th percentile of the ranked general and administrative costs from the surveyed data.

Consultation Services, Personal Emergency Response System Services, Day Habilitation and Supported Employment - The initial rate was set back in 1999 based on time studies in nursing facilities. Going forward, the rate is set based on a labor model that uses a Staff Support Hour (SSH) rate approach, which involves developing a single rate for a unit of staff time spent providing services for an individual.

Attendant Care, Homemaker Services, Companion Services, Chore Services, and Respite Care Services – The rate model used to develop rates for these services is described in Idaho Administrative Code (IDAPA) 16.03.10.307.04. Section

Illinois Waiver# IL.0350.R04.00 

IL Waiver for Adults w/DD

Waiver Name:
IL Waiver for Adults w/DD
Effective Date:
12/11/2017
Expiration Date:
12/11/2022

Services

List of Services for Illinois Waiver# IL.0350.R04.00

Cost Neutrality

Cost Neutrality for Illinois Waiver# IL.0350.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
23049 23049

Year 1 Waiver Services

List of Year 1 Waiver Services for Illinois Waiver# IL.0350.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Day Services hour 19280 878.92 $10.88
Supported Employment Individual hour 1458 535.29 $13.65
Supported Employment Group hour 886 486.21 $12.18

Year 5 Waiver Services

List of Year 5 Waiver Services for Illinois Waiver# IL.0350.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Day Services hour 19280 878.92 $11.67
Supported Employment Individual hour 1458 535.29 $14.65
Supported Employment Group hour 886 486.21 $13.07

Rate Determination Methods

Rate Determination Methods for Illinois Waiver# IL.0350.R04.00

Public Act 101-0001 amends the Illinois Income Tax Act and the Minimum Wage Law. The Department of Human Services is required to fund a $0.58 per hour wage increase in Chicago and a $0.62 per hour wage increase for the rest of Illinois for front-line personnel, including, but not limited to direct support persons, aides, front-line supervisors, qualified intellectual disabilities professionals, nurses, and non-administrative support staff working in community-based provider organizations serving individuals with developmental disabilities. The intent of the wage increase is to improve wages and/or benefits for the above referenced categories of employees. The $0.58 and $0.62 per hour wage increases are intended to benefit all covered employees and to be applied across the board. It is expected that all covered employees will receive the wage and corresponding fringe benefit increase effective January 1, 2020.

The CILA Rate Model Formula is used to calculate all wavier services except Adult Day Service (ADS) and Emergency Home Response Service (EHRS), which are set by the Department on Aging (DoA). The CILA Rate Model Formula combines a per diem basis and Purchase of Services (POS), fee-for-service/hourly for front-line personnel. The CILA Rate Model Formula calculates the overall rate increase, including fringe benefit allowance. See below for further explanation for each waiver service effected.

Adult Day Service

Adult Day Service (ADS) is defined as the direct care and supervision of adults in a community-based setting for the purpose of providing personal attention and promoting social, physical, and emotional well-being in a structured setting.

Residential Habilitation

Community-Integrated Living Arrangement (CILA) rates have been calculated using the CILA Rate Model Formula since 1994. The CILA models (24 hour, host family, intermittent and family) funding components are based on individual needs and the size of the home. CILAs are funded on a per diem basis and Purchase of Services (POS), which is fee-for-service/hourly for front-line personnel. Rates are based on system-wide provider cost data where possible and proxy values where necessary or appropriate. Rates have been subject to cost of living adjustments when enacted. Community Living Facility (CLF) and some CILA rates from legacy programs are calculated based on past individual provider cost reports. Rates are subject to cost of living adjustments when enacted and may be adjusted based on rate appeals.

The wage for front-line personnel in Residential Habilitation is calculated using the CILA Rate Model Formula. The formula calculates the overall rate increase, including fringe benefit allowance. The wage for front-line personnel in Residential Habilitation is increased by 3.8%. Increasing the wage to $13.00, equates to an increase of the baseline rate by 3.03944%. Applying the fringe benefit allowance of 25%, the total rate increase is 3.8%.

Community Day Services

The statewide, standard fee-for-service hourly rate is based on allowable costs from historical grant-funded site based Developmental Supports. It includes the following components:

• Direct Support Staff Wages;

• Direct Support Staff Supervision;

• Employment Related Expenditures, e.g. benefits, FICA, Unemployment Insurance, Workers’ Compensation Insurance;

• Professional Support Staff;

• Program Related Supplies, e.g., program materials, printing;

• Transportation Costs, e.g., vehicle operation costs, vehicle maintenance, insurance;

• Ownership/Occupancy Costs (Property Insurance, Maintenance costs, Utilities; and

• Administrative Overhead costs, e.g., Administrative Salaries, Office Space, Staff Training Costs, other allocated overhead. The wage for front-line personnel in

Community Day Services is calculated using the CILA Rate Model Formula. The formula calculates the overall rate increase, including fringe benefit allowance. The wage for front-line personnel in Community Day Services is increased by 3.64%. Increasing the wage to $13.00, equates to an increase of the baseline rate by 3.03944%. Applying the fringe benefit allowance of 20%, the total rate increase is 3.64%.

Supported Employment - Individual Employment Support and Supported Employment – Small Group Supports

The statewide, standard fee-for-service hourly rate is based on allowable costs from historical grant-funded Supported Employment Programs. It includes the following components:

• Job Coach Staff Wages;

• Job Coach Staff Supervision;

• Employment Related Expenditures, e.g. benefits, FICA, Unemployment Insurance, Workers’ Compensation Insurance;

• Professional Support Staff;

• Program Related Supplies; program materials, printing;

• Transportation Costs, e.g., vehicle operation costs, vehicle maintenance, insurance; and

• Administrative Overhead costs, e.g., Administrative Salaries, Office Space, Staff Training Costs, other allocated overhead. The wage for front-line personnel in Supported Employment is calculated using the CILA Rate Model Formula. The formula calculates the overall rate increase, including fringe benefit allowance. The wage for front-line personnel in Supported Employment is increased by 3.64%. Increasing the wage to $13.00, equates to an increase of the baseline rate by 3.03944%. Applying the fringe benefit allowance of 20%, the total rate increase is 3.64%.

Personal Support/Temporary Assistance Services

Rates for Personal Support and Temporary Assistance are negotiated between the participant, guardian (as applicable) or representatives and the providers with assistance from the Information and Assistance in Support of Participant Direction provider. The negotiated rates are specified in the Service Agreement and are subject to review and approval by the Operating Agency on either a targeted or sample basis. These rates are not subject to cost of living adjustments.

Home and Vehicle Modifications, Adaptive Equipment (including Assistive Technology)

Rates are usual and customary. Payments are subject to prior approval by the Operating Agency. Two bids are required for approval. Per-participant five-year cost limits and specific cost limits on rental housing governing the use of these services.

Non-medical Transportation

Statewide mileage rates are set by the Operating Agency. Per-trip rates are usual and customary charges. The rate is subject to cost of living adjustments when enacted by the General Assembly and signed by the Governor.

Emergency Home Response Services

The statewide rates for installation and monthly basic service are adopted from the rates by the Department on Aging for their persons who are elderly waiver.

EHRS is a 24-hour emergency communication link to assistance outside the home for participants with documented health and safety needs and mobility limitations. This service is provided by a two-way voice communication system consisting of a base unit and an activation device worn by the participant that will automatically link the participant to a professionally staffed support center.

Training and Counseling For Unpaid Care Givers

The counseling rate for unpaid care givers is identical to the standard statewide rate currently used in the waiver for participants receiving Individual Counseling services. The rate is based on available cost data for licensed social workers on contract with traditional developmental disabilities agencies. The rate is subject to cost of living adjustments when enacted. Reimbursement for training for unpaid care givers is based on usual and customary charges for the tuition or fees to attend the program. Transportation, meals and lodging to attend training are not included. Reimbursement for training for unpaid care givers is not subject to cost of living adjustments.

Behavior Intervention and Treatment

There are two rate levels for this service based on provider qualifications. The higher rate (Level I) is based on a weighted combination of Bureau of Labor Statistics wage for licensed clinical psychologists, provider survey results and a comparison to bargaining agreement wages for state employees. The lower rate (Level II) is set at 80% of the higher rate. Both rates are subject to cost of living adjustments when enacted.

The wage for front-line personnel in Behavior Intervention and Treatment is calculated using the CILA Rate Model Formula. The formula calculates the overall rate increase, including fringe benefit allowance. The wage for front-line personnel in Behavior Intervention and Treatment is increased by 3.64%. Increasing the wage to $13.00, equates to an increase of the baseline rate by 3.03944%. Applying the fringe benefit allowance of 20%, the total rate increase is 3.64%.

Behavioral Services (Psychotherapy and Counseling) and Skilled Nursing These rates are based on available cost data for clinical psychologists, social workers, and nurses on contract with traditional developmental disabilities agencies. The rates are subject to cost of living adjustments when enacted. These services include both individual and group psychotherapy and counseling.

The wage for front-line personnel in Behavioral Services (Psychotherapy and Counseling) and Skilled Nursing is calculated using the CILA Rate Model Formula. The formula calculates the overall rate increase, including fringe benefit allowance. The wage for front-line personnel in Behavioral Services (Psychotherapy and Counseling) and Skilled Nursing is increased by 3.64%. Increasing the wage to $13.00, equates to an increase of the baseline rate by 3.03944%. Applying the fringe benefit allowance of 20%, the total rate increase is 3.64%.

Physical Therapy, Occupational Therapy, and Speech Therapy

These rates are based on rates for these services in the Medicaid State Plan, converted to an hourly rate.

Information and Assistance in Support of Participant Direction

This a standard, statewide, hourly fee-for-service rate.

The wage for front-line personnel in Information and Assistance in Support of Participant Direction is calculated using the CILA Rate Model Formula. The formula calculates the overall rate increase, including fringe benefit allowance. The wage for front-line personnel in Information and Assistance in Support of Participant Direction is increased by 3.64%. Increasing the wage to $13.00, equates to an increase of the baseline rate by 3.03944%. Applying the fringe benefit allowance of 20%, the total rate increase is 3.64%.

24-Hour Stabilization Services

The rates for this service are initially established through a Request for Applications process. Through this process, the State compares the proposed rates of willing providers. A standard methodology is developed for the waiver service with variation based upon a number of factors defined below. The required components that are used to establish the rate are:

• Direct support staff wages;

• Professional staff wages and clinical contracts, e.g., QIDPs, Behavior Analysts, nurses, etc.;

• Employment-related expenditures, e.g., employee benefits, FICA, unemployment insurance, workers’ compensation, etc.;

• Program-related expenditures, e.g., supervision, supplies, etc.;

• Utilization factors;

• Administration, e.g., administrative salaries, staff travel, office space and expenses; and

• Transportation of individuals.

The following additional factors may influence the standard methodology and are the basis for rate variations. When all factors are equal, the rates produced by the standard methodology would be the same.

• Provider rates may vary due to geographic differences.

• A differential may be included in the rate for the level of expertise and skill of specific professional staff; the differential will again be uniform across all providers.

Continued to Main B Optional

Illinois Waiver# IL.0329.R04.00 

HCBS Waiver for Persons w/Brain Injury

Waiver Name:
HCBS Waiver for Persons w/Brain Injury
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for Illinois Waiver# IL.0329.R04.00

Cost Neutrality

Cost Neutrality for Illinois Waiver# IL.0329.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
3968 3521

Year 1 Waiver Services

List of Year 1 Waiver Services for Illinois Waiver# IL.0329.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Capitated one time 1 1117.9 $18.50
Day Habilitation MMAI one time 9 1.18 $1129.10
Day Habilitation MLTSS one time 2 1.18 $978.10
Day Habilitation one time 12 1.18 $819.62
Day Habilitation one time 0 1 $0.01
Prevocational Services Capitated hour 11 136.44 $27.96
Prevocational Services MLTSS hour 17 76 $43.25
Prevocational Services hour 2 136.44 $29.60
Prevocational Services MMAI hour 2 136.44 $29.60
Supported Employment Capitated hour 12 621.3 $7.97
Supported Employment MMAI hour 3 621.3 $6.13
Supported Employment hour 12 827.27 $10.01
Supported Employment MLTSS hour 16 621.3 $5.78

Year 5 Waiver Services

List of Year 5 Waiver Services for Illinois Waiver# IL.0329.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Capitated one time 0 0 $43.25
Day Habilitation MMAI one time 0 0 $43.25
Day Habilitation MLTSS one time 0 0 $43.25
Day Habilitation one time 20 86.8 $43.25
Day Habilitation one time 0 0 $0.01
Prevocational Services Capitated hour 0 0 $42.93
Prevocational Services MLTSS hour 0 0 $42.93
Prevocational Services hour 9 183.5 $42.93
Prevocational Services MMAI hour 0 0 $42.93
Supported Employment Capitated hour 0 0 $44.00
Supported Employment MMAI hour 0 0 $44.00
Supported Employment hour 0 0 $44.00
Supported Employment MLTSS hour 0 0 $44.00

Rate Determination Methods

Rate Determination Methods for Illinois Waiver# IL.0329.R04.00

The Department of Healthcare and Family Services (HFS), Illinois’ State Medicaid Agency, retains and exercises final authority over payment rates. It does so in collaboration with the waiver’s operating agency, the Illinois Department of Human Services, Home Services Program, which develops the proposed rates and shares the proposed rates and methodology with HFS for its approval. Rates of payment for program services since the initial 1915(c) waiver was approved have been established and updated as described below.

The rates are available to the public through the OA’s website: http://www.dhs.state.il.us/page.aspx?item=83520 Personal Assistant: Until July 2003, Personal Assistants were paid Illinois minimum wage as required by state statute and as formally established by the General Assembly in the Home Services Program (HSP) enabling legislation (20 ILCS 2405/3(f)) [originally(g)]. In March 2003, following a decision by the State Labor Relations Board, the Governor of Illinois signed Executive Order 2003-8 requiring an election to determine labor representation of personal assistants. SEIU won the election and was recognized as the sole and exclusive bargaining unit for personal assistants in the HSP. Negotiations commenced and a four year agreement was signed which specified the rates of payment for that time period. The Labor Relations Act was formally changed 7/26/03, to specify SEIU’s status in this regard. In July 2007, a second four year agreement was negotiated which likewise specified rates of payment for the contract period. A third agreement for a three year contract period became effective in July 2011. Although that agreement should have expired in July 2014, the rate in June 2014 has remained in effect while negotiations continued. On March 14, 2019, a one-time settlement agreement was reached to raise individual provider wages by $0.48 per hour as contract negotiations continued. Upon completion of the negotiations, the rate for individual providers was ultimately increased to $13.48 per hour. Below are the rates for individual providers that are affected by this change:

Personal Assistant: $13.48

The SEIU agreement indicates that hourly direct care staff rates receive periodic flat rate adjustments. In accordance with recent FLSA regulations, the State also allows for overtime and travel reimbursement to personal assistants. The rates do not include any direct or indirect administrative costs, are not geographically based, and exclude room and board costs. Rates are available to the public through the SEIU website and the Illinois Central Management Services website. The labor agreement is also posted on the OA’s website under the HSP.

Home Health Extended State Plan and “Other” Services: Home Health Extended State Plan and “Other” Services include: registered nurses, licensed practical nurses, intermittent nurse visits, HH Aides (CNAs) and therapists (OT, Speech and PT). The OA pays different rates depending on whether the service is provided by a licensed home health agency or by an independently licensed or certified provider.

Historically, the independently licensed or certified provider rates were negotiated on an individual participant basis with rate ceilings based on the prevailing wage rates for these providers statewide. Beginning in July 2012, the SEIU contract was expanded to include independently licensed or certified providers using a fixed rate schedule for each type of service. The rates are available to the public through the SEIU website and the Illinois Central Management Services website in the published labor agreement. The labor agreement is also posted on the OA’s website under the HSP. All home health rates are the same statewide except for children’s agency rates which differ geographically. In accordance with recent FLSA regulations, the State also allows for overtime and travel reimbursement to home health service providers. Current rates for individual home health providers are: RN: $29.75, LPN: 23.00, and CNA (home health aide): $ 16.00, physical therapist: $37.00, occupational therapist: $37.00, speech therapist (non-hospital): $37, speech therapist (hospital): $50.00. Current rates for nursing services provided through agencies: RN: $ 29.55, LPN: 25.47, and CNA (home health aide): $ 13.75.

Pursuant to the one-time settlement agreement that was reached with SEIU on On March 14, 2019, to raise individual provider wages, the following increases are proposed for individual nursing providers:

Registered Nurse: $30.23

Licensed Practical Nurse: $23.48

Certified Nurse Assistant: $16.48

In-home service (homemaker) rates are fixed unit rates based on the rates established by the Illinois Department on Aging (IDoA) in the Elderly Waiver (0143). To establish the initial rate in the original, 1982 joint Aging and Disability waiver, IDoA employed a Request for Proposals (RFP) process through which applicants indicated their costs for providing the service and the size of the population each applicant projected it could serve. The rate was then established at one standard deviation above the mean of the weighted costs received. In-home service (homemaker) service providers are required to expend a minimum of 77% of their total CCP revenues on direct service worker costs. The remaining 23% of revenues may be spent by the provider agencies at their discretion on administrative or program support costs. See 89 IAC 240.2040.

Expenses that may be counted as direct service worker costs include wages, health coverage, retirement, FICA, uniforms, workers compensation, travel reimbursement, FUTA and unemployment insurance (UI). Program support and administrative expenses include direct service worker supervisor costs, training costs, malpractice insurance, administration staff costs, consultant fees, supplies and equipment, telephone service, occupancy costs and postage. 89 IAC 240.2050.

Subsequent rates added cost of living adjustments (COLAs) to the previous rates or reflected changes negotiated as part of collective bargaining agreements between the State and SEIU. The in-home service rates were increased on January 1, 2003, and June 1, 2006, as a result of action taken by the Administration and General Assembly. Effective 7/1/08, an agreement between the State and SEIU raised the in-home services (homemaker) rate to coincide with the three-step increase in the federal Fair Minimum Wage Act of 2007. Also, effective July 1, 2008, the rate was enhanced pursuant to Illinois Public Act 95-713, to cover health insurance costs. Effective 8/1/17, Illinois Public Act 100-0023 provided for an increase to both the in-home service rate and the enhanced rate paid to service provider agencies that offer health insurance coverage. This Public Act further provided that the enhanced rate shall be adjusted using actuarial analysis based on the cost of care. Based upon this legislation the current In-home service (homemaker) rate is a fixed unit rate of $18.29 per hour of service. Based upon a recent rate study completed by IDOA, the proposed rate is indicated below: In-home service (homemaker): $20.28

The in-home service (homemaker) rates include administrative costs and direct care staff wages. The rates are not geographically based and do not include room and board.

In-home services (homemaker) rates are reviewed by IDoA annually to ensure budget sustainability, appropriateness, compliance with service requirements, and compliance with any new federal or state statutes or rules affecting the program. In reviewing fixed unit rates of reimbursement, the State takes into consideration (1) service utilization and cost information, and (2) current market conditions and trend analyses.

Adult Day Service (ADS) rates are based on rates established by the IDoA in their elderly Waiver (0143). The original ADST rate was established by legislation. The fee-for-service reimbursement rate structure consists of two fixed unit rates, one for ADS and another for ADS transportation (ADST). ADS and ADST rates were last increased in 2008. The State worked with an external vendor conduct the rate study.

After completion of focus groups for individuals receiving services and providers; reviewing ADS and ADST claims from the State’s EDW from SFY15, SFY16, and SFY17; and two provider surveys to obtain the necessary data to complete a thorough rate analysis for the ADS and ADST new service rates were developed.

Participant focus groups demonstrated that ADS and ADST services were highly valuable to them. They reported that the ADS centers provide an opportunity to engage with other older adults in a culturally responsive environment and provide medical resources that help keep them healthy and avoid hospitalization. Participants stated that the ADS centers are very responsive to their needs. Providers reported struggling to meet the required services of ADS and ADST due to current funding levels and the increased level of need of individuals receiving services.

The ADS and ADST claims from the State’s EDW from SFY15, SFY16, and SFY17 were used to calculate the average hours of ADS provided a day. The SFY17 billing data are also used to project the fiscal impact of recommended rates. Two separate provider surveys were conducted. A primary expense and service survey and a secondary follow up survey. Surveys were distributed using a contact list provided by IDoA. Both surveys were distributed to 56 ADS providers across the state. Of those 56 providers, 37 responded to the initial survey and 25 responded to the second survey. Twenty-two providers responded to both surveys.

Survey results:

• Salaries of the required staffing positions

• An average tax and fringe rate of 15.50% was reported

• Other ADS costs: Food, facilities and maintenance, social activities and other operating expenses accounted for $12,481 per FTE for ADS services

• Other ADST costs: Vehicle costs and other operating costs accounted for $13,160 per FTE for ADST services

After the data collection process, rate calculations were performed using blended rate, bottom-up, and model budget methodologies. The model budget methodology was selected. This methodology calculates service rates similar to a blended methodology by dividing eligible expenses by units. An additional benefit of this approach is its ability to display and adjust expected staffing levels, salaries, operating expenses, and inflation. This approach allows ADS/ADST rates to be tied to actual provider data and be aligned with program requirements.

The proposed ADS and ADST rates recommended by the State:

Adult Day Service $ 14.30

Adult Day Service Transportation $ 10.29 Information regarding public comment for ADS rates are described in Main 6-I. Continue to Main B Optional.

Indiana Waiver# IN.0378.R04.00 

IN Community Integration and Habilitation

Waiver Name:
IN Community Integration and Habilitation
Effective Date:
7/16/2020
Expiration Date:
7/15/2025

Services

List of Services for Indiana Waiver# IN.0378.R04.00

Cost Neutrality

Cost Neutrality for Indiana Waiver# IN.0378.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
10216 10969

Year 1 Waiver Services

List of Year 1 Waiver Services for Indiana Waiver# IN.0378.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Individual hour 7021 118 $25.47
Day Habilitation Small hour 5782 256 $9.10
Day Habilitation Medium hour 3249 355 $5.08
Day Habilitation Large hour 1039 38 $3.26
Prevocational Services Medium Group hour 2254 755 $5.12
Prevocational Services Large Group hour 1580 169 $3.26
Prevocational Services Small Group hour 1463 76 $9.04
Community Based Habilitation Small Group (Ends 7/31/2020 hour 2222 11 $9.15
Community Based Habilitation Medium Group (Ends 7/31/2020 hour 422 3 $5.04
Community Based Habilitation Individual (Ends 7/31/2020 hour 5593 11 $25.48
Facility Based Habilitation Small Group (Ends 7/31/2020 hour 3560 31 $9.05
Facility Based Habilitation Medium Group (Ends 7/31/2020 hour 2827 36 $5.13
Facility Based Habilitation Large Group (Ends 7/31/2020 hour 1039 3 $3.26
Facility Based Habilitation Individual (Ends 7/31/2020 hour 1428 10 $25.46
Facility Based Support Services hour 1 1 $2.02
Workplace Assistance hour 9 76 $27.96

Year 5 Waiver Services

List of Year 5 Waiver Services for Indiana Waiver# IN.0378.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Individual hour 7590 130 $27.57
Day Habilitation Small hour 6250 280 $9.85
Day Habilitation Medium hour 3513 388 $5.50
Day Habilitation Large hour 1123 41 $3.52
Prevocational Services Medium Group hour 2436 757 $5.54
Prevocational Services Large Group hour 1708 169 $3.52
Prevocational Services Small Group hour 1581 76 $9.79
Community Based Habilitation Small Group (Ends 7/31/2020 hour 0 0 $0.01
Community Based Habilitation Medium Group (Ends 7/31/2020 hour 0 0 $0.01
Community Based Habilitation Individual (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Small Group (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Medium Group (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Large Group (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Individual (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Support Services hour 1 1 $2.19
Workplace Assistance hour 10 76 $30.26

Rate Determination Methods

Rate Determination Methods for Indiana Waiver# IN.0378.R04.00

In 8-1-2018 amendment IN.0378.R03.05, Transitional Case Management was added to Case Management responsibilities which required an additional rate. Per CMS rules, Case Managers may be reimbursed for up to six months of service provision for individuals who are transitioning from an institutional setting to a community based waiver setting. The rate for this service is consistent with the monthly per member per month rate that Case Managers currently receive on this waiver. Case Managers will only be reimbursed for services occurring up to six months prior to the transition of the individual to waiver services.

a. Payment can occur for transitional case management activities once an individual is successfully transitioned into waiver services.

b. In the event an individual dies mid transition, payment will be provided for all transitional activities completed prior to the individual’s death.

A previously separate component of Case Management is now rolled into the reimbursement rate of the service. An annual per member per year reimbursement for additional person centered planning activities revolving around the LifeCourse Framework for Supporting Families was rolled into the rate for Case Management services. The reimbursement rate for this activity was based on an analysis of the time that would be needed to ensure effective person centered planning. The amount was determined utilizing trials with the PCISP model as a part of the Case Management Innovation Workgroup. The workgroup assisted in the evaluation of the time, resources and materials needed to effectively create a PCISP.

The rate determination methodology continues to rely on the methodology utilized in 2009. The original rate determination methodology is outlined below.

ONGOING FOR ALL RENEWALS AND AMENDMENTS:

FSSA retains final authority for rate setting and coverage criteria for all Medicaid services, including provider rates, the basis for any activities reimbursed through administrative funds, and state plan services provided to waiver participants.

The current Rate Determination Methods were carried forward from the prior renewal and will remain in effect for this waiver as described below. FSSA’s Division of Disability and Rehabilitative Services (DDRS) initiated and implemented a standardized provider reimbursement rate methodology in CY 2009. This methodology requires that providers be reimbursed for actual services delivered, that the rate for each waiver service is discreet and transparent, and that the rates treat all providers in a fair and equitable fashion. The standardized rate system was implemented in CY 2009.

Explanations of the existing Rate Development Tasks & Timelines, and the Rate Methodology are as follows: RATE DEVELOPMENT TASKS & TIMELINES

The provider reimbursement rate initiative involved three key tasks. These tasks were: reimbursement rate methodology review and evaluation; rate development and testing; and rate revision and implementation. A description of each task is as follows:

1. Reimbursement Rate Methodology Review and Evaluation: DDRS conducted a review of current provider expenditure and utilization data, reimbursement rate methodologies, assumptions and pricing incentives, budget forecasting and cost containment strategies, risk management and risk reserve practices. This review involved the examination of provider operating expense sheets, annual audited financial reports, and focused discussions with statewide provider organizations.

2. Rate Development and Testing: Initial provider reimbursement rates were published July 2007 and implemented over a twenty-four month period. These rates were based upon the fiscal and service utilization data, provider expenditure data, and program benchmarks based upon DDRS policy. This methodology / standard fee schedule identified critical cost factors and relevant pricing benchmarks.

This fee schedule together with service utilization standards served as the basis for calibration of the Inventory for Client and Agency Planning (ICAP) to resource allocation levels. Rate testing was initiated in January 2008 and involved only providers in BDDS District 4. Rate testing was expanded statewide to all providers in January 2009.

3. Rate Revision and Implementation: Rate implementation began in January 2008 and became effective statewide in January 2009. Rate revisions were implemented based upon evaluation and testing findings. DESCRIPTION OF RATE STRUCTURE

DDRS converted its provider reimbursement approach from a negotiated rate system to a standardized fee-for service system for its Medicaid Home and Community-Based Services (HCBS) waiver program.

There were three major components to the DDRS Rate Initiative:

Rate Component #1 - Direct Care Staff Time as the Billable Unit: With the exception of adaptive equipment / environmental modifications and transportation, all provider reimbursement is based upon the amount of direct care staff time delivered to the participant by the provider. In order to meet the conditions for payment, the participant must be Medicaid eligible, enrolled, in attendance, and receive a HCBS service; and the direct care staff must be actively employed and present to provide the HCBS service. In addition, the service provided must be consistent with the participant’s Person-Centered/Individualized Support Plan.

Rate Component #2 - Standardized Cost Centers: All provider reimbursement rates consist of four cost centers. These cost centers are:

• Direct care Staff Compensation: Two primary job classes were used from these compensation studies. Job classifications used for Personal Support Workers are staff who perform typical duties of a developmental disabilities attendant with a high school degree and no special training. Job classifications used for Habilitation Workers are staff who perform the duties of a developmental disabilities attendant with an Associate Arts degree or Certified Nursing Assistant, or special training.

• Employee Expenses: Employment related expenditures refer to the benefits package that is offered to all employees who are involved in the care and services provided to the person with disabilities and are divided into two groups. Discretionary costs are those associated with benefits provided at the discretion of the employer and are not mandated by local, state, or federal governments. Non-discretionary costs are those related to employment expenditures that are mandated by local, State, and Federal governments and are not optional to the employer.

• Program Supervision and Indirect Expenses: Program Related Expenditures are those that are part of the operation of the setting in which residential habilitation occurs and related to the programs which occur within the setting, but are not directly tied to the direct care staff. They include program management and clinical staff costs as well as program operational expenses.

• General & Administrative Expenses: General and Administrative costs are those associated with operating the organization’s business and administration and are not directly related to the clients or the programs that serve the clients.

Historical expenditures were used by DDRS as the basis for transportation rates. The average cost per person was utilized and, at the time of the 2009 then “DD Waiver” Renewal, the transportation rate was applied only to people who were receiving fewer than 35 hours per week of Residential Habilitation and Support each week under Indiana's comprehensive (then DD or Autism) Waivers. Note that the DD and Autism Waivers have since been combined and renamed as the Community Integration and Habilitation Waiver.

Rate Component #3 - Other Factors: In addition, standardized cost centers were applied.

At the time of the fifth amendment of the prior renewal, IN.0378.R02.05, Wellness Coordination was added as a standalone service among the array of available services. At the request of the operating agency, industry leaders collaboratively presented a summary of the costs of Registered Nursing (RN) and Licensed Practical Nursing (LPN) services within the industry. The cost centers presented for nursing services included salary, benefits, travel reimbursement, office space/phone/utilities, office supplies, medical assessment and treatment supplies, computer equipment/access, photocopy expenses, Liability Insurance and Continuing Education Unit expenses. Further consideration was given to the typical number of paid hours as well as to those costs associated with sick time, holiday leave, paid time off and training expenses. As presented, the template for nurse coverage assumed a staffing pattern employing nurses at the ratio of two (2) LPNs per one (1) RN, which may be adjusted depending on wellness needs of the client population. A monthly rate was derived from averaging the hourly costs to employ two LPNs per one RN, and dividing the total cost for an hour of service by the total number of nurses (three for purposes of the rate calculation) providing those service hours. The State reviewed the cost per billable hour presented by the industry in establishing the monthly rate for each tier of Wellness Coordination services. Labor and other costs were consistent with publicly available data for LPN and RN total compensation and other identified costs used to calculate the reimbursement rate.

There have been no changes to the rate methodology from the prior renewal to the current renewal. Addendum:

The Medicaid agency now solicits public input on rate determination methods through collaboration with industry

leaders in the collection and review of costs associated with the various service components. At any time, public comments may be received via the BQIS Helpline at BQISHelp@fssa.in.gov.

Information about payment rates is made available to waiver participants by their Case Manager. Current rates are continuously posted on the DDRS/BDDS website at:

http://www.in.gov/fssa/files/RatesChartDDRSWaivers.pdf

Prior to any rate changes, a bulletin of the rates is posted to IndianaMedicaid.com to advise providers of the rate changes. Once the changes occur, manuals are updated regularly to reflect the changed rates.

There have been no changes to the rate methodology from the prior renewal to the current renewal. CIH services for which the state’s standard rate methodology applies:

• Adult Day Services

• Behavioral Support Services

• Day Habilitation

• Community Transition

• Electronic Monitoring

• Music Therapy

• Occupational Therapy

• Personal Emergency Response System

• Physical Therapy

• Prevocational Services

• Psychological Therapy

• Recreational Therapy

• Rent and Food for Unrelated Live-in Caregiver

• Residential Habilitation and Support (provided hourly)

• Residential Habilitation and Support – Daily (RHS Daily)

• Respite

• Specialized Medical Equipment and Supplies

• Speech/Language Therapy

• Structured Family Caregiving

• Transportation

• Workplace Assistance

Indiana Waiver# IN.0387.R04.00 

IN Family Supports Waiver

Waiver Name:
IN Family Supports Waiver
Effective Date:
7/16/2020
Expiration Date:
7/15/2025

Services

List of Services for Indiana Waiver# IN.0387.R04.00

Cost Neutrality

Cost Neutrality for Indiana Waiver# IN.0387.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
24173 31777

Year 1 Waiver Services

List of Year 1 Waiver Services for Indiana Waiver# IN.0387.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Individual hour 3344 101 $25.28
Day Habilitation Small hour 5864 157 $9.16
Day Habilitation Medium hour 3291 275 $5.00
Day Habilitation Large hour 1053 34 $3.28
Prevocational Services Large Group hour 1581 182 $3.10
Prevocational Services Small Group hour 1626 67 $9.07
Prevocational Services Medium Group hour 2392 606 $5.10
Community Based Habilitation Small Group (Ends 7/31/2020 hour 2380 8 $9.12
Community Based Habilitation Medium Group (Ends 7/31/2020 hour 579 3 $5.07
Community Based Habilitation Individual (Ends 7/31/2020 hour 2066 11 $25.57
Facility Based Habilitation Small Group (Ends 7/31/2020 hour 3485 19 $9.19
Facility Based Habilitation Medium Group (Ends 7/31/2020 hour 2712 30 $4.94
Facility Based Habilitation Large Group (Ends 7/31/2020 hour 1053 3 $3.28
Facility Based Habilitation Individual (Ends 7/31/2020 hour 1277 6 $24.98
Facility Based Support Services hour 1 1 $2.02
Workplace Assistance hour 1 1 $28.81

Year 5 Waiver Services

List of Year 5 Waiver Services for Indiana Waiver# IN.0387.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Individual hour 4396 112 $27.36
Day Habilitation Small hour 7709 173 $9.91
Day Habilitation Medium hour 4327 304 $5.42
Day Habilitation Large hour 1384 38 $3.55
Prevocational Services Large Group hour 2078 184 $3.36
Prevocational Services Small Group hour 2138 68 $9.82
Prevocational Services Medium Group hour 3145 615 $5.52
Community Based Habilitation Small Group (Ends 7/31/2020 hour 0 0 $0.01
Community Based Habilitation Medium Group (Ends 7/31/2020 hour 0 0 $0.01
Community Based Habilitation Individual (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Small Group (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Medium Group (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Large Group (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Habilitation Individual (Ends 7/31/2020 hour 0 0 $0.01
Facility Based Support Services hour 2 1 $2.18
Workplace Assistance hour 2 1 $31.18

Rate Determination Methods

Rate Determination Methods for Indiana Waiver# IN.0387.R04.00

A previously separate component of Case Management is now rolled into the reimbursement rate of the service. An annual per member per year reimbursement for additional person centered planning activities revolving around the LifeCourse Framework for Supporting Families was rolled into the rate for Case Management services.

The rate determination methodology continues to rely on the methodology utilized in 2009. The original rate determination methodology is outlined below.

ONGOING FOR ALL RENEWALS AND AMENDMENTS

FSSA retains final authority for rate setting and coverage criteria for all Medicaid services, including provider rates, the basis for any activities reimbursed through administrative funds, and state plan services provided to waiver participants.

The current Rate Determination Methods were carried forward from the prior renewal and will remain in effect for this waiver as described below. FSSA’s Division of Disability and Rehabilitative Services (DDRS) initiated and implemented a standardized provider reimbursement rate methodology in CY 2009.

This methodology requires that providers be reimbursed for actual services delivered, that the rate for each waiver service is discreet and transparent, and that the rates treat all providers in a fair and equitable fashion. The standardized rate system was implemented in CY 2009.

EXTENDED SERVICES

For the new service Extended Services, the Extended Services rate in question was built upon the same cost centers and cost factors that have been utilized by DDRS since 2007 in the development of the existing rate for SEFA.

Explanations of the existing Rate Development Tasks & Timelines, and the Rate Methodology are as follows:

RATE DEVELOPMENT TASKS & TIMELINES

The provider reimbursement rate initiative involved three key tasks. These tasks were: reimbursement rate methodology review and evaluation; rate development and testing; and rate revision and implementation. A description of each task is as follows:

1. Reimbursement Rate Methodology Review and Evaluation: DDRS conducted a review of current provider expenditure and utilization data, reimbursement rate methodologies, assumptions and pricing incentives, budget forecasting and cost containment strategies, risk management and risk reserve practices. This review involved the examination of provider operating expense sheets, annual audited financial reports, and focused discussions with statewide provider organizations.

2. Rate Development and Testing: Initial provider reimbursement rates were published July 2007 and implemented over a twenty-four month period. These rates were based upon the fiscal and service utilization data, provider expenditure data, and program benchmarks based upon DDRS policy. This methodology / standard fee schedule identified critical cost factors and relevant pricing benchmarks.

Rate testing was initiated in January 2008 and involved only providers in BDDS District 4. Rate testing was expanded statewide to all providers in January 2009.

3. Rate Revision and Implementation: Rate implementation began in January 2008 and became effective statewide in January 2009. Rate revisions were implemented based upon evaluation and testing findings.

DESCRIPTION OF RATE STRUCTURE

DDRS converted its provider reimbursement approach from a negotiated rate system to a standardized fee-for-service system for all of its Medicaid Home and Community-Based Services (HCBS) waiver program.

There were three major components to the DDRS Rate Initiative:

Rate Component #1 - Direct Care Staff Time as the Billable Unit: With the exception of adaptive equipment and transportation, all provider reimbursement for the Family Supports Waiver is based upon the amount of direct care staff time delivered to the participant by the provider. In order to meet the conditions for payment, the participant must be Medicaid eligible, enrolled, in attendance, and receive a HCBS service; and the direct care staff must be actively employed and present to provide the HCBS service. In addition, the service provided must be consistent with the participant’s person-centered/individualized support plan.

Rate Component #2 - Standardized Cost Centers: All provider reimbursement rates consist of four cost centers. These cost centers are:

• Direct care Staff Compensation: Two primary job classes were used from these compensation studies. Job classifications used for Personal Support Workers are staff who perform typical duties of a developmental disabilities attendant with a high school degree and no special training. Job classifications used for Habilitation Workers are staff who perform the duties of a developmental disabilities attendant with an Associate Arts degree or Certified Nursing Assistant, or special training.

• Employee Expenses: Employment related expenditures refer to the benefits package that is offered to all employees who are involved in the care and services provided to the person with disabilities and are divided into two groups.

Discretionary costs are those associated with benefits provided at the discretion of the employer and are not mandated by local, state, or federal governments. Non-discretionary costs are those related to employment expenditures that are mandated by local, State, and Federal governments and are not optional to the employer.

• Program Supervision and Indirect Expenses: Program Related Expenditures are those that were part of the operation of the setting in which residential habilitation occurred and related to the programs which occur within the setting, but are not directly tied to the direct care staff. They included program management and clinical staff costs as well as program operational expenses.

• General & Administrative Expenses: General and Administrative costs are those associated with operating the organization’s business and administration and were not directly related to the clients or the programs that serve the clients.

Rate Component #3 - Other Factors: In addition, standardized cost centers were applied.

Historical expenditures were used by DDRS as the basis for transportation rates. The average cost per person was utilized and the transportation rate was applied only to people who were, at that time, receiving fewer than 35 hours per week of Residential Habilitation and Support each week under Indiana's comprehensive DD or Autism Waivers. (Note: While this uniform rate for Transportation services was developed using historical expenditures from other HCBS waivers, Transportation is available to all participants under the Family Supports Waiver and the rate was carried forward from the other HCBS waivers.)

Participant Assistance and Care (PAC) rates were derived through review and analysis of its reimbursable activities in comparison to reimbursable activities associated with State Plan and what were at that time the comprehensive "DD Waiver" services offering components of personal care and/or residential supports.

Additionally, the Medicaid agency now solicits public input on rate determination methods through collaboration with industry leaders in the collection and review of costs associated with the various service components. At any time, public comments may be received via the BQIS Helpline at BQISHelp@fssa.in.gov.

Information about payment rates is made available to waiver participants by their Case Manager. Current rates are continuously posted on the DDRS/BDDS website at: http://www.in.gov/fssa/files/RatesChartDDRSWaivers.pdf

Prior to any rate changes, a bulletin of the rates is posted to IndianaMedicaid.com to advise providers of the rate changes. Once the changes occur, manuals are updated regularly to reflect the changed rates.

FSW services for which the state’s standard rate methodology applies:

• Adult Day Services

• Behavioral Support Services

• Day Habilitation

• Music Therapy

• Occupational Therapy

• Participant Assistance and Care

• Personal Emergency Response System

• Physical Therapy

• Prevocational Services

• Psychological Therapy

• Recreational Therapy

• Respite

• Specialized Medical Equipment and Supplies

• Speech/Language Therapy

• Transportation

• Workplace Assistance

Indiana Waiver# IN.4197.R04.00 

IN Traumatic Brain Injury

Waiver Name:
IN Traumatic Brain Injury
Effective Date:
1/1/2018
Expiration Date:
12/31/2022

Services

List of Services for Indiana Waiver# IN.4197.R04.00

Cost Neutrality

Cost Neutrality for Indiana Waiver# IN.4197.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
200 200

Year 1 Waiver Services

List of Year 1 Waiver Services for Indiana Waiver# IN.4197.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Structured Day Program 15 minutes 16 3721 $4.17
Supported Employment 15 minutes 4 483 $9.54

Year 5 Waiver Services

List of Year 5 Waiver Services for Indiana Waiver# IN.4197.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Structured Day Program 15 minutes 18 2584 $3.49
Supported Employment 15 minutes 2 779 $9.54

Rate Determination Methods

Rate Determination Methods for Indiana Waiver# IN.4197.R04.00

To develop revised payment rates effective February 1, 2020, Indiana’s Family and Social Services Administration (FSSA) used the following primary data sources:

Data sources: To develop revised payment rates effective February 1, 2020, Indiana’s Family and Social Services Administration (FSSA) used the following primary data sources:

BLS data – Data elements incorporated in rate setting include Indiana average wage data for applicable occupation codes, healthcare industry benefits cost data used as a national benchmark, and healthcare inflation data, used to inflate the BLS average wage data from the May 2018 reporting period to the midpoint of the new rate year (July 2020).

Provider survey data – Data collected from providers informed public source gaps and provided corroborating support for key BLS inputs. FSSA collected provider survey response data related to provider costs (for employee salaries, benefits, administration and program support), average wage per hour, staffing information (such as number of employees relative to participants served, and the average number of service hours per employee), and operational structure.

Methodology: To develop prospective payment rate methodologies for the Division of Aging’s (DA’s) waiver program services, FSSA selected the following approaches:

Traditional cost model build-up - This approach reflects the program-related cost per unit of providing each covered service. The foundation is the labor cost per unit, which includes inflated wages and benefits costs, allocated to the service unit level. Administration and program support costs are calculated as a percentage of the labor cost per unit component. Select services also include an “other” cost component for unique requirements such as Electronic Visit Verification (EVV).

Key default rate inputs under this approach were as follows:

Direct care worker average hourly wage for non-accredited employees (before inflation): $11.35 based on BLS Indiana average of the 50th and 75th percentile wage for Personal Care Aides Wage inflation (2 years): 4% factor based on changes in Consumer Price Index for All Urban Consumers (CPI-U) levels for medical services

Productivity and Paid Time Off (PTO) factors: 6 % factor for productivity, or non-client facing time (such as training, notetaking, etc.) and 3% factor for PTO, based on provider survey data

Benefits factor: 19% factor based on BLS national benchmarks (includes Federally required benefits and 75% of national “insurance” benefits costs)

Administration and program support factor: 25% for administration and 6% for program support factor, based on costs reported in the provider survey

To appropriately reflect service requirements, rate inputs were modified from the defaults in the following:

Adult Day Services: Separate staffing ratios, supervisor span of control, and mix of supervisor wages (including RNs, LPNs, Psychiatric Aides, and Healthcare Support Workers) for each tier level to reflect higher resource requirements for levels 2 and 3. Also includes a $0.35 per unit meals cost component. Category 1 rates include a 16% program support adjustment to reflect enhanced setting requirements, while Category 2 includes the default 6% program support adjustment.

Adult Family Care: Rates assume 10 hours of service per day, with higher staffing ratios to reflect higher resource requirements for levels 2 and 3, and no productivity factor adjustment. Supervisor wages based on a mix of Healthcare Support Workers and RNs for all levels.

Attendant Care: Rate assume a 1:1 staffing ratio. Adjustments by provider type are as follows:

o Agency services: includes a supervisory cost component with a Healthcare Support Worker wage basis and a $0.05 per unit EVV adjustment

o Non-Agency services: includes a 12.5% administration adjustment and a $0.10 per unit EVV adjustment, with no supervisory cost component or adjustments for productivity, PTO, or program support

Care Management: Single monthly unit rate, based on the annual wage for Healthcare Social Workers allocated to the participant level with an assumed 50:1 staffing ratio

Home Maker: Rates assume a 1:1 staffing ratio, personal care aide median wage basis, and 10% program support factor, with no supervisor cost component. In addition:

o Agency services: includes a $0.05 per unit EVV adjustment

o Non-Agency services: includes a 12.5% administration adjustment and a $0.10 per unit EVV adjustment

Non-Medical Transportation: Uses the direct care worker wage for Bus Drivers, School or Special Client, and supervisor wage for Healthcare Support workers. Mileage unit rate includes a $0.58 per mile IRS allowable vehicle cost component, with no program support adjustment. Assumptions for units per hour and staffing ratio are higher for assisted transportation to reflect higher resource requirements.

Respite: Separate hourly unit rates for RN, LPN and unskilled services, each with a 1:1 staffing ratio and a $0.05 per unit EVV adjustment. Wage input assumptions are as follows:

o RN: Based on RN wage for direct care worker and supervisor o LPN: Based on LPN wage for direct care worker and RN wage for supervisor

o Unskilled: Based on default wage for direct care worker and Healthcare Support worker wage for supervisor

Rate composite approach - Based on a composite of rates for service components to reflect the value for the package of services. Includes tiered and bundled rates for Assisting Living, where the tiers are assigned based on the level of service assessment for each participant. The rate composite for Level 2 rates includes the following components:

Attendant Care: 4.5 units (1.13 hours per day) Home Maker: 4 units (1 hour per day)

Skilled Nursing: 1.5 units (22.5 minutes per day) Adult Day Service: 4 units (1 hour per day)

Emergency Response: One unit per month, or 0.03 units per day Non-Medical Transportation: 0.3 trips at 2 miles per trip per day)

Participant levels 1-3 are assigned based on an Indiana-specific Level of Service tool. Level 2 has the highest projected utilization and is the starting point of the

Assisted Living tiered rates. Under tiered rate adjustments, the Level 2 Attendant Care, Home Maker and Skilled Nursing rate components are adjusted upwards by 17% for the level 3 rate, and adjusted downward by 10% for the level 1 rate. These Assisted Living level differentials are informed by multiple discussions with stakeholders, provider survey results, and DA’s knowledge of service requirements. The enhanced Level 3 differential is also consistent with DA’s goal to incentivize services for participants with higher levels of need.

Consistent with the FSSA’s goals for person-centeredness and to streamline billing practices, Assisted Living services will be paid on a monthly unit basis for all months except admit and discharge months, in which case payment will be based on a daily unit. The monthly rate is equal to the daily rate multiplied by 29.7 days, based on average monthly utilization.

Market-based approach - Based on market prices (up to an annual or lifetime limit) or commercial benchmarks for Community Transition, Home Delivered Meals, Home Modifications, Nutritional Supplements, Personal Emergency Response, Pest Control, Specialized Medical Equipment, and Vehicle Modifications.

In addition to these services, there are select services where DA does not propose developing new rate methodologies at this time: Behavior Management, Emergency Response, Residential Habilitation, Structured Day Program, and Supported Employment. These services are primarily provided under the Division of Disability and Rehabilitation Services’ (DDRS’) waiver programs, and will be updated during the upcoming DDRS rate methodology update. In the interim, DA will increase the Behavior Management rate to match the current DDRS rate for the same service. For Emergency Response, DA will increase the rate to match the A&D rate for the same service.

The DA fee schedule can be found in the DA’s HCBS Waivers Public Comments webpage at: https://www.in.gov/fssa/da/5479.htm.

Changes to rates and rate setting methodology require 60 day tribal notice and 30 day public comment period as well as a waiver amendment. Further, Indiana code requires that all providers of Medicaid funded services be made aware of changes 30 days prior to the change effective date. All other providers are notified of rate changes through public notice and public comments, IHCP published banner pages; bulletins; and newsletters as prepared by the DA in collaboration with the Indiana Office of Medicaid Policy and Planning (OMPP) and distributed by FSSA's fiscal agent contractor.

The DA and the OMPP will continue to collaborate with the stakeholder community on any revisions made to the waiver rates. Their valuable input into the waiver rate reviews is necessary to ensure that rates are sufficient to continue provider participation and participant access to waiver services.

In the provider survey instructions, responses to FAQs, and the provider survey training webinar, providers were instructed to report only historical program-related costs from their fiscal year reporting period, and exclude non- program related costs and future potential cost increases from their survey responses. Program related costs were defined as the reasonable and necessary costs related to providing services covered under the Medicaid HCBS waiver programs, including costs incurred for clients covered by other payers so as long as the type of services provided to these clients were the same as those covered under the Medicaid HCBS waiver programs. Non-program related costs to be excluded were defined as operations not related to Medicaid HCBS waiver programs. In addition, providers were directed to exclude room and board expenses for residential services (such as the costs associated with housing, rent, interest or mortgage expenses, utilities, property maintenance, etc.) and meals (unless the meals were specifically covered under the waiver programs, such as for Adult Day Service).

Waiver Name:
IA HCBS AIDS/HIV
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for Iowa Waiver# IA.0213.R06.00

Cost Neutrality

Cost Neutrality for Iowa Waiver# IA.0213.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
35 39

Year 1 Waiver Services

List of Year 1 Waiver Services for Iowa Waiver# IA.0213.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Self Directed Community Support and Employment month 0 0 $0.01
FFS Self Directed Community Support and Employment month 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Iowa Waiver# IA.0213.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Self Directed Community Support and Employment month 0 0 $0.01
FFS Self Directed Community Support and Employment month 0 0 $0.01

Rate Determination Methods

Rate Determination Methods for Iowa Waiver# IA.0213.R06.00

441 Iowa Administrative Code (IAC) 79.1 sets forth the principles governing reimbursement of providers of medical and health services. Specifically, “[t]he basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule.

Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the member. Reimbursement types are described at 441 IAC 79.1(1), located here: http://dhs.iowa.gov/sites/default/files/441-79.pdf.

Homemaker, nursing, counseling, and home delivered meals are reimbursed through a fee schedule. Fee schedule rates and upper rate limits are defined in 441 IAC Chapter 79 and can be found online at: https://www.legis.iowa.gov/docs/ACO/chapter/441.79.pdf. the specific rule is 441-79.1(2). Home Health Aide services are reimbursed on a retrospective cost-related basis as described in IAC 441- 79.1(2).

Respite provided by home health agencies is based on the provider’s rate in effect 6/30/16 plus 1%, converted to a 15 minute rate. If no 6/30/16 rate: Lesser of maximum Medicare rate in effect 6/30/16 plus 1%, converted to a 15 minute rate or maximum Medicaid rate in effect 6/30/16 plus 1% converted to a 15 minute rate. Variations in fee schedule rates for Respite services are based on the type of provider delivering the respite services CDAC (Skilled and Unskilled) are reimbursed on the basis of the agreement of the member and the provider. CDAC reimbursement is subject to the upper rate limit in IAC. These upper rate limits are coded into ISIS so it cannot be exceeded within a member’s service plan. FFS claims are paid based on an approved service plan in ISIS.

Self-directed services (individual directed goods and services, self-directed personal care and self-directed community supports and employment) are reimbursed on the rate negotiated by member with the self-directed employee. Rate setting for self-directed services are identified in Appendix E.

The rate setting process for self-directed services is detailed in Appendix E-1-a. The services that may be included in a CCO budget for the BI waiver includes:

• CDAC unskilled

• Basic individual respite care

• Home Delivered Meals

• Homemaker

The Independent Support Broker is reimbursed at a rate negotiated between the member and the ISB not to exceed the upper rate limit in rule. The Financial Management Service (FMS) is reimbursed based on fee schedule rate not to exceed the upper rate limit allowed n rule.

A utilization adjustment factor is used to adjust the CCO budget to reflect statewide average cost and usage of waiver services. Annually, the Department determines the average cost for each waiver service. The average service cost is used to determine the “cap amount” of the CCO budget. The cap amount is used to ensure the participant stays within the program dollar cap limits within each waiver. The department also determines the percentage of services that are used, compared to what is authorized within a waiver service plan. This percentage is applied to the cap amount to determine the CCO “budget amount”. The budget amount is the total funds available to the participant in the monthly CCO budget. This UAF includes all HCBS waiver participants in the calculation, not just individuals participating in CCO.

The participant may choose to set aside a certain amount of the budget each month to save towards purchasing additional goods or services they cannot buy from the normal monthly budget. A savings plan must be developed by the participant, and approved by DHS prior to implementation. The good or service being saved for must be an assessed need identified in the participant’s service plan.

For services and items that are furnished under Part B of Medicare, the fee shall be the lowest charge allowed under Medicare. For services and items that are furnished only under Medicaid, the fee shall be the lowest charge determined by the department according to the Medicare reimbursement method described in section 1834(a) of the Social Security Act (42 U.S.C. 1395m), payment for durable medical equipment. Payment for supplies with no established Medicare fee shall be at the average wholesale price for the item less 10 percent. Payment for items with no Medicare fee, Medicaid fee, or average wholesale price shall be made at the manufacturer’s suggested retail price less 15 percent.

Payment for items with no Medicare fee, Medicaid fee, average wholesale price, or manufacturer’s suggested retail price shall be made at the dealer’s cost plus 10 percent. For selected medical services, supplies, and equipment, including equipment servicing, that generally do not vary significantly in quality from one provider to another, the payment shall be the lowest price for which such devices are widely and consistently available in a locality. Payment for used equipment shall not exceed 80 percent of the purchase allowance. No allowance shall be made for delivery, freight, postage, or other the CDAC and CCO services were set in accordance with 441 IAC 79.1(1):c.

When fee schedules are first established for a service, fee schedules are determined by the department with advice and consultation from the appropriate professional groups. For example, when the prevocational and supported employment rates (fee schedule) were being developed, a provider stakeholder group was established and worked with the Department for over two years in the rate development.

Individual service rate adjustments are made periodically to correct any rate inequity. With the AIDS/HIV waiver, this is a legislative appropriation process through provider association and individual providers lobbying efforts. A change to the rate for any service is done at the direction of the IA Legislature. When the department reviews reimbursement levels for adequacy; historical experience, current reimbursement levels, experiences in other states, and network adequacy are considered. During the past 10 years the legislature has approved a 1% (2016) and 2% (2013) across the board rate increases for HCBS waiver service providers. The most recent rate adjustment approved by the legislature occurred July 1, 2016 when all HCBS service rates were increased by 1%. The legislature can direct IME to increase or decreased provider rates through a legislative mandate. If so, then IME changes the IAC accordingly. All provider rates are part of the IAC and are subject to public comment any time there is change. This information is on the website as well as distributed to stakeholders when there is a change. Rate determination methods are set forth in IAC and subject to the State’s Administrative Procedures Act, which requires a minimum twenty-day public comment period. A public hearing by the state agency to take comments is not required unless at least twenty-five persons demand a hearing, though Agency’s often schedule a public hearing regardless of the number of comments received. The state agency may revise a rule in response to comments received but is not required to do so. At the time of service plan development, the case manager shares with the members the rates of the providers, and the member can chose a provider based on their rates. When a service is authorized in a participant’s comprehensive services plan, the providers of services receive a Notice of Decision which indicates the participant’s name, provider’s name, service to be provided, the dates of service to be provided, units of service authorized, and reimbursement rate for the service.

The state is currently reviewing all Medicaid fee schedules and will submit a report to the governor and legislature regarding how the current rates compare to the Medicare fee schedule or other appropriate reimbursement methodologies for specific services. The report will include a plan for phased-in implementation of any changes. It is currently projected that the review of Medicaid fee schedules will be completed prior to the end of SFY2020. MCO capitation rate development methodologies are described in the §1915(b) waiver and associated materials.

The services under the AIDS/HIV waiver are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Iowa Waiver# IA.0242.R06.00 

IA HCBS Intellectual Disabilities 

Waiver Name:
IA HCBS Intellectual Disabilities 
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Iowa Waiver# IA.0242.R06.00

Cost Neutrality

Cost Neutrality for Iowa Waiver# IA.0242.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
14203 14780

Year 1 Waiver Services

List of Year 1 Waiver Services for Iowa Waiver# IA.0242.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation ID Waiver, Per Day day 3825 102.59 $75.17
Day Habilitation, ID Waiver, 15 Minutes 15 minutes 3123 1047.86 $2.57
Day Habilitation, ID Waiver, Per Day - FFS day 460 102.59 $75.17
Day Habilitation, ID Waiver, 15 Minutes - FFS 15 minutes 376 1047.86 $2.57
Prevocational Service, full day day 1615 110.52 $61.11
Prevocational Service, hour hour 1436 69.23 $36.02
Prevocational Service, full day - FFS day 201 110.52 $61.11
Prevocational Service, hour - FFS hour 178 69.23 $36.02
Supported Employment Maintain Employment - Individual 15 minutes 647 18.12 $66.30
Supported Employment Maintain Employment - Small Group 15 minutes 810 1102.77 $2.84
Supported Employment Long Term Job Coaching month 2725 4.28 $1129.18
Supported Employment Maintain Employment - Individual - FFS 15 minutes 37 18.12 $66.30
Supported Employment Maintain Employment - Small Group - FFS 15 minutes 104 1102.77 $2.84
Supported Employment Long Term Job Coaching - FFS month 255 4.28 $1129.18
Self Directed Community Support and Employment month 218 9.59 $791.95
Self Directed Community Support and Employment FFS month 1792 9.59 $791.95

Year 5 Waiver Services

List of Year 5 Waiver Services for Iowa Waiver# IA.0242.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation ID Waiver, Per Day day 4140 102.59 $81.37
Day Habilitation, ID Waiver, 15 Minutes 15 minutes 3380 1047.86 $2.78
Day Habilitation, ID Waiver, Per Day - FFS day 498 102.59 $81.37
Day Habilitation, ID Waiver, 15 Minutes - FFS 15 minutes 407 1047.86 $2.78
Prevocational Service, full day day 1748 110.52 $66.15
Prevocational Service, hour hour 1554 69.23 $38.99
Prevocational Service, full day - FFS day 217 110.52 $66.15
Prevocational Service, hour - FFS hour 193 69.23 $38.99
Supported Employment Maintain Employment - Individual 15 minutes 700 18.12 $71.77
Supported Employment Maintain Employment - Small Group 15 minutes 877 1102.77 $3.07
Supported Employment Long Term Job Coaching month 2950 4.28 $1222.26
Supported Employment Maintain Employment - Individual - FFS 15 Minutes 40 18.12 $71.77
Supported Employment Maintain Employment - Small Group - FFS 15 minutes 112 1102.77 $3.07
Supported Employment Long Term Job Coaching - FFS month 276 4.28 $1222.26
Self Directed Community Support and Employment month 236 9.59 $857.23
Self Directed Community Support and Employment FFS month 1940 9.59 $857.23

Rate Determination Methods

Rate Determination Methods for Iowa Waiver# IA.0242.R06.00

All provider rates are part of Iowa Administrative Code (IAC) Rules and are subject to public comment any time there is change. Rate setting methodologies used by the Department are identified in IAC 441- 79.1(1) Types of reimbursement.

Payments for waiver services for fee-for-service (FFS) enrollees are made by DHS through the MMIS. For FFS members, providers submit claims monthly for services provided by the agency. Providers may submit manual or electronic claims form. Electronic claims must utilize a HIPAA compliant software, PC-ACE Pro 32, and be processed by the IME Provider Services Unit. Manual claims are directed to the Iowa Medicaid Enterprise (IME)/Provider Services Unit. Providers submit a claim form that accurately reflects: (1) the provider's approved NPI provider number; (2) the appropriate waiver procedure code(s) that correspond to the waiver services authorized in the ISIS service plan; and (3) the appropriate waiver service unit(s) and fee that corresponds to the ISIS service plan.

The IME issues provider payments weekly every Monday. The MMIS system edits insure that payments will not be made for services that are not included in an approved ISIS service plan. Any change to ISIS data generates a new authorization milestone for the case manager. The ISIS process culminates in a final ISIS milestone that verifies an approved service plan has been entered into ISIS.

For payments made by the IME: Providers are informed about the process for billing Medicaid directly through annual provider training, IME informational bulletins, and the IME provider manual. When a provider enrolls as a Medicaid provider, the IME Provider Services Unit mails the provider information on billing Medicaid directly. The Provider billing manual is also available on the Iowa DHS website at: http://dhs.iowa.gov/policy-manuals/medicaid-provider.

At the time of service plan development, the case manager shares provider rates with the member and the member can chose a provider based on their rates. They may also get rate information from a service provider or by viewing the rates in the IAC available on the DHS website. When a service is authorized in a member’s service plan, the providers of services receives a Notice of Decision (NOD), which indicates the participant’s name, provider’s name, service to be provided, the dates of service to be provided, units of service authorized, and reimbursement rate for the service.

Daily SCL, residential based SCL, full day adult day care, and full day Habilitation services are reimbursed using a tiered rate fee schedule. Member assignment to a tiered rate fee schedule is defined in Iowa Administrative Code (IAC) 441-79.1(30).

Personal emergency response, respite, transportation, prevoc services, supported employment, adult day care (15 min. and 1/2 day units), Day Habilitation (15 – min. units), financial management services, independent support broker and home and vehicle modification are reimbursed by fee schedules. The fee schedule is the actual charge made by the provider not to exceed the upper payment limit. The upper payment limit is established to address the reasonableness of the charge. If the provider rate is under the upper max, it is reasonable.

Fee schedules are determined by the department with advice and consultation from the appropriate professional group at the time the fee schedule is first developed. The fees reflect the amount of time and resources involved in each procedure. The fee scheduled rate is applied to all providers equally, meaning all providers may charge up to the maximum fee schedule rate. Provider may charge less than the maximum fees schedule. Individual service rate adjustments are made periodically to correct any rate inequity. With the ID waiver, this is a legislative appropriation process through provider association and individual providers lobbying efforts. The legislature can direct IME to increase or decreased provider rates through a legislative mandate. There is no set cycle for the Legislature to increase or decrease HCBS provider rates. The IME will change the IAC Rules accordingly. All provider rates are part of IAC and are subject to public comment any time there is a rate rule change. Information is on the website and is distributed to stakeholders when there is a change. Rate determination methods are set forth in IAC and subject to the State’s Administrative Procedures Act, which requires a minimum twenty-day public comment period.

If product cost is involved, reimbursement is based either on a fixed fee, wholesale cost, or on actual acquisition cost of the product to the provider, or product cost is included as part of the fee schedule. Providers on fee schedules are reimbursed the lower of:

(1) The actual charge made by the provider of service.

(2) The maximum allowance under the fee schedule for the item of service in question.

Payment levels for fee schedule providers of service will be increased on an annual basis by an economic index reflecting overall inflation as well as inflation in office practice expenses of the particular provider category involved to the extent data is available. Variations in this methodology are set forth in subrules IAC 79.1(3) to 79.1(9) and 79.1(15). Fee schedules in effect for the providers covered by fee schedules can be obtained from the department’s website at: dhs.iowa.gov/ime/providers/csrp/fee-schedule.

SCL provided in 15- minute units is a retrospectively limited prospective rate. With this rate, providers are reimbursed on the basis of a rate for a unit of service calculated prospectively based on projected or historical costs of operation.

• The prospective rates for new providers who have not submitted six months of cost reports will

be based on a projection of the provider’s reasonable and proper costs of operation until the provider has submitted an annual cost report that includes a minimum of six months of actual costs.

• The prospective rates paid established providers who have submitted an annual report with

a minimum of a six-month history are based on reasonable and proper costs in a base period and are adjusted annually for inflation.

• The prospective rates paid to both new and established providers are subject to the maximums listed in subrule 79.1(2) and to retrospective adjustment based on the provider’s actual, current costs of operation as shown by financial and statistical reports submitted by the provider, so as not to exceed reasonable and proper costs actually incurred by more than 4.5 percent.

Interim Medical Monitoring and Treatment rates are established two ways and is based on the enrollment type of the IMMT provider. IMMT services provided by a supported community living provider is a retrospectively limited prospective rate as noted for SCL provided in 15 – minute units above. IMMT provided by a home health agency is a cost-based rate for home health aide services provided by a home health agency. The difference in how rates are developed for IMMT is due to the use of existing rate setting methodologies for services similar to IMMT. An SCL provider will use the same rate setting methodology for IMMT as it does for SCL 15- minutes units since the service costs for both SCL and IMMT are the same or very similar. IMMT provided by a home health agency will use the same rate setting methodology used for a home health aide as they would be the same or similar cost for providing IMMT. CDAC (Skilled and Unskilled) are reimbursed on the basis of the agreement of the member and the provider with an upper payment limit established by the State.

For services that the participant self-directs (CCO), the member negotiates a rate with the entity providing services, goods, and supports.

For the FMS and ISB services, the IME sets the upper rate limit for those services as established in IAC 441-79.1(2). Respite provided by home health agencies use the maximum Medicare rate converted to a fifteen-minute unit.

Home health and nursing Services are based on a fee schedule as determined by Medicare.

For transportation, the rate is fee schedule. Providers are paid at the provider’s rate, not to exceed the upper rate limit at 441 IAC 79.1(2).

Prevocational service rates are fee schedules.

For payments made to FFS by the IME: Providers are informed of the process for billing and payment through Medicaid through annual provider training, IME info bulletins, and the IME provider manual. The Provider billing manual is also available on the Iowa DHS website at: http://dhs.iowa.gov/policy-manuals/medicaid-provider.

For payments made by an MCO: Providers are informed about the process for billing and payment through the annual provider training, IME informational bulletins, and the MCO provider manual and related materials. MCO provider materials are available through each MCO portal.

CCO Employment Agreement form 470-4427 Item 13: The employee will sign and submit a bi-weekly accurate time sheet of all services rendered including the type of service rendered, the date, and the number of service hours delivered. Time sheets must be signed by both the employer and employee. The employee acknowledges that the employee is responsible for submitting time sheets to the FMS within five business days from the end of the payroll cycle. Time sheets received after five business days will be paid with the next payroll cycle. Time sheets received after 30 days of the last day of service provided will not be paid.

441 IAC 79.1 sets forth the principles governing reimbursement of providers of medical and health services. Specifically, “[t]he basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule. Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the member.

Reimbursement types are described at 441 IAC 79.1(1).

Payment for items with no Medicare fee, Medicaid fee, average wholesale price, or manufacturer’s suggested retail price shall be made at the dealer’s cost plus 10 percent. The actual invoice for the item from the manufacturer must be submitted with the claim. Catalog pages or printouts supplied by the provider are not considered invoices. For selected medical services, supplies, and equipment, including equipment servicing, that generally do not vary significantly in quality from one provider to another, the payment shall be the lowest price for which such devices are widely and consistently available in a locality. Payment for used equipment shall not exceed 80 percent of the purchase allowance. No allowance shall be made for delivery, freight, postage, or other the CDAC and CCO services were set in accordance with 441 IAC 79.1(1)c.

Setting the capitation rates with the MCOs is the responsibility of the IME Managed Care Unit. MCO capitation rate development methodologies are described in the §1915(b) waiver and associated materials.

Iowa Waiver# IA.4155.R06.00 

IA HCBS Elderly Waiver

Waiver Name:
IA HCBS Elderly Waiver
Effective Date:
10/1/2018
Expiration Date:
9/30/2023

Services

List of Services for Iowa Waiver# IA.4155.R06.00

Cost Neutrality

Cost Neutrality for Iowa Waiver# IA.4155.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
10237 10653

Year 1 Waiver Services

List of Year 1 Waiver Services for Iowa Waiver# IA.4155.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
SD Community Support and Employment month 353 12 $55.41

Year 5 Waiver Services

List of Year 5 Waiver Services for Iowa Waiver# IA.4155.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
SD Community Support and Employment month 369 12 $57.66

Rate Determination Methods

Rate Determination Methods for Iowa Waiver# IA.4155.R06.00

The following are reimbursed by fee schedules: (1) assisted living; (2) chore services; (3) personal emergency response or portable locator system; (4) nutritional counseling; (5) homemaker; (6) adult day health; (7) home delivered meals; (8) mental health outreach; (9) assistive devices; (10) senior companion; (11) respite (unless detailed otherwise below); and home and vehicle modification.

-Home Health Aide, Nursing Services, and Respite provided by home health agencies are based on a Medicare Low Utilization Payment Adjustment (LUPA)rates with state geographic wage adjustments less a budget-neutrality factor maintain Medical Assistance expenditures within the amounts appropriated by the Iowa General Assembly.

- Consumer directed attendant care services are reimbursed based on the agreement of the member and the provider.

- Case management services shall be reimbursed on the basis of a payment rate for a 15-minute unit of service based on reasonable and proper costs for service provision. Response: Providers are reimbursed throughout each fiscal year on the basis of a projected unit rate for each participating provider. The projected rate is based on reasonable and proper costs of operation, pursuant to federally accepted reimbursement principles (generally Medicare or OMB A-87 principles).

The methodology for determining the reasonable and proper cost for service provision for case management assumes the following:

1. The indirect administrative costs shall be limited to 23 percent of other costs. Other costs include: professional staff – direct salaries, other – direct salaries, benefits and payroll taxes associated with direct salaries, mileage and automobile rental, agency vehicle expense, automobile insurance, and other related transportation.

2. Mileage shall be reimbursed at a rate no greater than the state employee rate.

3. The rates a provider may charge are subject to limits established at 79.1(2).

4. Costs of operation shall include only those costs that pertain to the provision of services which are authorized under rule 441—90.3(249A).

-The upper rate limit for transportation is the median nonemergency medical transportation contract rate paid per mile or per trip within the member’s DHS region.

For services that the member self-directs through the Consumer Choices Option (i.e., self-directed personal attendant care, individualized directed goods and services, and self-directed community support and employment), the member negotiates a rate with the entity providing services, goods, and supports. The Financial Management Service and the Individualized Service Budget supports of CCO are reimbursed by a fee schedule that sets an upper limit for those services.

441 Iowa Administrative Code 79.1 sets forth the principles governing reimbursement of providers of medical and health services. Specifically, “[t]he basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule. Generally, institutional types of providers such as hospitals and nursing facilities are reimbursed on a cost-related basis, and practitioners such as physicians, dentists, optometrists, and similar providers are reimbursed on the basis of a fee schedule. Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the member. Reimbursement types are described at 441 Iowa Administrative Code 79.1(1):

c. Fee schedules. Fees for the various procedures involved are determined by the department with advice and consultation from the appropriate professional group.

The fees are intended to reflect the amount of resources (time, training, experience) involved in each procedure. Individual adjustments will be made periodically to correct any inequity or to add new procedures or eliminate or modify others. If product cost is involved in addition to service, reimbursement is based either on a fixed fee, wholesale cost, or on actual acquisition cost of the product to the provider, or product cost is included as part of the fee schedule. Providers on fee schedules are reimbursed the lower of:

(1) The actual charge made by the provider of service.

(2) The maximum allowance under the fee schedule for the item of service in question.

Fee schedules in effect for the providers covered by fee schedules can be obtained from the department’s Web site at: http://dhs.iowa.gov/ime/providers/csrp/fee-schedule. All provider rates are part of Iowa Administrative Code and are subject to public comment any time there is change. Rate determination methods are set forth in Iowa Administrative Code and subject to the State’s Administrative Procedures Act, which requires a minimum twenty-day public comment period. A public hearing by the state agency to take comments is not required unless at least twenty-five persons demand a hearing, though Agency’s often schedule a public hearing regardless of the number of comments received. The state agency may revise a rule in response to comments received but is not required to do so. This information is on the website as well as distributed to stakeholders when there is a change. Legislators consider constituent input and volume regarding the sufficiency of the rates balanced with budgetary allowances. If there are changes in rates, methods or standards for payment rates, then that information would be part of the rules change that would be included in public notice.

The rate methodology for each service would have been first set when that particular service was first available under any of the seven HCBS waivers. A change to the rate for any service is done at the direction of the Iowa legislature. This year the legislature has directed the state to review all current Medicaid fee schedules and submit a report to the governor and legislature regarding how the current rates compare to the Medicare fee schedule or other appropriate reimbursement methodologies for specific services. The report will include a plan for phased-in implementation of any changes.

Managed Care was implemented in April 2016. MCO capitation rate development methodologies are described in the

§1915(b) waiver and associated materials. MCO rates are blended between fee-for-service and managed care capitated payments based on the anticipated percentage of unduplicated participants per delivery system.

Iowa Waiver# IA.0345.R04.00 

IA HCBS Waiver for Persons w/Physical Disabilities

Waiver Name:
IA HCBS Waiver for Persons w/Physical Disabilities
Effective Date:
11/1/2017
Expiration Date:
10/31/2022

Services

List of Services for Iowa Waiver# IA.0345.R04.00

Cost Neutrality

Cost Neutrality for Iowa Waiver# IA.0345.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1492 1615

Year 1 Waiver Services

List of Year 1 Waiver Services for Iowa Waiver# IA.0345.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Self Directed Community Support and Employment hour 59 134.9 $14.96

Year 5 Waiver Services

List of Year 5 Waiver Services for Iowa Waiver# IA.0345.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Self Directed Community Support and Employment hour 64 134.9 $15.90

Rate Determination Methods

Rate Determination Methods for Iowa Waiver# IA.0345.R04.00

Personal emergency response, home and vehicle modification, specialized medical equipment and transportation are reimbursed by fee schedules.

Consumer Directed Attendant Care Services (Skilled and Unskilled) are reimbursed on the basis of the agreement of the member and the provider. The rate is agreed upon between the provider and member not to exceed the upper limit.

The personal emergency response and locator service fee schedule upper rate limit was set at the national average price paid for the equipment installation and ongoing monthly maintenance. Providers are paid their installation fee and monthly maintenance fee not to exceed the upper rate limit established in rule.

The home and vehicle modifications and specialized medical equipment is based on payment made on the amount authorized by the department through a quotation, contract, or invoice submitted by the provider.

For transportation, the fee schedule is based on a county contract rate for transportation or the median Medicaid established non-emergency transportation rate paid per mile or per trip within the member's DHS region. The transportation county rate is set based on the usual and customary transportation rate in the community (including rural and urban).

For services and items that are furnished under Part B of Medicare, the fee shall be the lowest charge allowed under Medicare. Payment for supplies with no established Medicare fee shall be at the average wholesale price for the item less 10 percent.

For services and items that are furnished only under Medicaid, the fee shall be the lowest charge determined by the department according to the Medicare reimbursement method described in section 1834(a) of the Social Security Act (42

U.S.C. 1395m), payment for durable medical equipment.

Payment for items with no Medicare fee, Medicaid fee, or average wholesale price shall be made at the manufacturer’s suggested retail price less 15 percent.

Payment for items with no Medicare fee, Medicaid fee, average wholesale price, or manufacturer’s suggested retail price shall be made at the dealer’s cost plus 10 percent. The actual invoice for the item from the manufacturer must be submitted with the claim. Catalog pages or printouts supplied by the provider are not considered invoices.

For selected medical services, supplies, and equipment, including equipment servicing, that generally do not vary significantly in quality from one provider to another, the payment shall be the lowest price for which such devices are widely and consistently available in a locality.

Payment for used equipment shall not exceed 80 percent of the purchase allowance.

No allowance shall be made for delivery, freight, postage, or other the CDAC and CCO services were set in accordance with 441 Iowa Administrative Code 79.1(1):c.

CCO:

For the consumer choices option service rates, the department computes the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality. Respite and home and vehicle modification services are not subject to the utilization adjustment.

For services that the member self-directs through the Consumer Choices Option (i.e., self-directed personal attendant care, individualized directed goods and services, and self-directed community support and employment), the member negotiates a rate with the entity providing services, goods, and supports. The Financial Management Service and the Individualized Supports Broker through CCO are reimbursed by a fee schedule that sets an upper limit for those services. The rate is agreed upon between the provider and member not to exceed the upper limit.

Overview

441 Iowa Administrative Code 79.1 sets forth the principles governing reimbursement of providers of medical and health services. Specifically, “[t]he basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule. Generally, institutional types of providers such as hospitals and nursing facilities are reimbursed on a cost-related basis, and practitioners such as physicians, dentists, optometrists, and similar providers are reimbursed on the basis of a fee schedule. Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the member. Reimbursement types are described at 441 Iowa Administrative Code 79.1(1):

Fee schedules. Fees for the various procedures involved are determined by the department with advice and consultation from the appropriate professional group. The fees are intended to reflect the amount of resources (time, training, experience) involved in each procedure. Individual adjustments will be made periodically to correct any inequity or to add new procedures or eliminate or modify others.

If product cost is involved in addition to service, reimbursement is based either on a fixed fee, wholesale cost, or on actual acquisition cost of the product to the provider, or product cost is included as part of the fee schedule. Providers on fee schedules are reimbursed the lower of:

(1) The actual charge made by the provider of service.

(2) The maximum allowance under the fee schedule for the item of service in question.

Fee schedules in effect for the providers covered by fee schedules can be obtained from the department’s Web site at: http://dhs.iowa.gov/ime/providers/csrp/fee-schedule.

All provider rates are part of Iowa Administrative Code and are subject to public comment any time there is change. Rate determination methods are set forth in Iowa Administrative Code and subject to the State’s Administrative Procedures Act, which requires a minimum twenty-day public comment period. A public hearing by the state agency to take comments is not required unless at least twenty-five persons demand a hearing, though Agency’s often schedule a public hearing regardless of the number of comments received. The state agency may revise a rule in response to comments received but is not required to do so. This information is on the website as well as distributed to stakeholders when there is a change. Legislators consider constituent input and volume regarding the sufficiency of the rates balanced with budgetary allowances.

Fee for Service provider billing manuals are located at https://dhs.iowa.gov/ime/providers/rulesandpolicies. Waiver service fee schedule upper payment rates are located in the Iowa Administrative Code at https://dhs.iowa.gov/ime/providers/rulesandpolicies, Chapter 79.

A change to the rate for any service is done at the direction of the Iowa legislature. This year (2018) the legislature has directed the state to review all current Medicaid fee schedules and submit a report to the governor and legislature regarding how the current rates compare to the Medicare fee schedule or other appropriate reimbursement methodologies for specific services. The report will include a plan for phased-in implementation of any changes.

MCO:

MCO capitation rate development methodologies are described in the §1915(b) waiver and associated materials. The average cost per unit is illustrated as a combination of that assumed previously for the fee-for-service population blended with the applicable portion of the year at the assumed managed care unit cost rates. The cost per unit for services delivered under managed care were developed as the fee-for-service cost per unit amounts grossed up to reflect total capitation payment reimbursement representing the average LTSS blended capitation rate for the rate cells. Non- contract providers would be responsible for submitting claims to the MCO. The MCO would then reimburse the provider at a rate consistent with the MCO’s contract with the State. Non-contract providers would be responsible for submitting claims to the MCO. The MCO would then reimburse the provider at a rate consistent with the MCO’s contract with the State.

Information for billing and payment:

• For payments made by the IME: Providers are informed about the process for billing and payment through Medicaid through annual provider training, IME informational bulletins, and the IME provider manual. When a provider has been enrolled as a Medicaid provider, IME Provider Services mails the provider an enrollment packet that includes how the provider can bill Medicaid directly. The Provider billing manual is also available on the Iowa DHS website at: http://dhs.iowa.gov/policy-manuals/medicaid-provider.

• For payments made by an MCO: Providers are informed about the process for billing and payment through the annual provider training, IME informational bulletins, and the MCO provider manual and related materials. MCO provider materials are available through each MCO portal.

• CCO Time Sheet form 470-4429: All time recorded on the time sheets needs to be documented to the nearest quarter hour. Time sheets must be received by the Financial Management Service within 30 days of the last day of service provided. Time sheets must be submitted by the 7th/22nd days of the month to be paid by the 15th/last day of the month.

• CCO Employment Agreement form 470-4427 Item 13: The employee will sign and submit to the employer, or the guardian or designated personal representative, a bi-weekly accurate time sheet of all services rendered including the type of service rendered, the date, and the number of service hours delivered (to the nearest quarter hour). Time sheets must be signed by both the employer and employee (or the guardian or designated personal representative). The employee acknowledges that the employee is responsible for submitting time sheets to the FMS within five business days from the end of the payroll cycle. Time sheets received after five business days will be paid with the next payroll cycle. Time sheets received after 30 days of the last day of service provided will not be paid.

Iowa Waiver# IA.0299.R05.00 

IA Home and Community Based Services - Brain Injury

Waiver Name:
IA Home and Community Based Services - Brain Injury
Effective Date:
10/1/2019
Expiration Date:
9/30/2024

Services

List of Services for Iowa Waiver# IA.0299.R05.00

Cost Neutrality

Cost Neutrality for Iowa Waiver# IA.0299.R05.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1560 1747

Year 1 Waiver Services

List of Year 1 Waiver Services for Iowa Waiver# IA.0299.R05.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Service, Hour hour 46 482 $12.23
Prevocational services, Career Exploration, hour hour 22 482 $12.23
FFS Prevocational Service, Hour hour 6 482 $12.23
FFS Prevocational services, Career Exploration, Hour hour 3 482 $12.23
Small Group Supported Employment 15 Minutes 15 minutes 30 2040 $2.00
Individual Supported Employment Hour hour 68 12 $581.60
Long Term Job Coaching - Monthly month 96 62.75 $70.28
Long Term Job Coaching Hour hour 18 60 $69.02
FFS Small Group Supported Employment 15 Minutes 15 minutes 0 2040 $2.00
FFS Individual Supported Employment hour hour 1 12 $581.60
FFS Long Term Job Coaching - Monthly month 12 62.75 $70.28
FFS Long Term Job Coaching Hour
Self-Directed Community Support and Employment month 2 9.2 $491.60
FFS Self Directed Community Support and Employment month 360 9.2 $491.60

Year 5 Waiver Services

List of Year 5 Waiver Services for Iowa Waiver# IA.0299.R05.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Service, Hour hour 50 482 $13.24
Prevocational services, Career Exploration, hour hour 24 482 $13.24
FFS Prevocational Service, Hour hour 6 482 $13.24
FFS Prevocational services, Career Exploration, Hour hour 3 482 $13.24
Small Group Supported Employment 15 Minutes 15 minutes 31 2040 $2.16
Individual Supported Employment Hour hour 74 12 $629.54
Long Term Job Coaching - Monthly month 120 62.75 $76.08
Long Term Job Coaching Hour hour 19 60 $74.71
FFS Small Group Supported Employment 15 Minutes 15 minutes 1 2040 $2.16
FFS Individual Supported Employment hour hour 1 12 $629.54
FFS Long Term Job Coaching - Monthly month 12 62.75 $76.08
FFS Long Term Job Coaching Hour hour 0 60 $74.71
Self-Directed Community Support and Employment month 2 9.2 $532.12
FFS Self Directed Community Support and Employment month 390 9.2 $532.12

Rate Determination Methods

Rate Determination Methods for Iowa Waiver# IA.0299.R05.00

441 Iowa Administrative Code (IAC) 79.1 sets forth the principles governing reimbursement of providers of medical and health services. Specifically, “[t]he basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule.

Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the member. Reimbursement types are described at 441 IAC 79.1(1), located here: http://dhs.iowa.gov/sites/default/files/441-79.pdf.

Fee schedule rates and upper rate limits are located at 441 IAC Chapter 79 and can be found online at: https://www.legis.iowa.gov/docs/ACO/chapter/441.79.pdf and specific fee schedules are located on the IME Fee Schedule webpage: https://dhs.iowa.gov/ime/providers/csrp/fee-schedule

Supported community living rates are based on a retrospectively limited prospective rate configured the IME's rate setting unit in coordination with the provider.

Retrospectively limited prospective rates. Providers are reimbursed on the basis of a rate for a unit of service calculated prospectively for each participating provider (and, for supported community living daily rates, for each consumer or site) based on projected or historical costs of operation subject to the maximums listed in subrule 79.1(2) and to retrospective adjustment pursuant to subparagraph 79.1(1)“e”(3).

(1) The prospective rates for new providers who have not submitted six months of cost reports will be based on a projection of the provider’s reasonable and proper costs of operation until the provider has submitted an annual cost report that includes a minimum of six months of actual costs.

(2) The prospective rates paid established providers who have submitted an annual report with a minimum of a six-month history are based on reasonable and proper costs in a base period and are adjusted annually for inflation.

(3) The prospective rates paid to both new and established providers are subject to the maximums listed in subrule 79.1(2) and to retrospective adjustment based on the provider’s actual, current costs of operation as shown by financial and statistical reports submitted by the provider. If a BI Waiver provider’s payments for Medicaid-covered services exceed the actual Medicaid costs for services adjusted for the legislative inflation percentage, the Department will recoup the overpayment by requiring the BI Waiver provider will return an amount equal to the overpayment to the Iowa Medicaid Enterprise, and the IME will make an offsetting adjustment to the CMS-64

PERS, behavior programming, family counseling and training, adult day care, case management, prevocational service, supported employment, respite, specialized medical equipment, HVM, transportation and FMS are reimbursed by fee schedules.

Respite provided by home health agencies is based on the provider’s rate in effect 6/30/16 plus 1%, converted to a 15 minute rate. If no 6/30/16 rate: Lesser of maximum Medicare rate in effect 6/30/16 plus 1%, converted to a 15 minute rate or maximum Medicaid rate in effect 6/30/16 plus 1% converted to a 15 minute rate. Variations in fee schedule rates for Respite services are based on the type of provider delivering the respite services

CDAC (Skilled and Unskilled) are reimbursed on the basis of the agreement of the member and the provider. CDAC reimbursement is subject to the upper rate limit in IAC. These upper rate limits are coded into ISIS so it cannot be exceeded within a member’s service plan. FFS claims are paid based on an approved service plan in ISIS.

For services that the participant self-directs (i.e. self-directed personal attendant care, individualized directed goods and services, and self-directed community support and employment)the participant negotiates a rate for the entity providing services, goods, and supports.

The rate setting process is detailed in Appendix E-1-a. The services that may be included in a CCO budget for the BI waiver includes:

• CDAC unskilled

• Adult Day Care

• Home and vehicle modification

• Prevocational services

• Basic individual respite care

• Supported community living

• Supported employment

• Transportation

The Independent Support Broker is reimbursed at a rate negotiated between the member and the ISB not to exceed the upper rate limit in rule. The Financial Management Service (FMS) is reimbursed based on fee schedule rate not to exceed the upper rate limit allowed n rule.

A utilization adjustment factor is used to adjust the CCO budget to reflect statewide average cost and usage of waiver services. Annually, the Department determines the average cost for each waiver service. The average service cost is used to determine the “cap amount” of the CCO budget. The cap amount is used to ensure the participant stays within the program dollar cap limits within each waiver. The department also determines the percentage of services that are used, compared to what is authorized within a waiver service plan. This percentage is applied to the cap amount to determine the CCO “budget amount”. The budget amount is the total funds available to the participant in the monthly CCO budget. This UAF includes all HCBS waiver participants in the calculation, not just individuals participating in CCO.

The participant may choose to set aside a certain amount of the budget each month to save towards purchasing additional goods or services they cannot buy from the normal monthly budget. A savings plan must be developed by the participant, and approved by DHS prior to implementation. The good or service being saved for must be an assessed need identified in the participant’s service plan.

For transportation, the rate is fee schedule based average rate paid to all NEMT contracted providers within the Mental Health Disability Services (MHDS) region in which the member resides.

IMMT rates are established two ways and is based on the enrollment type of the IMMT provider. IMMT services provided by a supported community living provider is a retrospectively limited prospective rate as noted for SCL provided in 15 minute units above. IMMT provided by a home health agency is a cost based rate for home health aide services provided by a home health agency. The difference in how rates are developed for IMMT is due to the use of existing rate setting methodologies for services similar to IMMT. An SCL provider will use the same rate setting methodology for IMMT as it does for SCL 15 minute units since the service costs for both SCL and IMMT are the same or very similar. The IME utilizes claim system edits to prevent payment to the SCL/IMMT providers for IMMT and daily SCL on the same date of service. The department uses different Healthcare common procedure codes and level II modifiers to distinguish the IMMT service rendered by a daily SCL provider and the daily SCL service rendered by the same provider. IMMT provided by a home health agency will use the same rate setting methodology used for a home health aide as they would be the same or similar cost for providing IMMT.

For services and items that are furnished under Part B of Medicare, the fee shall be the lowest charge allowed under Medicare. For services and items that are furnished only under Medicaid, the fee shall be the lowest charge determined by the department according to the Medicare reimbursement method described in section 1834(a) of the Social Security Act (42 U.S.C. 1395m), payment for durable medical equipment. Payment for supplies with no established Medicare fee shall be at the average wholesale price for the item less 10 percent. Payment for items with no Medicare fee, Medicaid fee, or average wholesale price shall be made at the manufacturer’s suggested retail price less 15 percent.

Payment for items with no Medicare fee, Medicaid fee, average wholesale price, or manufacturer’s suggested retail price shall be made at the dealer’s cost plus 10 percent. For selected medical services, supplies, and equipment, including equipment servicing, that generally do not vary significantly in quality from one provider to another, the payment shall be the lowest price for which such devices are widely and consistently available in a locality. Payment for used equipment shall not exceed 80 percent of the purchase allowance. No allowance shall be made for delivery, freight, postage, or other the CDAC and CCO services were set in accordance with 441 IAC 79.1(1):c.

When fee schedules are first established for a service, fee schedules are determined by the department with advice and consultation from the appropriate professional groups. For example, when the prevocational and supported employment rates (fee schedule) were being developed, a provider stakeholder group was established and worked with the Department for over two years in the rate development.

Individual service rate adjustments are made periodically to correct any rate inequity. With the BI waiver, this is a legislative appropriation process through provider association and individual providers lobbying efforts. A change to the rate for any service is done at the direction of the IA Legislature. When the department reviews reimbursement levels for adequacy; historical experience, current reimbursement levels, experiences in other states, and network adequacy are considered. During the past 10 years the legislature has approved a 1% and 2% across the board rate increases for HCBS waiver service providers. The most recent rate adjustment approved by the legislature occurred July 1, 2016 when all HCBS service rates were increased by 1%. The legislature can direct IME to increase or decreased provider rates through a legislative mandate. If so, then IME changes the IAC accordingly. All provider rates are part of the IAC and are subject to public comment any time there is change. This information is on the website as well as distributed to stakeholders when there is a change. Rate determination methods are set forth in IAC and subject to the State’s Administrative Procedures Act, which requires a minimum twenty-day public comment period. A public hearing by the state agency to take comments is not required unless at least twenty-five persons demand a hearing, though Agency’s often schedule a public hearing regardless of the number of comments received. The state agency may revise a rule in response to comments received but is not required to do so. At the time of service plan development, the case manager shares with the members the rates of the providers, and the member can chose a provider based on their rates. When a service is authorized in a participant’s comprehensive services plan, the providers of services receive a Notice of Decision which indicates the participant’s name, provider’s name, service to be provided, the dates of service to be provided, units of service authorized, and reimbursement rate for the service.

The state is currently reviewing all Medicaid fee schedules and will submit a report to the governor and legislature regarding how the current rates compare to the Medicare fee schedule or other appropriate reimbursement methodologies for specific services. The report will include a plan for phased-in implementation of any changes. MCO capitation rate development methodologies are described in the §1915(b) waiver and associated materials.

The services under the Brain Injury waiver are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

Iowa Waiver# IA.4111.R07.00 

Iowa HCBS Health and Disability Waiver

Waiver Name:
Iowa HCBS Health and Disability Waiver
Effective Date:
11/1/2017
Expiration Date:
10/31/2022

Services

List of Services for Iowa Waiver# IA.4111.R07.00

Cost Neutrality

Cost Neutrality for Iowa Waiver# IA.4111.R07.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
3410 3619

Year 1 Waiver Services

List of Year 1 Waiver Services for Iowa Waiver# IA.4111.R07.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Self-Directed Community Support and Employment monthly 407 12 $262.91

Year 5 Waiver Services

List of Year 5 Waiver Services for Iowa Waiver# IA.4111.R07.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Self-Directed Community Support and Employment monthly 441 12 $284.58

Rate Determination Methods

Rate Determination Methods for Iowa Waiver# IA.4111.R07.00

Fee schedules. Fees for the various procedures involved are determined by the department with advice and consultation from the appropriate professional group. The fees are intended to reflect the amount of resources (time, training, and experience) involved in each procedure. Following are the rate setting models used for the fee schedule services listed below:

o Adult Day Services – The rate is the Veterans Administration (VA) contacted rate. In the absence of a VA rate, the reimbursement is the lower of the billed amount or the upper payment limit defined in Iowa Administrative Code.

o Counseling – The rate for Individual counseling is lower of billed amount or the upper payment limit defined in Iowa Administrative Code; Group counseling is lower of billed amount or the upper payment limit defined in Iowa Administrative Code divided by 6 or more persons.

o Home Delivered Meals – The rate is the lower of billed amount or the upper payment limit defined in Iowa Administrative Code, not to exceed 14 meals per week.

o Home Health Aide – The rate is the lower of billed amount or the upper payment limit defined in Iowa Administrative Code.

o Homemaker – The rate is the lower of billed amount or the upper payment limit defined in Iowa Administrative Code.

o Nursing – The rate is the lower of billed amount or the upper payment limit defined in Iowa Administrative Code.

o Nutritional Counseling – The rate is the county contracted rate. In the absence of a county contracted rate, lower of billed amount or the upper payment limit defined in Iowa Administrative Code.

o Respite – The rate is the lower of billed amount or the upper payment limit defined in Iowa Administrative Code.

Consumer Directed Attendant Care Services (Skilled and Unskilled) are reimbursed on the basis of the agreement of the member and the provider.

- Home Health Aide and Nursing Services are based on a Medicare Low Utilization Payment Adjustment (LUPA) rates with state geographic wage adjustments less a budget-neutrality factor maintain Medical Assistance expenditures within the amounts appropriated by the Iowa General Assembly.

- Interim medical monitoring and treatment service rates are a cost based rate based on EPSDT private duty nursing and personal cares services provided by a home health agency. The Iowa Medicaid Enterprise, through the provider auditing and rate setting unit, is responsible for rate setting.

The personal emergency response and locator service fee schedule upper rate limit was set at the national average price paid for the equipment installation and ongoing monthly maintenance. Providers are paid their installation fee and monthly maintenance fee not to exceed the upper rate limit established in rule.

The home and vehicle modifications and specialized medical equipment is based on payment made on the amount authorized by the department through a quotation, contract, or invoice submitted by the provider.

For services and items that are furnished under Part B of Medicare, the fee shall be the lowest charge allowed under Medicare.

For services and items that are furnished only under Medicaid, the fee shall be the lowest charge determined by the department according to the Medicare reimbursement method described in section 1834(a) of the Social Security Act (42 U.S.C. 1395m), payment for durable medical equipment.

Payment for supplies with no established Medicare fee shall be at the average wholesale price for the item less 10 percent.

Payment for items with no Medicare fee, Medicaid fee, or average wholesale price shall be made at the manufacturer’s suggested retail price less 15 percent.

Payment for items with no Medicare fee, Medicaid fee, average wholesale price, or manufacturer’s suggested retail price shall be made at the dealer’s cost plus 10 percent. The actual invoice for the item from the manufacturer must be submitted with the claim. Catalog pages or printouts supplied by the provider are not considered invoices.

For selected medical services, supplies, and equipment, including equipment servicing, that generally do not vary significantly in quality from one provider to another, the payment shall be the lowest price for which such devices are widely and consistently available in a locality.

Payment for used equipment shall not exceed 80 percent of the purchase allowance.

No allowance shall be made for delivery, freight, postage, or other the CDAC and CCO services were set in accordance with 441 Iowa Administrative Code 79.1(1):c.

CCO:

For the consumer choices option service rates, the department computes the utilization adjustment factor for each service by dividing the net costs of all claims paid for the service by the total of the authorized costs for that service, using at least 12 consecutive months of aggregate service data. The utilization adjustment factor shall be no lower than 60 percent. The department shall analyze and adjust the utilization adjustment factor at least annually in order to maintain cost neutrality. Respite and home and vehicle modification services are not subject to the utilization adjustment.

For services that the member self-directs through the Consumer Choices Option (i.e., self-directed personal attendant care, individualized directed goods and services, and self-directed community support and employment), the member negotiates a rate with the entity providing services, goods, and supports. The Financial Management Service and the Individualized Service Budget supports of CCO are reimbursed by a fee schedule that sets an upper limit for those services.

Overview

441 Iowa Administrative Code 79.1 sets forth the principles governing reimbursement of providers of medical and health services. Specifically, “[t]he basis of payment for services rendered by providers of services participating in the medical assistance program is either a system based on the provider’s allowable costs of operation or a fee schedule. Generally, institutional types of providers such as hospitals and nursing facilities are reimbursed on a cost-related basis, and practitioners such as physicians, dentists, optometrists, and similar providers are reimbursed on the basis of a fee schedule. Providers of service must accept reimbursement based upon the department’s methodology without making any additional charge to the member. Reimbursement types are described at 441 Iowa Administrative Code 79.1(1):

Fee schedules. Fees for the various procedures involved are determined by the department with advice and consultation from the appropriate professional group. The fees are intended to reflect the amount of resources (time, training, experience) involved in each procedure. Individual adjustments will be made periodically to correct any inequity or to add new procedures or eliminate or modify others. If product cost is involved in addition to service, reimbursement is based either on a fixed fee, wholesale cost, or on actual acquisition cost of the product to the provider, or product cost is included as part of the fee schedule. Providers on fee schedules are reimbursed the lower of:

(1) The actual charge made by the provider of service.

(2) The maximum allowance under the fee schedule for the item of service in question.

Fee schedules in effect for the providers covered by fee schedules can be obtained from the department’s Web site at: http://dhs.iowa.gov/ime/providers/csrp/fee-schedule. All provider rates are part of Iowa Administrative Code and are subject to public comment any time there is change. Rate determination methods are set forth in Iowa Administrative Code and subject to the State’s Administrative Procedures Act, which requires a minimum twenty-day public comment period. A public hearing by the state agency to take comments is not required unless at least twenty-five persons demand a hearing, though Agency’s often schedule a public hearing regardless of the number of comments received. The state agency may revise a rule in response to comments received but is not required to do so. This information is on the website as well as distributed to stakeholders when there is a change. Legislators consider constituent input and volume regarding the sufficiency of the rates balanced with budgetary allowances.

MCO:

MCO capitation rate development methodologies are described in the §1915(b) waiver and associated materials. To estimate the fee-for-service population in Waiver Year 4, the State assumed that the same number of unique individuals would receive services for the waiver year, although the payment basis will be blended between fee-for-service and managed care based on the waiver effective date and managed care implementation date. As such, the average cost per unit is illustrated as a combination of that assumed previously for the fee-for-service population blended with the applicable portion of the year at the assumed managed care unit cost rates. The cost per unit for services delivered under managed care were developed as the fee-for-service cost per unit amounts grossed up to reflect total capitation payment reimbursement representing the average LTSS blended capitation rate for the rate cells. Non-contract providers would be responsible for submitting claims to the MCO. The MCO would then reimburse the provider at a rate consistent with the MCO’s contract with the State. Non-contract providers would be responsible for submitting claims to the MCO. The MCO would then reimburse the provider at a rate consistent with the MCO’s contract with the State.

Kansas Waiver# KS.0224.R06.00 

KS HCBS-I/DD Waiver

Waiver Name:
KS HCBS-I/DD Waiver
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Kansas Waiver# KS.0224.R06.00

Cost Neutrality

Cost Neutrality for Kansas Waiver# KS.0224.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
9491 9491

Year 1 Waiver Services

List of Year 1 Waiver Services for Kansas Waiver# KS.0224.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports 15 minutes 6725 4401.33 $3.79
Supported Employment 15 minutes 54 531.5 $3.25

Year 5 Waiver Services

List of Year 5 Waiver Services for Kansas Waiver# KS.0224.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports 15 minutes 6725 4401.33 $3.79
Supported Employment 15 minutes 54 531.5 $3.25

Rate Determination Methods

Rate Determination Methods for Kansas Waiver# KS.0224.R06.00

These measures and collection/reporting protocols, together with others that are part of the KanCare MCO contract, are included in a statewide comprehensive KanCare quality improvement strategy which is regularly reviewed and adjusted. That plan is contributed to and monitored through state interagency monitoring, which includes program managers, contract managers, fiscal staff and other relevant staff/resources from both the state Medicaid agency and the state operating agency. State staff request, approve, and assure implementation of contractor corrective action planning and/or technical assistance to address non-compliance with performance standards as detected through on-site monitoring, survey results and other performance monitoring. These processes are monitored by both contract managers and other relevant state staff, depending upon the type of issue involved, and results tracked consistent with the statewide quality improvement strategy and the operating protocols of interagency monitoring.

K.S.A. 39-1801 et.al, aka The Developmental Disabilities Reform Act (DDRA) mandates the establishment of a system of funding, quality assurance and contracting. Further, the statute requires an independent, professional review of the rate structures on a biennial basis resulting in a recommendation to the legislature regarding rate adjustments.

The recommendation shall be adequate to support:

A) A system of employee compensation competitive with local conditions,

B) training and technical support to attract and retain qualified employees,

C) a quality assurance process which is responsive to consumer's needs and which maintains the standards of quality service. The State Medicaid agency solicits public comments regarding the rate determination methods through publication in the Kansas

Public Register. This rate determination method is used for all IDD services regardless of whether the service is reimbursed through a tiered rate or a single rate.

Throughout the history of the Kansas IDD waiver, Kansas has used tiered rates to reimburse providers of many waiver services including day and residential supports. The initial rates were developed based on the recommendations of an actuarial contracted with by the State.

In 1995, the Kansas Legislature passed the Developmental Disabilities Reform Act (DDRA). Among other things, as stated above, the Act requires KDADS to conduct biennial rate studies. A requirement of the study is to make recommendations to the Kansas Legislature regarding the adequacy of reimbursement rates.

Based on the results of these rate studies, the Kansas Legislature, in the past, has appropriated money to the Department For Aging and Disability Services for the specific purpose of adjusting reimbursement rates.

A sheet that includes all rates for all waiver services is available to providers and participants upon request.

Under the KanCare comprehensive managed care program, capitation rates are established consistent with federal regulation requirements, by actuarially sound methods, which take into account utilization, medical expenditures, program changes and other relevant environmental and financial factors. The resulting rates are certified to and approved by CMS.

Under KanCare, the State sets the floor HCBS service rates which serve as the minimum MCOs are required to pay providers. These rates, as established by the State, are available on the KMAP website.

Capitation rates are based on actuarial analysis of historical data for all IDD program services. These rates are based on historical claims and carried forward for KanCare Managed Care. The MCO's are responsible for trending costs and demonstrating financial experience going forward. Based on the data collected, the MCO may request the State's review for cost adjustments.

Fee for Service

Certain populations have the ability to opt out of the Managed Care delivery system and receive services via fee-for- service (FFS). The FFS provider would be paid per the state’s fee schedule. The State is responsible for setting FFS rates. In managed care, the FFS rates are the minimum required to be paid by MCOs, but actual rates are negotiated by the provider through the contracting process.

Day Supports and Residential services FFS rates are set with tiered rates. All other IDD services are reimbursed by a single rate. The State Operating Agency, in coordination with the State Medicaid Agency, is responsible for FFS rate determination. The State ensures FFS rates are adequate by ensuring a provider network is available in the rare event there is an opt out from Managed Care. In the event, there are no FFS providers available due solely to the FFS rate, the state would make necessary adjustments to ensure providers are available. FFS rates can be found via State Bulletins via the State’s KMAP website.

The State ensures FFS rates are adequate by ensuring a provider network is available in the rare event there is an opt out from Managed Care. In the event, there are no FFS providers available due solely to the FFS rate, the state would make necessary adjustments to ensure providers are available. FFS rates can be found via State Bulletins via the State’s KMAP website. Waiver participants can obtain FFS rates by contacting the State Operating Agency directly.

The State understands that this section must be amended with a description of a public comment process compliant with the guidance as laid out in 42 CFR 447.205 if anyone enrolled in the waiver were to opt out of managed care

Kentucky Waiver# KY.0333.R04.00 

Acquired Brain Injury

Waiver Name:
Acquired Brain Injury
Effective Date:
1/1/2017
Expiration Date:
12/31/2021

Services

List of Services for Kentucky Waiver# KY.0333.R04.00

Cost Neutrality

Cost Neutrality for Kentucky Waiver# KY.0333.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
383 383

Year 1 Waiver Services

List of Year 1 Waiver Services for Kentucky Waiver# KY.0333.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Training 15 minutes 284 2320 $4.39
Supported Employment 15 minutes 2 27 $7.98

Year 5 Waiver Services

List of Year 5 Waiver Services for Kentucky Waiver# KY.0333.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Training 15 minutes 383 3256 $6.16
Supported Employment 15 minutes 3 27 $7.98

Rate Determination Methods

Rate Determination Methods for Kentucky Waiver# KY.0333.R04.00

Provider rates are established utilizing a fee-for-service system. The provider rates are being established based on other 1915(c) waiver programs with similar services and target populations as well as historical utilization. Provider rate setting is established in program regulations. All ordinary administrative regulations are subject to a public comment process during promulgation.

Kentucky Waiver# KY.0477.R02.00 

Acquired Brain Injury- Long Term Care

Waiver Name:
Acquired Brain Injury- Long Term Care
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for Kentucky Waiver# KY.0477.R02.00

Cost Neutrality

Cost Neutrality for Kentucky Waiver# KY.0477.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
400 400

Year 1 Waiver Services

List of Year 1 Waiver Services for Kentucky Waiver# KY.0477.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Training 15 minutes 169 3614.65 $3.97
Supported Employment 15 minutes 9 581.63 $7.95

Year 5 Waiver Services

List of Year 5 Waiver Services for Kentucky Waiver# KY.0477.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Training 15 minutes 257 3614.65 $3.97
Supported Employment 15 minutes 14 581.63 $7.95

Rate Determination Methods

Rate Determination Methods for Kentucky Waiver# KY.0477.R02.00

Provider rates are established utilizing a fee-for-service system. The provider rates are being established based on other 1915(c) waiver programs with similar services and target populations as well as historical utilization. Provider rate setting is established in program regulations. All ordinary administrative regulations are subject to a public comment process during promulgation.

Kentucky Waiver# KY.0475.R02.00 

KY Michelle P Waiver

Waiver Name:
KY Michelle P Waiver
Effective Date:
9/1/2017
Expiration Date:
8/31/2022

Services

List of Services for Kentucky Waiver# KY.0475.R02.00

Cost Neutrality

Cost Neutrality for Kentucky Waiver# KY.0475.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
10500 10500

Year 1 Waiver Services

List of Year 1 Waiver Services for Kentucky Waiver# KY.0475.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Access 15 minutes 1771 1902.85 $5.54
Day Training 15 minutes 1702 3436.02 $2.75
Supported Employment 15 minutes 321 163.63 $5.54

Year 5 Waiver Services

List of Year 5 Waiver Services for Kentucky Waiver# KY.0475.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Access 15 minutes 1992 1902.85 $5.54
Day Training 15 minutes 1916 3436.02 $2.75
Supported Employment 15 minutes 362 163.63 $5.54

Rate Determination Methods

Rate Determination Methods for Kentucky Waiver# KY.0475.R02.00

DMS works collaboratively with the operating agency to review historical usage and expenditures to develop the

proposed rate structure. All rates must be approved by DMS and are incorporated into Medicaid state regulations,

which are subject to public comment when promulgated or amended.

Paid claim data was reviewed for waiver participants for October 2010 through March 2011 which included total

units paid per service, total unduplicated users, total cost, and average units of service and average cost. Data was

trended forwarded using historical information, factoring in rate of growth. For new services, rates were established

based on rates paid for other services that require similar education and experience.

An Exceptional Supports Funding Protocol has been developed to provide extraordinary services to an individual

experiencing challenging medical, psychiatric or maladaptive behavioral issues. It is estimated that 8% of

individuals enrolled in the MPW waiver will have support needs beyond the normal reimbursement rate(s)typically

receiving prior authorization.

The process for an exceptional supports request requires providers to submit a person centered plan of care based

upon assessed needs as determined by Supports Intensity Scale (SIS) and Health Risk Screening Tool (HRST). The

providers do not request a specific exceptional support tier, but instead exceptional supports are authorized based on

specific information concerning the individual’s needs and the plans to address those needs. DDID management

staff must review and authorize any exceptional rates or limits.

The Exceptional Supports rate levels can authorize for 1.25, 1.5, 1.75, or 2 times the established, standard maximum

rate for Day Training, Community Access, Personal Assistance and Respite.

Rates are established in program regulations. All ordinary administrative regulations are subject to a public

comment process during promulgation.

An independent cost study will be conducted during the third waiver year to review the appropriateness of the rates.

Kentucky Waiver# KY.0314.R04.01 

KY Supports for Community Living

Waiver Name:
KY Supports for Community Living
Effective Date:
3/1/2017
Expiration Date:
2/28/2022

Services

List of Services for Kentucky Waiver# KY.0314.R04.01

Cost Neutrality

Cost Neutrality for Kentucky Waiver# KY.0314.R04.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4941 4941

Year 1 Waiver Services

List of Year 1 Waiver Services for Kentucky Waiver# KY.0314.R04.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Training 15 minutes 4179 5943 $2.29
Supported Employment 15 minutes 256 534 $10.25
Community Access 15 minutes 230 2398 $7.50

Year 5 Waiver Services

List of Year 5 Waiver Services for Kentucky Waiver# KY.0314.R04.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Training 15 minutes 4889 5943 $2.52
Supported Employment 15 minutes 300 533 $11.28
Community Access 15 minutes 269 2398 $8.25

Rate Determination Methods

Rate Determination Methods for Kentucky Waiver# KY.0314.R04.01

MODIFICATION: Commonwealth of Kentucky Legislature passed HB200, which requires this waiver be amended to allow for a 10% rate increase for all services.

SCL claims with dates of service from 1/1/2014 through 1/1/2015 were collected, including payments, members, and units for each line of service. From those 3 data points, DMS also calculated (1) percent of members utilizing the service (2) rate for the service or cost per person, depending on the nature of the service [cost per person was used for those services without a defined unit and rate] and (3) units per member per month.

The estimates for the 5 waiver years assume the following:

1. The waiver, which currently has 4,940 slots will be 96% full in waiver year 1, 97% full in year 2, up to 100% full in waiver year 5. We do not assume it is completely full in year 1 because some slots are reserved in the waiver application for emergency purposes and filled gradually.

2. The percentage of members using each service in the shortened data pull will also use those services in each waiver year. For example, if 75% of members use a given service in the data pull, then 75% of total waiver members will use that service in each waiver year. The exceptions to this are those lightly utilized services. Some services, presumably due to their newness, are currently not heavily utilized. These estimates assume that at least 1% of members will utilize every service in waiver year 1, moving up to at least 5% in waiver year 5.

3. Total units for each service are equal to the total number of users (per bullet 2) multiplied by the units per member per month calculated from the original data, multiplied by 11.5 (the average number of months per member).

4. Costs for each service are equal to the number of units multiplied by the rate of average cost per person.

It should be noted that these estimates do differ from the previous estimates. This is due to the fact that the previous estimates were based on six months of data which we, mistakenly, assumed to be a full 12 months of data. The current data pull is limited, but accurate. For that reason the assumptions outlined above are even more important.

DMS works collaboratively with the operating agency to review historical usage and expenditures to develop the rate structure. All rates must be approved by DMS and are incorporated into Medicaid state regulations, which are subject to public comment when promulgated or amended.

There is not a cost of living increase. The state continuously evaluates rates to determine that adequate access to and statewide coverage of services is available.

Each time DMS files a regulation with the Legislative Research Commission it:

• Disseminates the regulation to a large distribution list (known as “RegWatch”) as required by Kentucky law to everyone who requests to receive copies of and notice of Medicaid regulations upon filing. Along w/the regulation DMS advises via the email of the public comment period and how to submit comments.

• Publishes the regulation on a DMS regulation web site (each regulation also contains a page stating the public comment period and how to submit comments).

• Adopting administrative regulations requires that they are published by the Legislative Research Commission; that public comments are solicited and may be submitted in writing or by testimony at a public hearing; that the administrative agency responsible for the regulations must respond to all public comments and file a statement of consideration with the Legislative Research Commission; and that regulations are considered by two legislative committees prior to adoption. Interested individuals and groups may ask to be notified when regulations related to a certain subject, such as Medicaid waivers, are adopted or amended.

Payment rates are incorporated into Kentucky Administrative Regulations. Payment rates are made available to waiver participants and family members, as well as advocacy groups, individual providers, provider associations and the general public through the regulation promulgation and public comment process described above. In addition, waiver payment rates are available on the DMS web site on a continuing basis.

Louisiana Waiver# LA.0401.R03.04 

LA New Opportunities Waiver

Waiver Name:
LA New Opportunities Waiver
Effective Date:
1/1/2017
Expiration Date:
12/31/2021

Services

List of Services for Louisiana Waiver# LA.0401.R03.04

Cost Neutrality

Cost Neutrality for Louisiana Waiver# LA.0401.R03.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
8900 9100

Year 1 Waiver Services

List of Year 1 Waiver Services for Louisiana Waiver# LA.0401.R03.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 1824 3224 $1.91
Prevocational Services 15 minutes 889 3098 $1.66
Supported Employment 15 minutes 1064 2619 $14.51
Community Integration and Development 15 minutes 9 240 $3.31

Year 5 Waiver Services

List of Year 5 Waiver Services for Louisiana Waiver# LA.0401.R03.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 1824 3224 $1.91
Prevocational Services 15 minutes 909 3098 $1.66
Supported Employment 15 minutes 1088 2619 $14.51
Community Integration and Development 15 minutes 9 240 $3.31

Rate Determination Methods

Rate Determination Methods for Louisiana Waiver# LA.0401.R03.04

Rates for the payment of services are determined by the Office of Citizens with Developmental Disabilities (OCDD) upon approval by Medicaid. OCDD sets these rates with input from a group of interested parties, including but not limited to providers and or provider groups, program participants, advocates, and Medicaid representatives. Proposed service rates are promulgated through the Medicaid rulemaking process with includes opportunity for public input and comment. Final approval of proposed rates and oversight of the rate determination process is done by the Medicaid Director or his designee.

Rates for each service is based on following for each service:

INDIVIDUAL AND FAMILY SUPPORT, CENTER-BASED RESPITE, EMPLOYMENT RELATED TRAINING, SUPPORTED EMPLOYMENT, DAY HABILITATION, INDIVIDUAL AND FAMILY SUPPORT (SELF-DIRECTION) The state of Louisiana will use a combination of a Fee Schedule and Tiered model for rate setting for HCBS services that utilize personal care services. Based on this methodology, providers will receive a fixed, pre-determined rate for each 15-minute increment of service provided.

A. The rate model begins with an examination of state specific data for direct support workers available from the Louisiana Workforce Commission as a means to identify a base wage employee wage for personal care attendants

(PCA).

B. The state Medicaid agency implemented mandatory Cost Reporting for HCBS providers who provide personal care services. The cost reports were used to verify expenditures and to support rate setting for personal care services rendered to waiver recipients. The information from the report was used to determine the base PCA wage, employee benefits factor, productivity adjustment, administrative costs, program support costs, and staffing ratios.

C. After these factors are used to set a base personal care services rate, the state Medicaid agency applies a tiered rate factor based on characteristics of the (1) individual population characteristics (developmental disabilities) and (2) acuity of the individual (determined by assessment).

D. A final rate is then determined. As with all rates, the availability of state funding or LDH’s ability to secure appropriation will be considered in the final determination of rates.

E. Rates are required to be reviewed bi-annually using Cost Report Data. Newly suggested rates based on wage rate adjustments are subject to the availability of funding or LDH secured appropriation.

F. All rate reimbursement methodology changes are subject to Medicaid Rulemaking Procedures, which include a public posting and public comment period.

G. All new rates are published in the Louisiana Register, the state’s Medicaid Website, Case Management Agencies, and available through request.

Currently, supported employment, day habilitation, and employment related training rates were established by using the Louisiana Rehabilitative Services rate for employment services. The rates for Day Habilitation were negotiated between providers and LDH based on provider cost of providing the service and availability of state funding. The availability of state funding or LDH’s ability to secure appropriation will be considered in the final determination of rates for Community Integration and Development.

With the state’s move to Cost Reports for Personal Care Services and its use to determine the cost of Personal Care Services, the state is planning a possible move to Cost Reports and Fee Schedule rate setting for its vocational services.

PROFESSIONAL SERVICES AND SKILLED NURSING

Professional Services and Skilled Nursing rates were established by looking at the rate of similar services provided under the Medicaid State Plan. For state plan look-a-like services, the rate of the similar service under the state plan was used (i.e. RN, LPN, CNA services). For all other professional services, the rate was negotiated based upon the provider cost of rendering the service balanced against the potential cost of waiver and the availability of state funding. The negotiation process involved meeting with providers of the services, collection of informal surveys, and information gathered from the Louisiana Workforce Commission (State Department of Labor). After all data was gathered, a rate was developed and proposed. This suggested rate was then adjusted after consideration of available funding or LDH’s ability to secure appropriation.

Personal Emergency Response System rates are based on the actual cost of providing the service.

Community Living Adaptations, Equipment, and Supplies, and One Time Transitional Services are paid at the cost of the provision of services with each having an annual cap. This cap was set based on the historical cost of providing the service.

Substitute Family Care and Supported Living rates are the result of negotiations between the advocates, stakeholders, and waiver personnel based on provider cost of providing the service, historical utilization trends, and state funds available. The availability of state funding or LDH’s ability to secure appropriation will be considered in the final determination of rates.

The availability of state funding or LDH’s ability to secure appropriation will be considered in the final determination of rates” for each of the services:

Community Integration and Development

The Adult Companion Care rate is paid to the provider at a daily rate. This rate includes the cost of payment to the Adult Companion worker for services delivered plus an additional cost component payable to the Adult Companion Care provider for oversight, monitoring, and facilitating an agreement between the provider and Adult Companion worker. The rate was based on the limited services expected to be provided, the anticipated users of the service and their level of need, plus an estimate of the amount of actual direct care service hours to be provided each day.

Both Housing Stabilization and Housing Stabilization Transition Service rates are based on the rate paid to support coordination agencies, which employ individuals who have obtained a bachelor’s degree and are qualified to provide two levels of supervision. An agency trainer or nurse consultant who meets the requirements as a support coordinator can also be reimbursed a per quarter hour rate for services provided. Administrative support, travel and office operating expenses are included in the 15 minute billing rate.

All proposed rates are then plugged into a cost projection and model to produce an estimated total program cost and average cost per recipient, which is then used to determine the effects of these rates on program cost effectiveness. Rates are then renegotiated or changed as needed.

Payment rates are available to participants through provider agencies, support coordinators and agencies, as well as through publication in the Louisiana Register. Participants may also receive information on service rates by contacting their Regional OCDD Waiver Services and Supports Office.

Louisiana Waiver# LA.0472.R02.00 

LA Residential Options Waiver (ROW)

Waiver Name:
LA Residential Options Waiver (ROW)
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Louisiana Waiver# LA.0472.R02.00

Cost Neutrality

Cost Neutrality for Louisiana Waiver# LA.0472.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1025 1025

Year 1 Waiver Services

List of Year 1 Waiver Services for Louisiana Waiver# LA.0472.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 2.5 hours 65 298 $18.50
Prevocational Services 2.5 hours 32 353 $22.50
Supported Employment 15 minutes 32 212 $2.60

Year 5 Waiver Services

List of Year 5 Waiver Services for Louisiana Waiver# LA.0472.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 2.5 hours 107 298 $18.50
Prevocational Services 2.5 hours 52 353 $22.50
Supported Employment 15 minutes 52 212 $2.60

Rate Determination Methods

Rate Determination Methods for Louisiana Waiver# LA.0472.R02.00

Rates for the ROW are initiated by the OCDD with input from a group of interested parties, including but not limited to providers and or provider groups, program participants, advocates,& Medicaid representatives. OCDD's process for developing rates for ROW waiver services is based on rates for similar services in other waivers with review by Medicaid personnel for appropriateness. The overall budget cap for each person in the ROW is established based on his overall (ICAP) score. This allows flexibility for each individual's plan to include an array of services needed within the overall budget cap. If the Medicaid personnel concur that the rates are feasible, can be utilized within the individual's overall budget and represent cost neutrality, then they are submitted to the Medicaid Director as part of the waiver application for final review and approval. Subsequently the reimbursement methodology is included in the Medicaid rulemaking process. This rulemaking process includes further opportunity for public comment. As rates are proposed for each service in the ROW, OCDD presents the rates and service definitions to the Medicaid liaison and other Medicaid representatives as part of the waiver application review.

1.OCDD recommends rates to Medicaid based on the following hierarchy of factors:

a)If there is a comparable service already existing in another OCDD program(i.e. Waiver)that rate is mirrored.

b)If there is no existing comparable service, OCDD explores the rates that are compatible with other similar services which are provided by Medicaid (i.e. nursing services).

c)If no comparable Medicaid services and rates exists, OCDD explores services in the general community that are comparable and attempts to match the prevailing competitive rates.

2.Based on the choices available in #1 above, OCDD recommends the service rate to Medicaid where it is reviewed and a determination made of the fiscal impact and budget availability for funding with a final determination made on the service rate.

The ROW budgets follow the ICAP rates which were rebased and are developed within Medicaid. Therefore, the Medicaid Director has not only oversight, but also direct control over the rate determination process.

No rate can be implemented without the approval of the Medicaid Agency.

Rates for each service are based on the following:

*Adult Day Health Care (ADHC): The methodology for calculating each individual component of the overall ADHC rate is a product of the median cost multiplied by an index factor. The resultant calculations provide reasonable and adequate reimbursement required to cover the costs of economic and efficient ADHC services.

The base rate is calculated using the most recent audit or desk review cost for all ADHC providers filing acceptable full year cost reports and includes the following components:

a. Direct care-calculated at 115% of the median cost trended forward to rate year;

b. Care related costs-calculated at 105% of the median trended forward to the rate year;

c. Administrative and operating costs-calculated at 105% of the median trended forward to the rate year:

d. Property/capital costs-calculated at the median cost; and

e. Transportation costs-calculated for each provider based on their cost report

The cost report process is conducted yearly.

Because of the wide variation in transportation cost, which is influenced by the rural or urban location of the ADHC center and the number of participants using the ADHC’s transportation services versus other means of transportation (e.g. transportation provided by family, etc.), the transportation component of ADHC reimbursement is calculated and paid individually to each ADHC center. Rates may be updated when additional funding is appropriated by the legislature using the most recent audited cost reports at that time. For inflationary increases the state uses various sources of data. For Administrative and operating cost component we use the CPI-All Items (South Region) index and for the Direct Care Cost Component we use the Consumer Price Index-Medical Services (South Region)index.

*Community Living Supports (CLS) and Out-of-Home Respite rates were negotiated based upon the estimated provider cost of rendering the service and similar services as provided in other waivers. The cost of transportation is built into the CLS rate.

When CLS is self-directed, the method of rate determination differs from when the service is provider managed. The provider-managed rate includes a cost component in addition to the rate paid for the services delivered. This additional cost component serves as an "administrative fee" which is payable to the CLS provider for exercising oversight, monitoring, and facilitating an agreement between the CLS provider and CLS worker. This cost component is absent when this service is self-directed. Otherwise, these rates for self-direction are initiated by OCDD and submitted to Medicaid in the same manner and in accordance with the same processes, including opportunity for public comment, as other service rates.

In addition, Factor D charts in Appendix J of the ROW Application reflect a weighted average cost per unit for each year which includes the average of shared rates for Community Living Supports.

*Professional Services and Nursing rates were based upon several factors: the cost to the provider to provide the service, the cost to secure the service out in the community, the cost of similar services in current OCDD contracts, and state payment rates for full time employees.

*Services and rates for dental services were taken from an existing packaged plan of dental services as offered to Medicaid recipients under the EPSDT, Pregnant Woman and Adult Denture programs.

*Louisiana considered the following factors in establishing its ROW day habilitation, prevocational services and supported employment rates as part of its negotiations with providers and with input from other stakeholders: (1) allowances for direct support worker and other staff wages; (2) the provider's overhead costs; (3) transportation costs (per mile) from the vocational agency to all work sites; and (4) a profit margin for the provider.

The rate allowed by the State for supported employment, day habilitation, and pre-vocational services take the following factors into consideration when determining the rate: wages (55%); administrative (10%); overhead, which includes costs for building, equipment, supplies, insurance, and gas (30%); and profit margin (5%). The value of the profit margin is consistent with and comparable to that of similar services provided in the community. The State's estimated profit margin is at 5% of the rate. The value of the administrative and overhead costs are consistent with and comparable to that of similar services provided in the community.

*Transportation rates for Community Access were based on transportation rates payable in other waivers.

*Personal Emergency Response System rates are based on the actual cost of providing the service.

*One Time Transitional Services are paid at the cost of the provision of services with an annual cap. This cap was set based on the historical cost allowed for providing the service in other waivers.

*Environmental Accessibilities Adaptations and Assistive Technology/ Specialized Medical Equipment and Supplies costs are based on historical expenditures for these services in waivers serving similar populations.

*The Companion Care rate is paid to the provider at a daily rate. This rate includes the cost of payment to the Companion worker for services delivered plus an additional cost component payable to the Companion Care provider for oversight, monitoring, and facilitating an agreement between the provider and Companion worker. The rate was based on the limited services expected to be provided, the anticipated users of the service and their level of need, plus an estimate of the amount of actual direct care service hours to be provided each day.

*The rates for the Host Home service are graduated according to level of need. The Host Home rates were determined by the increased complexity of the individuals' needs and the associated responsibilities of the Host Home dictated by the score on the ICAP.

*Shared Living and Shared Living-Conversion rates are based on several factors: employee costs, including wages and benefits; indirect costs such as transportation and administration; and staffing requirements and occupancy. All rates are graduated according to the intensity of the need of the individual. The Shared Living rates were determined by the staffing level/ratio required for the increasing acuity level of the individuals being served. The greater the acuity level, the greater the amount of staffing needed. The acuity level was determined by each individual's score on the ICAP.

The ROW per diem rates and annual budget amounts are calculated based on State Fiscal Year ICAP rates used to determine ICF/DD funding under four acuity levels of recipient needs (intermittent, limited, extensive & pervasive), minus applicable adjustments (provider fees and patient liability). These ROW rates per acuity level are based on each participant's ICAP score and set the overall budget amount (or cap) a ROW participant must fall within when choosing an array of services and tailoring a support plan to meet individual needs. Although the budget amounts set overall caps on expenditures per acuity level, there is much flexibility in choosing individual services which have minimal to no caps placed upon them.

*Support Coordination Services Rate is contracted monthly service rate paid to support coordination providers. The monthly rate is based upon the average service utilization billed. The monthly rate reflects the cost of average units a nationally recognized rate-setting consultant who surveyed providers relative to their time, activities performed, staffing requirements, general administrative and indirect expenses.

Both Housing Stabilization and Housing Stabilization Transition Service rates are based on the rate paid to support coordination agencies which employ individuals who have obtained a bachelors degree and are qualified to provide two levels of supervisions. An agency trainer or nurse consultant who meets the requirements a support coordinator can also be reimbursed a per quarter rate for services provided. Administrative support, travel and office operating expenses are included in the 15 minute billing rate.

OCDD’s process for developing rates for ADHC waiver services is based on rates for similar services in other waivers with review by Medicaid personnel for appropriateness. If Medicaid personnel concur that the rates are feasible and will help facilitate cost neutrality, then they are submitted to the Medicaid Director as part of the waiver application for final review and approval. Subsequently, the reimbursement methodology is included in the Medicaid rulemaking process. This rulemaking process includes further opportunity for public comment.

All proposed rates are then factored into a cost projection and model to produce and estimated total program cost and average cost per recipient which is then used to determine the effects of these rates on program cost effectiveness. Rates are then renegotiated or changed as needed.

Payment rates are available to participants through provider agencies, support coordinators and agencies, as well as through publication in the Louisiana Register, the official journal for the state of Louisiana. Participants may also receive information on service rates by contacting their OCDD Local Governing Entity (LGE). OCDD solicited public input from recipients, providers, and advocacy organizations to determine rate, structure methodology, etc. This is accomplished through meetings with these entities around the state.

Waiver Name:
LA Supports Waiver 
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Louisiana Waiver# LA.0453.R03.00

Cost Neutrality

Cost Neutrality for Louisiana Waiver# LA.0453.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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2100 2400

Year 1 Waiver Services

List of Year 1 Waiver Services for Louisiana Waiver# LA.0453.R03.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 644 2798 $2.37
Prevocational Services 15 minutes 257 2463 $3.62
Supported Employment 15 minutes 551 185 $41.24

Year 5 Waiver Services

List of Year 5 Waiver Services for Louisiana Waiver# LA.0453.R03.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 883 2938 $2.37
Prevocational Services 15 minutes 206 2956 $1.85
Supported Employment 15 minutes 629 250 $41.24

Rate Determination Methods

Rate Determination Methods for Louisiana Waiver# LA.0453.R03.00

The Office of Citizens with Developmental Disabilities (OCDD) determines the rates of payment for services. Service rates are promulgated by Medicaid through a rulemaking process, which includes opportunity for public input through written comments, which are entered into record, and a public hearing, where comments may be read into record. This process affords Medicaid oversight of the rate determination process.

The rates in the Supports Waiver were established when the waiver was created back in 2006. With the exception for a couple of changes to the rate due to appropriation changes or changes in unit of service, the rates have basically remained the same.

The Rate Subcommittee used three years of data from state vocational services to create the Supports Waiver service rates before the inception of the waiver. The Rate Subcommittee was disbanded after the waiver application was submitted and approved in 2006.

Rates for Supported Employment, Day Habilitation, and Prevocational were based on ten years of historic usage of these services, and costs of providing these services as evidenced by data from a 3-year pilot project in which nine small, medium and large, urban and rural state general funded contracted Vocational and Habilitation Providers participated. The project broke down line item costs for each approved cost category, as well as showing specific individual’s outlier costs each month. Information from the project was shared with all current state general funded Vocational and Habilitation providers, and other stakeholders. The Rates Subcommittee used this information to develop the specific rates for these three services. The cost of Prevocational Services is based upon the provider cost of rendering the service and then adjusted based on the availability of state funding or LDH's ability to secure appropriation.

The Rates Subcommittee set Respite and Habilitation rates at the current rate being paid through the New Opportunities Waiver (NOW) for Individual and Family Support (which includes Respite and Personal Care Attendant services).

Family members requested that the compensation for these two services remain at the current NOW rate in order to attract quality staff. The NOW waiver rates were defined by actual service costs, reviewed and approved by the NOW stakeholder group. The cost of In-home Respite is based upon the provider cost of rendering the service and then adjusted based on the availability of state funding or LDH's ability to secure appropriation.

The cost of Personal Emergency Response System is based on actual utilization costs from 239 providers of the service over a 12-month period.

Support Coordination was one of the services addressed by the Rate Subcommittee. The original rate was based on the State Plan Support Coordination services provided for recipients in the New Opportunities Waiver who would represent a similar population to be served. Several adjustments were made based on assumptions of the workload and vocational planning. As with all other SW services, the rate has remained constant with the exceptions being changes in appropriation. The cost of Support Coordination services are based upon the provider cost of rendering the service and then adjusted based on the availability of state funding or LDH's ability to secure appropriation.

The cost of Prevocational Services is based upon the provider cost of rendering the service and then adjusted based on the availability of state funding or LDH's ability to secure appropriation. The cost of In-home Respite is based upon the provider cost of rendering the service and then adjusted based on the availability of state funding or LDH's ability to secure appropriation.

Both Housing Stabilization and Housing Stabilization Transition Service rates are based on the rate paid to support coordination agencies, which employ individuals who have obtained a bachelor’s degree and are qualified to provide two levels of supervision. An agency trainer or nurse consultant who meets the requirements as a support coordinator can also be reimbursed a per quarter hour rate for services provided. Administrative support, travel and office operating expenses are included in the 15 minute billing rate.

Maine Waiver# ME.0995.R01.00 

ME HCBS for Adults w/Other Related Conditions

Waiver Name:
ME HCBS for Adults w/Other Related Conditions
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Maine Waiver# ME.0995.R01.00

Cost Neutrality

Cost Neutrality for Maine Waiver# ME.0995.R01.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
67 67

Year 1 Waiver Services

List of Year 1 Waiver Services for Maine Waiver# ME.0995.R01.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Planning hour 2 60 $28.00
Community Support 15 minutes 45 3328 $5.28
Work Support 15 minutes 22 3328 $6.91
Employment Specialist Services 15 minutes 1 72 $7.42

Year 5 Waiver Services

List of Year 5 Waiver Services for Maine Waiver# ME.0995.R01.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Planning hour 2 60 $28.00
Community Support 15 minutes 67 3328 $5.33
Work Support 15 minutes 5 3328 $6.91
Employment Specialist Services 15 minutes 1 72 $7.42

Rate Determination Methods

Rate Determination Methods for Maine Waiver# ME.0995.R01.00

Provider payment rates are based on the dollar amounts authorized for the program in the State budget. Providers may also participate in the legislative process and propose bills that support rates. The rate-setting and finance divisions of the Department ultimately use the budget to establish the amounts that can be paid under each service. The rate setting unit sets and reviews all rates to ensure that they are economic, efficient and sufficient. The State periodically engages in rate reviews of this waiver. The State engaged in a comprehensive rate study for waiver services in 2016. The State regularly assesses rates and will apply the same methodology used in the 2016 rate study. The State Legislature also provides Budget oversight and direction in regard to rates.

All rates are proposed through the State's rule making process which requires a public hearing with a ten day comment period, or a thirty day comment period in place of a public hearing. This allows providers the chance to comment on the proposed rates. All rate changes must go through the State's rule making process. This process includes publishing the rule changes in the newspapers and on the Department's website, holding a public hearing and allowing for a comment period. During this time, any waiver provider or participant are welcome to present testimony on the proposed rates. Furthermore, all MaineCare policies are posted on the Department's website for access at any time.

The case management rate has been in existence for a period of time and is consistent with other waiver program rates for the same/similar service.

The Personal care rate was increased within the past five years and was driven by state legislation.

The Career Planning rate has been in existence for a period of time and is consistent with other waiver programs for the same service.

For Transportation Services: The state of Maine is moving from a fee-for-service reimbursement model to a full risk capitation model for MaineCare’s NEMT services. The rates were calculated and were consistent with CMS requirements that the capitation rates be actuarially sound and appropriate for the population covered for the program and conform to capitol standards of Practice and promulgated by the actuarial standards board by Deloitte Consulting LLP. The data base variables (by region) included paid amount, number of rides, rides per thousand, average cost per ride, miles, miles per ride, cost per ride, and base per member per month. Transportation to and from the services is provided under the transportation brokerage and only the transportation incidental to the provision of the service is a component of the service rate for Community Support, Home Support-per diem & 1/4 hour, Work Support and Employment Specialist Services.

For Home Support: Home Support-Remote Support-Monitor Only; & Home Support- Interactive Support rates are consistent. The Remote Support; Remote Support - Monitor; and Remote Support - Interactive Support quarter hour average units of service reflect the 2016 372 report utilization which equals $6.29 and $ 1.62 per quarter hour. All the Home Support average quarter hour rates did not require 24/7 level of care and were below the maximum allowance allowed in Chapter 3 of the MaineCare Policy Rate Allowances. In addition, the Home Support quarter hour rate "cost per client" were less than the Home Support per diem cost per client expenditures (which requires 24/7 level of care).

When rates were initially established in 2013, the State set rates in accordance with rates established for similar procedure codes. The rates established for the state’s Section 21 waiver (0159) were used for the following services: Home Support (remote), Home Support (quarter hour), Home Support (per diem), Community Support, Work Support, Employment Specialist Services, Consultation Services, Home Accessibility Adaptations, Specialized Medical Equipment, Maintenance OT, Maintenance PT, Maintenance Speech, Non-Traditional Communication Services, and Communication Aids. Assistive Technology Services rates were based on a review of actual costs for these services. Personal Care rates were based on similar rates for services included in the state’s Section 19 waiver (0276). Care coordination rates were based on rates for state plan targeted case management services for a similar group on individuals.

As noted above, when rates were initially established in 2013, the State set rates in accordance with rates established for similar procedure codes. The rates established for the state’s Section 21 waiver (0159) were used for the following services: Home Support (remote), Home Support (quarter hour), Home Support (per diem), Community Support, Work Support, Employment Specialist Services, Consultation Services, Home Accessibility Adaptations, Specialized Medical Equipment, Maintenance OT, Maintenance PT, Maintenance Speech, Non-Traditional Communication Services, and Communication Aids. Assistive Technology Services rates were based on a review of actual costs for these services. Personal Care rates were based on similar rates for services included in the state’s Section 19 waiver (0276). Care coordination rates were based on rates for state plan targeted case management services for a similar group on individuals.

The State’s rate setting unit reviews rates on at least a semi-annual basis. In the event rates are found to be insufficient to ensure an adequate pool of providers, the unit will either adjust rates or engage in a new comprehensive rate study. The State may review rates more often in the event stakeholders raise access issues directly with state staff. The State also has several regular series of meetings with groups of providers and advocates, during which rate adequacy is routinely discussed.

Maine Waiver# ME.1082.R01.01 

ME HCBS for Member with Brain Injury

Waiver Name:
ME HCBS for Member with Brain Injury
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Maine Waiver# ME.1082.R01.01

Cost Neutrality

Cost Neutrality for Maine Waiver# ME.1082.R01.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
250 250

Year 1 Waiver Services

List of Year 1 Waiver Services for Maine Waiver# ME.1082.R01.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Planning hour 1 1 $28.00
Employment Specialist Services 15 minutes 1 1 $7.49
Work Support-Individual 15 minutes 10 505 $6.91

Year 5 Waiver Services

List of Year 5 Waiver Services for Maine Waiver# ME.1082.R01.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Planning per hour 1 1 $28.00
Employment Specialist Services 1/4 hour 1 1 $7.49
Work Support-Individual 1/4 hour 10 505 $6.91

Rate Determination Methods

Rate Determination Methods for Maine Waiver# ME.1082.R01.01

Rate determination and oversight is the responsibility of the Department of Health and Human Services’ Office of MaineCare Services (OMS), in collaboration with the Office of Aging and Disability Services (OADS).

Provider payment rates have been established through a variety of mechanisms, including consideration of historic cost and budget data, comparisons to rates paid for similar services in other programs, and targeted rate studies. Rates are published online and any revisions are subject to the State’s rulemaking process, which includes opportunity for public comment.

Recognizing that it has been many years since provider payment rates have been comprehensively reviewed and that current rates lack thorough documentation, the State intends to undertake a rate study for all services except those noted below. The State is in the process of engaging Burns & Associates, Inc., a national health policy consulting firm that has previously assisted the State in reviewing Medicaid payment rates, to develop a rate-setting methodology that produces prospective fee-for-service rates that comply with federal requirements.

The rate study will include the following:

- A series of meetings with service providers at key milestones in the study, including development of a draft provider survey and consideration of survey results.

- Development and administration of a provider survey related to service design and costs.

- Identification of benchmark data, including Bureau of Labor Statistics cross-industry wage and benefit data as well as rates for comparable services in similar programs.

- Development of rate models that include specific assumptions related to the various costs associated with delivering each service, including direct care worker wages, benefits, and ‘productivity’ (i.e., billable time); staffing ratios; mileage; facility expenses; and agency program support and administration.

- A public comment process through which proposed rate models will be emailed to providers and other stakeholders, and posted online. Interested parties will have several weeks to submit written comments.

The rate study will be completed during waiver year 1. The State will submit an amendment to this waiver to update the rate-setting methodology and incorporate any changes to payment rates resulting from the rate study. Implementation of any changes to payment rates will proceed through the State’s rulemaking process, which provides further opportunity for public comment.

The use of detailed, transparent rate models will allow both the State and stakeholders to provide regular reviews of the ongoing adequacy of the rates (for example, ensuring that the wage assumptions included in the models remain appropriate).

Rates for a few services are set through alternative methodologies:

- Assistive Technology Device and Transmission services are reimbursed based on actual costs.

- Transportation services are reimbursed through a full-risk capitation models based on rates established by a contracted actuary.

The Department will submit a waiver amendment to adjust the rates by June 30, 2020.

The Department of Health and Human Services commits to ongoing communication with CMS about progress in the rate study process. In regular meetings, the Department will provide updates regarding the rate activities, and the timeline for submitting the waiver amendment.

Provider payment rates are based on the dollar amounts authorized for the program in the State budget. Providers may also participate in the legislative process and propose bills that support rates. The rate-setting and finance divisions of the Department ultimately use the budget to establish the amounts that can be paid under each service. Rate setting unit sets and reviews all rates to ensure that they are economic, efficient and sufficient. The State periodically engages in rate reviews of this waiver. The State Legislature also provides Budget oversight and direction in regard to rates. Rates are uniform for all providers across each service.

All rates are proposed through the State's rule making process which requires a public hearing with a ten day comment period, or a thirty day comment period in place of a public hearing. This allows providers the chance to comment on the proposed rates. All rate changes must go through the State's rule making process. This process includes publishing the rule changes in the newspapers and on the Department's website, holding a public hearing and allowing for a comment period. During this time, any waiver provider or participant is welcome to present testimony on the proposed rates.

Furthermore, all MaineCare policies are posted on the Department's website for access at any time.

There have been no changes in rates. The rates were developed as follows:

Assistive Technology: The assessment was based on the rate in the state plan, although the providers differ slightly with the ones serving the participants in this waiver (who must have experience with persons with brain injuries). The transmission is the cost of the monthly fee for the cable or internet. Any equipment or installation costs come under the Assistive Technology device. The rate for each Assistive Technology device is subject to a review and approval process at the Office of Aging and Disability Services (OADS).

The case management rate has been in existence for a period of time and is consistent with other waiver program rates for the same/similar service. Rates for Care Coordination, Career Planning, and Work Support were originally set based on rates in the ME.0995 and ME.0159 waivers. Since that time, there have been rate increases for ME.0159, so the rates for ME.0159 and ME.1082 no longer match.

The Career Planning and Work Support rate has been in existence for a period of time and is consistent with other waiver program rates for the same/similar service.

The Home Support rates were based on the current rate paid for residential services for this population. Remote Support-Interactive Support used the same rate as the direct care service of $6.27 since the care is one-to-one. Remote Support-monitor only of $1.62 is approximately equivalent to a group rate of $3.75. This is the average group size that would occur during monitoring only.

The Work Ordered Day Club House rate was based on the rate Georgia pays for the same service.

Employment Specialist Services: The rates for this service were published in state rule and were determined by a combination of factors:

* Analysis of claims data for five year period

* Analysis of costs associated with costs of each service

* Provider Survey

* Analysis comparing comparable positions within Maine and across a selection of other states

For Transportation Services-The state of Maine has moved from a fee-for-service reimbursement model to a full risk capitation model for MaineCare’s NEMT services. The rates were calculated and were consistent with CMS requirements that the capitation rates be actuarially sound and appropriate for the population covered for the program and conform to capitol standards of Practice and promulgated by the actuarial standards board by Deloitte Consulting LLP. The data base variables (by region) included paid amount, number of rides, rides per thousand, average cost per ride, miles, miles per ride, cost per ride, and base per member per month. Transportation to and from the services is provided under the transportation brokerage and only the transportation incidental to the provision of the service is a component of the service rate for Home Support-per diem & 1/4 hour, Work Support and Employment Specialist Services.

The State’s rate setting unit reviews rates on at least a semi-annual basis. In the event rates are found to be insufficient to ensure an adequate pool of providers, the unit will either adjust rates or engage in a new comprehensive rate study. The State may review rates more often in the event stakeholders raise access issues directly with state staff. The State also has several regular series of meetings with groups of providers and advocates, during which rate adequacy is routinely discussed.

Maine Waiver# ME.0467.R02.03 

ME Support Services for Adults w/ID or Autistic Disorder

Waiver Name:
ME Support Services for Adults w/ID or Autistic Disorder
Effective Date:
1/1/2016
Expiration Date:
12/31/2020

Services

List of Services for Maine Waiver# ME.0467.R02.03

Cost Neutrality

Cost Neutrality for Maine Waiver# ME.0467.R02.03

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2078 2635

Year 1 Waiver Services

List of Year 1 Waiver Services for Maine Waiver# ME.0467.R02.03

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Support 15 minutes 1002 2329 $5.33
Work Support - Group Two Participants 15 minutes 210 471 $3.46
Work Support - Group Three Participants 15 minutes 35 471 $2.30
Work Support - Group Four Participants 15 minutes 30 471 $1.73
Work Support - Group Five Participants 15 minutes 2 471 $1.38
Work Support - Group Six Participants 15 minutes 78 471 $1.15
Career Planning hour 437 60 $28.00
Employment Specialist Services 15 minutes 42 121 $7.42
Work Support - Individual 15 minutes 83 555 $6.91

Year 5 Waiver Services

List of Year 5 Waiver Services for Maine Waiver# ME.0467.R02.03

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Support 15 minutes 2372 2193 $6.53
Work Support - Group Two Participants 15 minutes 7 418 $4.24
Work Support - Group Three Participants 15 minutes 2 26 $2.82
Work Support - Group Four Participants 15 minutes 2 159 $2.12
Work Support - Group Five Participants 15 minutes 2 144 $1.69
Work Support - Group Six Participants 15 minutes 1 1 $1.41
Career Planning hour 38 26 $34.29
Employment Specialist Services 15 minutes 42 70 $9.09
Work Support - Individual 15 minutes 380 532 $8.46

Rate Determination Methods

Rate Determination Methods for Maine Waiver# ME.0467.R02.03

The rates for ME.0467 are subject to review and amendment by the State legislature. For example, rate and cap increases effective July 1, 2018 resulted from the Maine Legislature’s passage of P.L. 2017, Ch. 459, Parts A and B. The legislation requires the Department to amend its rules for reimbursement for Section 29(ME.0467) to increase rates for specific procedure codes. The legislation directs the Department to increase the rates for specific procedure codes in equal proportion to the funding provided for that purpose. The legislation also requires the rate increases to be effective July 1, 2018. The legislation also provides that the Department ensure that caps and limitations on services "are increased to reflect increases in reimbursements that result from this Part." Therefore, in addition to rate increases, the Department proposes to increase affected service limits in this waiver to ensure that rate increases do not result in decreased level of services for participants.

The rates for the majority of the waiver services are included in the MaineCare Benefits Manual, Section 29, Chapter III. Those that are not specified in the policy are based on actual costs.

Home Support, Respite, Shared Living, Community Support, Work Support, and Employment Specialist Services: The rates for these services are published in state rule and were determined by a combination of factors:

* Analysis of claims data for five year period

* Analysis of costs associated with costs of each service

* Provider Survey

* Analysis comparing comparable positions within Maine and across a selection of other states

The rates are prospective, fee-for-service rates. Rates are published and the public is allowed time to comment. Community Support is paid at a standardized rate per 1/4 hour unit and the rate is based on an overall program staff: participant ratio of 1:4.

Career Planning is paid at a standardized rate per hour unit.

Remote Support-Interactive Support uses the same rate as the direct care service of $7.75 since the care is one to one. Remote Support-monitor only $ of 1.63 is approximately equivalent to a group rate of 3.75. This is the average group size that would occur during monitoring only.

Work Support is an individualized service and is paid at a standard 1/4 hour unit rate.

Prior to publication, these rates go through the State Medicaid Agency, Finance Division, Commissioner's office for oversight and approval. All rates are proposed in rule and open to public comment.

Home Accessibility Adaptations: These goods and/or services are reimbursed at cost as long as there is prior approval from DHHS. DHHS requires at least two estimates for Home Accessibility Adaptations being requested and approves the most cost effective estimate.

Assistive Technology-The assessment is based on the rate in the state plan, although the providers differ slightly with the ones serving the participants in this waiver must have experience with Intellectual Disabilities. The transmission is the cost of the monthly fee for the cable or internet. Any equipment or installation costs come under the Assistive Technology device.

This information is gathered by OADS and presented to the Rate Setting Division within DHHS. Rate Setting analyzes the data and formulates the final rate. This rate goes through the State's rule-making process, whereby it is reviewed by the Medicaid Agency, and other DHHS offices. Notification of the rate is made public in several newspapers and providers are also notified electronically. The Department holds a public hearing and/or comment period after publishing notice of the change. All comments are reviewed, summarized and responded to by the Department.

Sometimes changes are made as a result of comments.

The most recent rate study was done July 2017 by Burns & Associates, a rate-setting consulting firm contracted to the Maine Department of Health and Human Services, working in collaboration with the Department’s rate-setting unit. Rates are regularly reviewed for economy, efficiency, and quality of care through regular, ongoing collaboration by the Office of Aging and Disability Services, the Office of MaineCare Services, and DHHS’s rate-setting unit.

Transportation Services- The state of Maine has moved from a fee-for-service reimbursement model to a full risk capitation model for MaineCare NEMT services. The rates were calculated and were consistent with CMS requirements that the capitation rates be actuarially sound and appropriate for the population covered for the program and conform to capital standards of Practice and promulgated by the actuarial standards board by Deloitte Consulting LLP. The data base variables (by region) included paid amount, number of rides, rides per thousand, average cost per ride, miles, miles per ride, cost per ride, and base per member per month.

Shared Living/Adult Foster Care is the same rate as Maine's comprehensive waiver ME0159.

Waiver Name:
Community Pathways
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Maryland Waiver# MD.0023.R07.02

Cost Neutrality

Cost Neutrality for Maryland Waiver# MD.0023.R07.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
16000 16380

Year 1 Waiver Services

List of Year 1 Waiver Services for Maryland Waiver# MD.0023.R07.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Exploration Large Group – New day 750 184 $70.01
Career Exploration Small Group – New day 750 184 $70.01
Career Exploration Facility- New day 600 184 $70.01
Career Exploration Large Group day 0 0 $0.01
Career Exploration Small Group day 0 0 $0.01
Career Exploration Facility day 0 0 $0.01
Day Habilitation 1:1 - New day 0 0 $0.01
Day Habilitation 2:1 - New day 0 0 $0.01
Day Habilitation Small Group 2-5 - New day 0 0 $0.01
Day Habilitation Large Group 6- 10 - New day 0 0 $0.01
Supported Employment ** ENDING JUNE 30, 2021** day 3985 184 $70.01
Community Development Services day 1350 154 $98.66
Community Development Services New hour 0 0 $0.01
Employment Discovery and Customization ** ENDING JUNE 30, 2021** day 22 29 $79.70
Employment Services: Co-Worker Employment Supports month 0 0 $0.01
Employment Services: Discovery Milestone 1 milestone 0 0 $0.01
Employment Services: Follow Along Supports month 0 0 $0.01
Employment Services: Job Development hour 0 0 $0.01
Employment Services: Ongoing Job Supports hour 0 0 $0.01
Employment Services: Customized Self-Employment Services milestone 0 0 $0.01
Employment Services Discovery Milestone 2 milestone 0 0 $0.01
Employment Services Discovery Milestone 3 milestone 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Maryland Waiver# MD.0023.R07.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Exploration Large Group – New day 812 368 $4.58
Career Exploration Small Group – New day 812 368 $13.74
Career Exploration Facility- New day 649 368 $2.75
Career Exploration Large Group day 0 0 $0.01
Career Exploration Small Group day 0 0 $0.01
Career Exploration Facility day 0 0 $0.01
Day Habilitation 1:1 - New day 586 1236 $55.52
Day Habilitation 2:1 - New day 59 1236 $111.44
Day Habilitation Small Group 2-5 - New day 9379 1236 $12.10
Day Habilitation Large Group 6- 10 - New day 2345 1236 $5.30
Supported Employment ** ENDING JUNE 30, 2021** day 0 0 $0.01
Community Development Services day 0 0 $0.01
Community Development Services New hour 2574 308 $37.23
Employment Discovery and Customization ** ENDING JUNE 30, 2021** day 0 0 $0.01
Employment Services: Co-Worker Employment Supports month 21 2 $520.00
Employment Services: Discovery Milestone 1 milestone 780 1 $692.50
Employment Services: Follow Along Supports month 2479 6 $221.48
Employment Services: Job Development hour 728 45 $69.25
Employment Services: Ongoing Job Supports hour 2479 900 $36.91
Employment Services: Customized Self-Employment Services milestone 21 1 $277.00
Employment Services Discovery Milestone 2 milestone 780 1 $2077.51
Employment Services Discovery Milestone 3 milestone 780 1 $1385.00

Rate Determination Methods

Rate Determination Methods for Maryland Waiver# MD.0023.R07.02

The rate methodologies for Community Pathways Waiver Fee Payment System (FPS) services will vary from Waiver Years (WYs) 1-2 and WYs 3-5 as DDA transitions from a prospective payment system to a reimbursement model.

Simultaneously DDA will also transition from the current standalone platform, PCIS2, to the Medicaid Long Term Services and Supports system, or LTSSMaryland. New proposed rates from the rate study completed this year will be used for non-FPS services but will not be used for FPS services until DDA transitions both the payment model and the IT system in WY 3.

In WY2, DDA is planning a pilot program to submit claims with LTSSMaryland for a small group of individuals using the new rates. This will ensure that any issues that arise during the pilot can be identified and corrected so that the system is ready for full implementation in WY3.

In WYs 1-2, FPS services, or those services whose claims are submitted using PCIS2, will continue to use rates based on the current rate methodology. The new rates for these services will not be adopted until DDA transitions to submitting claims using LTSSMaryland. Current rates will continue to be used for: Community Development Services (formerly Community Learning Services), Community Living Group Home Services (formerly Residential Habilitation), Day Habilitation, Employment Discovery & Customization, Personal Supports, and Supported Employment.

The current rate methodology can be found on page 246 of the Community Pathways Waiver Application for 1915(c) HCBS Waiver: MD.0023.R06.01 - Jul 01, 2016 found here:

https://dda.health.maryland.gov/Documents/2016/Community%20Pathways%20Waiver%20Amendment%201%20MD%200023%2

%20Effective%20July%201%202016.pdf

In accordance with Maryland law (Chapter 648 of the Acts of 2014), and to meet requirements of §1902(a)(30)(A) of the Social Security Act, the DDA procured a contractor, Johnston, Villegas-Grubbs & Associates (JVGA), to conduct an independent cost-driven rate setting study. JVGA developed the Brick Method ™, which is a structure used to develop standard fees for disability services that utilizes cost categories and studies their relationship to direct service support costs, or the wages of people performing the service. The foundation of the Brick is the direct support professional wage derived from the May 2015 State Occupational Employment and Wage Estimate Bureau of Labor Statistics (BLS) data.

Included in the rates are four standard cost components that are assumed to be common to all social and medical services. They are Employment Related Expenses (EREs), Program Support (PS), Facility Costs (day habilitation only) and General and Administrative costs of 11% included in all services except Market Rate services. In Maryland, Training and Transportation (Trans.) components were also studied and used to develop the rates. JVGA surveyed and analyzed the general ledgers of approximately 70 DDA providers to standardize the cost component and rates. The Rate Study Report was released on November 3, 2017 and is published on DDA’s website at https://dda.health.maryland.gov/Pages/Rate_Study_Report.aspx.

Beginning in WY2 on December 1, 2019, a representative group of participants will be the first transitioned to the new Employment Services, Day Habilitation Service grouping (i.e. small and large groups), Community Living Enhanced Supports, and Support Services outlined within the new PCP detail service authorization. This will be done to ensure fiscal payment strategies used within LTSSMaryland are functional. This transition plan will support live testing of the new detailed service authorization and fee-for-service billing functionality in LTSSMaryland and the Medicaid Management Information System (MMIS) prior to implementing these changes. This testing is being done to reduce the risk of payment issues for all participants and providers.

The group of participants who will test the system will be from different regions and supported by various providers to support the transition to new services and the new fee-for-services payments. The initial group size will be small to ensure that there are adequate resources to quickly resolve issues, if they arise.

Fee schedule Service Rates (WYs 1-5)

Behavioral Support Services (BSS)- The rates for Behavioral Assessment, Plan and Consulting are based on the BLS hourly wage job code 19-3039 and rates for Brief Support Implementation Services is based on the BLS hourly wage job code 19-3031. All BSS service rates include ERE 32.7%, PS 33%, and Training 13.4%. The productivity assumption is 8 hours for the Plan and the hourly rate for Brief Support Implementation is converted to a 15 minute rate.

Environmental Assessment -The rate is based on the BLS hourly wage job code 29-1122 with a productivity assumption of 6 hours and includes ERE 32.7%, PS 33%, and Training 13.4. Family and Peer Mentoring - This new service is based on a similar service provided in Arizona’s Raising Special Kids program and applying Maryland cost values. To calculate the rate for Family and Peer Mentoring, JVGA recommended a wage level based on BLS job descriptions and wage levels for Maryland and used the program support percentage calculated for Targeted Case Management. Since this is a new service without any history, JVGA based the percentage of employment related expenses and general and administrative costs on the Arizona Raising Special Kids services.

Housing Support Services - The rate is based on the hourly wage BLS job code 19-4099 and includes ERE 32.7%, PS 25.7%, and Training 8.6%

Medical Day Care – The rate is established by the Medicaid program.

Nursing Services – The rates are based on hourly BLS wage data job code 29-1141 and include ERE 32.7%, PS 33%, Training 13.4%, and a 5% no show factor.

Respite Care Services (Hourly and Daily) - The hourly rate is based on the BLS wage job code 39-9021 and includes ERE 32.7%, Training at 8.6%, and Trans. 2%. The daily rate is based on the hourly rate with an assumption of 16 hours of services. For WYs 2-5, the Respite daily rate is based on the hourly rate with an assumption of 16 hours of service with a 12% G&A to address increased administrative cost associated with the new billing system.

Career Exploration - The rate is based on hourly BLS wage job code 39-9021 and includes ERE 32.7%, PS 35.6%, Training 5.8%, Trans. 13.7%, and a 3.6% closure factor. The rate assumes staff to client ratios of 1:6 for Large Group, 1:2 for Small Group, and 1:10 for Facility.

Fee Schedule Service Rates (WYs 3-5)

Employment Services( Follow-Along, On-going Job Supports and Co-Worker Employment Supports) –The rates are based on BLS hourly wage job code 21-1093 and include ERE 32.7%, PS 35.6%, Training 5.8%, and Trans. 13.7%. Follow-Along Supports rate assumes a 5% No Show factor and 6 hours a month, On-going Job Supports rate assumes a 5% No Show factor and Co-Worker Employment Supports hourly rate is limited to a milestone payment of $500 a month.

. The milestone payment will only be made after DDA or FMS determines with evidence that the required activities have been completed as per DDA regulations and policy.

Employment Services (Discovery, Job Development and Self-Employment Services) - The rates are based on hourly BLS wage job code 21-1012 and include ERE 32.7%, PS 35.6%, Training 11.6%, and Trans. 13.7%. The self-employment plan assumes 4 hours and job development is billed hourly. Discovery is a milestone service that assumes 10, 20, and 30 hours to complete each of the three milestones levels one to three. Each discovery milestone must be completed as per DDA regulations and policy with evidence of completion of the required activities before DDA or the FMS approve them for payment.

Personal Supports- The rate is based on hourly BLS wage job code 39-9021 and includes ERE 32.7%, PS 25.7%, Training 8.6%, and a 5% no show factor and will be billed in 15 minute increments.

Personal Supports Enhanced Supports- The hourly rate was developed by Optumus, a vendor hired to validate JVGA rates and develop rates for new services. The rate, developed using the Brick method, is based on BLS wage data job code 21-1093 and includes the components ERE 30.1%, Program Support 24.3%, Training 11.7%, Transportation 6.5%, 5% for no show and 12% G&A.

Day Habilitation Services- The new Day Habilitation rates were developed by Optumas using the Brick method. The rates Day Habilitation 1:1 and 2:1 are based on 75% of the BLS wage data job code 21-1093 and include components ERE 30.1%, Facility 22.3%, Program Support 31.8%, Transportation 17.6%, 11.7% Training, Closures 3.61%, and 12% G&A. The hourly rate is doubled for Day Habilitation 2:1. The rates for Habilitation Small and Large groups are based on 50% of the BLS wage data job code 21-1093 and include components ERE 30.1%, Facility 22.3%, Program Support 31.8%, Transportation 17.6%, Training, 8 %, Closures 3.61%, and 12% G&A.

Dedicated Supports Community Living Group Home 1:1 and 2:1, Dedicated Supports Community Living Enhanced Supports 1:1 and 2:1 and Dedicated Supports Supported Living 1:1 and 2:1- The hourly rates are based on 75% of BLS wage job code 21-1093 and include the following components: ERE 30.1%, Program Support 24.3%, Transportation 6.5%, Training 11.7 % , except for Dedicated Supports Community Living Enhanced Supports 1:1 and 2:1 Training is 18.7%, and 12% G&A.

Market Rate Services (WYs 1-5)

Assistive Technology and Services, Environmental Modifications, Live-In Caregiver Supports, Remote Support Services, Respite Care Camp, , Transition Services, Transportation and Vehicle Modifications -Payments for market rate services are based on the specific needs of the participant and the piece of equipment, type of modifications, or service design and delivery method as documented in the PCP and associated Service Funding Plan. For needed services identified in the team planning process that do not lend themselves to an hourly rate (i.e. assistive technology, environmental modifications, etc.), the estimated actual cost, based on the identified need (i.e. a specific piece of equipment) or historical cost data, is included in the participant's service budget. The applicable service definitions and limitations included in the waiver application provide any additional requirements for payment of these services. The Regional Office fiscal staff review provider invoices to ensure costs for market rate services are authorized on an individual’s PCP. The rate study established upper pay limits for these services, except for Assistive Technology. Assistive Technology includes various devices that are driven by market cost. Items that cost more than $1,000 must be recommended by an independent evaluation of the participant’s needs. All requests are reviewed and approved by the DDA Regional Offices. The payment limit and any other limiting parameters will be programmed into MMIS to avoid overpayment of these services.

Family Caregiver Training and Empowerment Services and Participant Education, Training and Advocacy Supports – These are new services based on similar services provided in Arizona’s Raising Special Kids program .These services do not lend themselves to an hourly rate but are based on the needs of the participant with costs constrained to an upper pay limit or meeting a milestone.

***CONTINUED IN MAIN B***

Maryland Waiver# MD.1506.R01.01 

MD Community Supports Waiver

Waiver Name:
MD Community Supports Waiver
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Maryland Waiver# MD.1506.R01.01

Cost Neutrality

Cost Neutrality for Maryland Waiver# MD.1506.R01.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
900 2160

Year 1 Waiver Services

List of Year 1 Waiver Services for Maryland Waiver# MD.1506.R01.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Exploration Facility Based day 3 184 $70.01
Career Exploration Small Group day 3 184 $70.01
Career Exploration Facility Based day 3 184 $70.01
Day Habilitation 1:1 day 170 206 $93.67
Day Habilitation 2:1 day 0 0 $0.01
Day Habilitation Small Group 2-5 day 0 0 $0.01
Day Habilitation Large Group 6-10 day 0 0 $0.01
Community Development Services day 53 154 $98.66
Employment Discovery and Customization **ENDING JUNE 30, 2021** day 1 29 $79.70
Employment Services Discovery Milestone 1 milestone 0 0 $0.01
Employment Services Discovery Milestone 2 milestone 0 0 $0.01
Employment Services Discovery Milestone 3 milestone 0 0 $0.01
Employment Services Job Development hour 0 0 $0.01
Employment Services Follow Along month 0 0 $0.01
On-going Job Supports hour 0 0 $0.01
Employment Services Co-Worker Employment Supports month 0 0 $0.01
Employment Services Customized Self-Employment Services milestone 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Maryland Waiver# MD.1506.R01.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Exploration Facility Based hour 7 368 $2.69
Career Exploration Small Group hour 7 368 $13.47
Career Exploration Facility Based hour 7 368 $4.49
Day Habilitation 1:1 hour 22 1236 $54.63
Day Habilitation 2:1 hour 4 1236 $109.25
Day Habilitation Small Group 2-5 hour 323 1236 $11.86
Day Habilitation Large Group 6-10 hour 108 1236 $5.19
Community Development Services hour 108 308 36/50
Employment Discovery and Customization **ENDING JUNE 30, 2021** day 0 0 $0.01
Employment Services Discovery Milestone 1 milestone 204 1 $678.92
Employment Services Discovery Milestone 2 milestone 204 1 $2036.78
Employment Services Discovery Milestone 3 milestone 204 1 $1357.84
Employment Services Job Development hour 204 45 $67.89
Employment Services Follow Along month 41 6 $217.14
On-going Job Supports hour 163 900 $36.19
Employment Services Co-Worker Employment Supports month 10 2 $510.00
Employment Services Customized Self-Employment Services milestone 4 1 $271.56

Rate Determination Methods

Rate Determination Methods for Maryland Waiver# MD.1506.R01.01

The rate methodologies for Community Supports Waiver Fee Payment System (FPS) services will vary in Waiver Years (WYs) 1-3 and WYs 4-5 as DDA transitions from a prospective payment system to a reimbursement model.

Simultaneously DDA will also transition from the current standalone platform, PCIS2, to the Medicaid Long Term Services and Supports system, or LTSSMaryland. New rates from the rate study completed November 2017 will be used for non-FPS services but will not be used for FPS services until DDA transitions both the payment model and the IT system in WY 4.

In WYs 1-3, FPS services, or those services whose claims are submitted using PCIS2, will continue to use rates based on the current rate methodology. The new rates for these services will not be adopted until DDA transitions to submitting claims using LTSSMaryland. Current rates will continue to be used for: Community Development Services (formerly Community Learning Services), Day Habilitation, Employment Discovery & Customization, Personal Supports (ending WY3), and Supported Employment (ending WY3).

The DDA determines payment rates for rate-based waiver services with input from the public. The Community Services Reimbursement Rate Commission (CSRRC), an independent commission within the Maryland Department of Health (MDH), provides input into the rate setting process. The commission is concerned with issues regarding community services for individuals with developmental disabilities or psychiatric disabilities, with particular emphasis on the rates paid to service providers, wage rates of direct care workers, uncompensated care, solvency of providers, and consumer safety costs. DDA rates vary slightly based on the federally recognized wage enhancement areas. Wage enhancement areas result in slightly higher service rates for District of Columbia Metro and Wilmington Metro. Rates are available on the DDA website and rate changes are made through the regulatory process, which includes publication in the Maryland Register.

In 1998, initial rates for the Fee Payment System (FPS) were developed and cover four programs— Community Supported Living Arrangements (CSLA) now Personal Supports, day, residential, and supported employment. FPS is based on two rates – the provider and individual component. The provider component pays a flat rate for Administrative, General, Capital, and Transportation (AGC&T) cost centers. As the FPS rates were developed, this component was arrived at in a cost neutral manner by bringing all providers to the weighted mean AGC&T as reported on their cost reports.

FPS also covers “add-ons” to accommodate temporary changes in client needs (usually for a period under one year, but can be extended), and one-time supplemental costs for special equipment, assistive technology, accessibility modifications to structures, and other needs that are not covered by Medicaid, private insurance, or any other state or federal health program. The rates used for FPS services are historical in nature and outlined in COMAR 10.22.17.06 through 10.22.17.13. Daily FPS rates are computed using the following three components:

1) The individual component, which assesses the service needs of the individual as determined by their matrix score using an assessment tool called the Individual Indicator Rating Scale (IIRS). This component also includes regional rate adjustments that increase for certain high-cost areas of the State.

2) The provider component, which accounts for the indirect costs of providing care. These are fixed Statewide per diem rates, with separate scales for day and residential programs.

3) The add-on component, addresses additional service needs which were not covered under the IIRS matrix score. Add- ons are negotiated at the regional level with each provider. It is important to note that not all individuals require add- ons, but the majority of individuals do have add-ons included in their FPS rates.

In accordance with Maryland law (Chapter 648 of the Acts of 2014), and to meet requirements of §1902(a)(30)(A) of the Social Security Act, the DDA procured a contractor, Johnston, Villegas-Grubbs & Associates (JVGA), to conduct an independent cost-driven rate setting study. JVGA developed the Brick Method ™, which is a structure used to develop standard fees for disability (and other services) that utilizes cost categories and studies their relationship to direct service support costs (the wages of people performing the service). The foundation of the Brick is the direct support professional wage derived from the May 2015 State Occupational Employment and Wage Estimate Bureau of Labor Statistics (BLS) data. Included in the rates are four standard cost components that are assumed to be common to all social and medical services. They are Employment Related Expenses (EREs), Program Support (PS), facility cost (day habilitation only) and General and Administrative costs of 11% included in all services except Market Rates services. In Maryland, Training and Transportation (Trans.) components were also studied and used to develop the rates. JVGA surveyed and analyzed the general ledgers of approximately 70 DDA providers to standardize the cost component and rates. The Rate Study report was released on November 3, 2017 and is published along with the rates on DDA’s website at https://dda.health.maryland.gov/Pages/home.aspx.

Fee schedule Service Rates (WYs 1-5)

Behavioral Support Services (BSS)- The rates for Behavioral Assessment, Behavioral Plan (WY3-5) and Behavioral Consulting are based on the BLS hourly wage data for a Psychologist or Other PhD with the productivity assumption of 8 hours for the Assessment and 8 hours for the Plan and including the cost components: Employment Related Expenditures at 32.7%, Program Support at 33%, Training expenditures at 13.4%, and administrative costs at 11%. The rates for the Behavioral Plan (WY1-2) and Brief Support Implementation Services are based on the hourly wage of Clinical, Counseling & School Psychologists and including cost components: Employment Related Expenditures at 32.7%, Program Support at 33%, Training expenditures at 13.4%, and administrative costs at 11%. The productivity assumption is 8 hours for the Plan.

Environmental Assessment - The rate for Environmental Assessments is based on hourly wage data from the Bureau of Labor Statistics data for Occupational Therapists with a productivity assumption of 6 hours and including cost components Employment Related Expenditures at 32.7%, Program Support at 33%, Training expenditures at 13.4%, and administrative costs at 11%.

Family and Peer Mentoring - This new service is based on a similar service provided in Arizona’s Raising Special Kids program and applying Maryland cost values. To calculate the rate for Family and Peer Mentoring, JVGA recommended a wage level based on BLS job descriptions and wage levels for Maryland and used the program support percentage calculated for Targeted Case Management. Since this is a new service without any history, JVGA based the percentage of employment related expenses and general and administrative costs on the Arizona Raising Special Kids services.

Housing Support Services- The rate is based on the hourly BLS wage job code 19-4099 and includes ERE 32.7%, PS 25.7%, and Training 8.6%.

Medical Day Care- The rate is established by the Medicaid program.

Nursing Services- The rates are based on hourly BLS wage data job code 29-1141 and includes ERE 32.7%, PS 33%, Training 13.4%, and a 5% no show factor.

Respite Care Services (Hourly and Daily) - The hourly rate is based on the BLS wage data job code 39-9021 and includes ERE 32.7%, Training at 8.6%, and Trans. 2%. The daily rate is based on the hourly rate with an assumption of 16 hours of service. For WYs 2-5, the Respite daily rate is based on the hourly rate with an assumption of 16 hours of service with a 12% G&A to address increased administrative cost associated with the new billing system.

Career Exploration- The rate is based on hourly BLS wage job code 39-9021, and includes ERE 32.7%, PS 35.6%, Training 5.8%, Trans. 13.7%, and a 3.6% closure factor. The rate assumes staff to client ratios of 1:6 for Large Group, 1:2 for Small Group, and 1:10 for Facility.

Fee schedule Service Rates (WYs 4-5)

Employment Services( Follow-Along, On-going Job Supports and Co-Worker Employment Supports) –The rates are based on BLS hourly wage job code 21-1093 and include ERE 32.7%, PS 35.6%, Training 5.8%, and Trans. 13.7%. Follow-Along Supports rate assumes a 5% No Show factor and 6 hours a month, On-going Job Supports rate assumes a 5% No Show factor and Co-Worker Employment Supports hourly rate is limited to a milestone payment of $500 a month.

. The milestone payment will only be made after DDA or FMS determines with evidence that the required activities have been completed as per DDA regulations and policy. Employment Services (Discovery, Job Development and Self-Employment Services) - The rates are based on hourly BLS wage job code 21-1012 and include ERE 32.7%, PS 35.6%, Training 11.6%, and Trans. 13.7%. The self-employment plan assumes 4 hours and job development is billed hourly. Discovery is a milestone service that assumes 10, 20, and 30 hours to complete each of the three milestones levels one to three. Each discovery milestone must be completed as per DDA regulations and policy with evidence of completion of the required activities before DDA or the FMS approve them for payment.

Personal Supports- The rate is based on hourly BLS wage job code 39-9021 and includes ERE 32.7%, PS 25.7%, Training 8.6%, and a 5% no show factor and will be billed in 15 minute increments.

Personal Supports Enhanced Supports- The hourly rate was developed by Optumas, a vendor hired to validate JVGA rates and develop rates for new services. The rate, developed using the Brick method, is based on BLS wage data job code 21-1093 and includes the components ERE 30.1%, Program Support 24.3%, Training 11.7%, Transportation 6.5%, 5% for no show and 12% G&A.

Day Habilitation Services- The new Day Habilitation rates were also developed by Optumas using the Brick method. The rates Day Habilitation 1:1 and 2:1 are based on 75% of the BLS wage data job code 21-1093 and include components ERE 30.1%, Facility 22.3%, Program Support 31.8%, Transportation 17.6%, 11.7% Training, Closures 3.61%, and 12% G&A. The hourly rate is doubled for Day Habilitation 2:1. The rates for Day Habilitation Small and Large groups are based on 50% of the BLS wage data job code 21-1093 and include components ERE 30.1%, Facility 22.3%, Program Support 31.8%, Transportation 17.6%, 8% Training, 8 % Training, Closures 3.61%, and 12% G&A.

***CONTINUED IN MAIN-B-ADDITIONAL NEEDED INFORMATION***

Massachusetts Waiver# MA.40702.R02.00 

Acquired Brain Injury Non-Residential Habilitation (ABI-N) Waiver

Waiver Name:
Acquired Brain Injury Non-Residential Habilitation (ABI-N) Waiver
Effective Date:
5/1/2018
Expiration Date:
4/30/2023

Services

List of Services for Massachusetts Waiver# MA.40702.R02.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.40702.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
120 120

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.40702.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 6 1590 $9.15
Community Based Day Supports 15 minutes 6 3468 $5.16
Day Services per diem 24 92 $102.90
Individual Support and Community Habilitation 15 minutes 90 1858 $10.91

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.40702.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 6 1668 $10.62
Community Based Day Supports 15 minutes 18 3468 $5.99
Day Services per diem 24 97 $119.45
Individual Support and Community Habilitation 15 minutes 90 1949 $12.66

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.40702.R02.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. The HCBS rate regulation was last updated effective January 1, 2017. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

The rates for all waiver services in this waiver were established in accordance with the above statutory requirements. Additional information on the rate development for each waiver service follows.

The ABI waiver rates can be found in EOHHS ABI waiver services regulations 101 CMR 359.00 (Rates for Home and Community Based Services Waivers). The regulation can be found on the MassHealth website: www.mass.gov/eohhs/gov/departments/masshealth/

101 CMR 359.00 establishes rates for waiver services based on and tied to existing rate setting methodologies for similar/same services when possible. As such, the rates for waiver services in this waiver are established in one of four ways, as follows:

1. For waiver services in which there is a comparable Medicaid state plan rate, the waiver service rate was established in regulation at the comparable Medicaid state plan rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All Medicaid state plan rates were established in regulation pursuant to this same statutory requirement. Medicaid State Plan rates are developed using provider cost data submitted to the Center for Health Information and Analysis (CHIA) in accordance with provider cost reporting requirements under 957 CMR 6.00: Cost Reporting Requirements. The provider cost data is used to calculate rates that meet the statutory rate adequacy requirements noted above. There are no differences in the rate methodology between these state plan and waiver services. No additional CAF was used for the waiver services using the comparable state plan rate. This applies to the following waiver services:

Occupational, Physical and Speech Therapy (set in accordance with 114.3 CMR 50.00: Rates for Home Health Services for agency services and 114.3 CMR 39.00 Rehabilitation Center Services out-of-office visit rates for Individual Providers)

Specialized Medical Equipment (set in accordance with 114.3 CMR 22.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment)

Transportation (set in accordance with 114.3 CMR 27.00 Ambulance Services)

2. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation at the comparable POS rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. In determining the rates for Individual Support and Community Habilitation, EOHHS used the most recent complete state fiscal year UFR available and determined the average across providers of that service for each line item, which are then used to build each rate.

The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

Individual Support and Community Habilitation (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

Community Based Day Supports (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Support Services)

3. For waiver services in which there is no comparable state plan or EOHHS POS rate, a rate for the waiver service was developed and established under 101 CMR 359.00 after public hearing pursuant to MGL Chapter 118E, Section 13D, and as described below. This applies to the following waiver services: Adult Companion, Chore, Day Services, Homemaker, Agency Personal Care and Supported Employment.

For Adult Companion, Agency Personal Care, Chore Services, Homemaker Services, rates were developed using applicable FY2016 agency data for comparable services provided through the Executive Office of Elder Affairs (EOEA) Home Care Program, which provides elders in the Commonwealth with long term services and supports that enable them to live in the community, and is the largest purchaser of these services. Home Care Program services include Adult Companion, Agency Personal Care, Chore Services, and Homemaker Services. For these services, the median of contracted service prices excluding the outliers was found. Outliers were removed for any pricing in the database that was 2 standard deviations away from the mean for that service. For Agency Personal Care, Chore Services, and Homemaker Services, this median was used as the rate. For Adult Companion, however, this methodology yielded a median slightly lower than the previously established rate for Adult Companion; therefore the previous Adult Companion rate was maintained. The methodology and data sources used in this 2016 analysis were consistent with the method used previously in past analysis. Calculations were performed using SAS statistical software.

Rates for Day Services were developed using FY2010 contract data for Community Based Day Support Services purchased by the Department of Developmental Services, and remained unchanged from the prior effective rate period based on provider input gathered during the public hearing process for the proposed updates to the rates established under 101 CMR 359.00. The FY2010 contract data for Community Based Day Support Services was based on model budgets for providers of this service, which included line items for staff salaries (including management and direct care staff), tax and fringe benefits, occupancy, other expenses and administrative allocation. The salaries used to impute direct care resources reflect the weighted average for the applicable job titles. The unit cost elements for the other direct program costs are based on the median for the applicable input. The model budget was based on a provider capacity of 15 clients, operating at 90% of this capacity, with a ratio of 1 staff member for every 3 clients.

Rates for Supported Employment Services are based on historic rates for such services from the rate regulation 114.4 CMR 10.00: Rates for Competitive Integrated Employment Services. The rates were then updated with a retrospective CAF of 6.86%. Data for the calculation of the CAF came from Global Insights. The CAF is the percent increase between the base period index number (i.e., the listed index value for 2012Q3) and the effective period index number (i.e., the average of the index numbers over the effective period of the rate regulation [2017Q1 through 2018Q4]).

4. Home Accessibility Adaptations, Respite and Transitional Assistance are paid at Individual Consideration (IC). Where IC rates are designated, the appropriate payment rate is determined in accordance with the following standards and criteria established in 101 CMR 359.00:

(a) the amount of time required to complete the service or item;

(b) the degree of skill required to complete the service or item;

(c) the severity or complexity of the service or item;

(d) the lowest price charged or accepted from any payer for the same or similar service or item, including, but not limited to any shelf price, sale price, advertised price, or other price reasonably obtained by a competitive market for the service or item; and

(e) the established rates, policies, procedures, and practices of any other purchasing governmental unit in purchasing the same or similar services or items.

All costs that are not eligible for federal financial participation, such as room and board, are specifically excluded from the rate computation of any waiver services.

The waiver case manager will inform the participant of the availability of information about waiver services payment rates and 101 CMR 359.00.

Massachusetts Waiver# MA.40701.R02.01 

MA Acquired Brain Injury w/Residential Habilitation

Waiver Name:
MA Acquired Brain Injury w/Residential Habilitation
Effective Date:
5/1/2018
Expiration Date:
4/30/2023

Services

List of Services for Massachusetts Waiver# MA.40701.R02.01

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.40701.R02.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
Cost Neutrality Year 5 786

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.40701.R02.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 99 1003 $9.15
Community Based Day Supports 15 minutes 60 3457 $5.16
Day Services per diem 349 123 $102.90

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.40701.R02.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 130 1034 $10.62
Community Based Day Supports 15 minutes 236 3565 $5.99
Day Services per diem 382 127 $119.45

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.40701.R02.01

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. The HCBS rate regulation was last updated effective January 1, 2017. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

The rates for all waiver services in this waiver were established in accordance with the above statutory requirements. Additional information on the rate development for each waiver service follows.

The ABI waiver rates can be found in EOHHS ABI waiver services regulations 101 CMR 359.00 (Rates for Home and Community Based Services Waivers). The regulation can be found on the MassHealth website: www.mass.gov/eohhs/gov/departments/masshealth/

101 CMR 359.00 establishes rates for waiver services based on and tied to existing rate setting methodologies for similar/same services when possible. As such, the rates for waiver services in this waiver are established in one of four ways, as follows:

1. For waiver services in which there is a comparable Medicaid state plan rate, the waiver service rate was established in regulation at the comparable Medicaid state plan rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All Medicaid state plan rates were established in regulation pursuant to this same statutory requirement. Medicaid State Plan rates are developed using provider cost data submitted to the Center for Health Information and Analysis (CHIA) in accordance with provider cost reporting requirements under 957 CMR 6.00: Cost Reporting Requirements. The provider cost data is used to calculate rates that meet the statutory rate adequacy requirements noted above. There are no differences in the rate methodology between these state plan and waiver services. No additional CAF was used for the waiver services using the comparable state plan rate. This applies to the following waiver services:

Occupational, Physical and Speech Therapy (set in accordance with 114.3 CMR 50.00: Rates for Home Health Services for agency services and 114.3 CMR 39.00 Rehabilitation Center Services out-of-office visit rates for Individual Providers)

Specialized Medical Equipment (set in accordance with 114.3 CMR 22.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment)

Transportation (set in accordance with 114.3 CMR 27.00 Ambulance Services)

2. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation at the comparable POS rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. In determining the rates for Residential Habilitation and Shared Living – 24 Hour Supports, EOHHS used the most recent complete state fiscal year UFR available and determined the average across providers of that service for each line item, which are then used to build each rate.

The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

Residential Habilitation (set in accordance with 101 CMR 420.00 Rates for Adult Long-Term Residential Services)

Shared Living – 24 Hour Supports (set in accordance with 101 CMR 411.00 Rates for Certain Placement and Support Services)

Community Based Day Supports (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Support Services)

3. For waiver services in which there is no comparable state plan or EOHHS POS rate, a rate for the waiver service was developed and established under 101 CMR 359.00 after public hearing pursuant to MGL Chapter 118E, Section 13D, and as described below. This applies to the following waiver services: Assisted Living, Day Services and Supported Employment.

Rates for Assisted Living were developed from the previously effective MFP Waiver rate regulation at 101 CMR 357.00. The historic rates were based on existing rates for comparable service components (including personal care, skilled nursing visits, and homemaker, supportive home care aide, and individual support/community habilitation, where applicable), and weighted by projected units per week. The rates remained unchanged based on provider input gathered during the public hearing process for the proposed rate updates to the rates established under 101 CMR 359.00.

Rates for Day Services were developed using FY2010 contract data for Community Based Day Support Services purchased by the Department of Developmental Services, and remained unchanged from the prior effective rate period based on provider input gathered during the public hearing process for the proposed updates to the rates established under 101 CMR 359.00. The FY2010 contract data for Community Based Day Support Services was based on model budgets for providers of this service, which included line items for staff salaries (including management and direct care staff), tax and fringe benefits, occupancy, other expenses and administrative allocation. The salaries used to impute direct care resources reflect the weighted average for the applicable job titles. The unit cost elements for the other direct program costs are based on the median for the applicable input. The model budget was based on a provider capacity of 15 clients, operating at 90% of this capacity, with a ratio of 1 staff member for every 3 clients.

Rates for Supported Employment Services are based on historic rates for such services from the rate regulation 114.4 CMR 10.00: Rates for Competitive Integrated Employment Services. The rates were then updated with a retrospective CAF of 6.86%. Data for the calculation of the CAF came from Global Insights. The CAF is the percent increase between the base period index number (i.e., the listed index value for 2012Q3) and the effective period index number (i.e., the average of the index numbers over the effective period of the rate regulation [2017Q1 through 2018Q4]).

4. Transitional Assistance is paid at Individual Consideration (IC). Where IC rates are designated, the appropriate payment rate is determined in accordance with the following standards and criteria established in 101 CMR 359.00:

(a) the amount of time required to complete the service or item;

(b) the degree of skill required to complete the service or item;

(c) the severity or complexity of the service or item;

(d) the lowest price charged or accepted from any payer for the same or similar service or item, including, but not limited to any shelf price, sale price, advertised price, or other price reasonably obtained by a competitive market for the service or item; and

(e) the established rates, policies, procedures, and practices of any other purchasing governmental unit in purchasing the same or similar services or items.

All costs that are not eligible for federal financial participation, such as room and board, are specifically excluded from the rate computation of any waiver services. The waiver case manager will inform the participant of the availability of information about waiver services payment rates and 101 CMR 359.00.

Waiver Name:
MA Adult Supports
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Massachusetts Waiver# MA.0828.R02.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.0828.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4530 6730

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.0828.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Supported Employment 15 minutes 1591 2292 $3.94
Day Habilitation Supplement 15 minutes 361 2519 $4.31
Community Based Day Supports 15 minutes 2301 3254 $3.76
Individual Supported Employment 15 minutes 1139 506 $11.96
Individual Day Supports 15 minutes 94 2941 $5.30

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.0828.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Supported Employment 15 minutes 2364 2292 $4.15
Day Habilitation Supplement 15 minutes 536 2519 $4.55
Community Based Day Supports 15 minutes 3419 3254 $3.96
Individual Supported Employment 15 minutes 1692 506 $12.62
Individual Day Supports 15 minutes 140 2941 $5.58

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.0828.R02.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

Additional information on the rate development for waiver service follows.

1. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in POS regulation after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. EOHHS uses the most recent complete state fiscal year UFR available to determine the average across providers of that service for each line item, which are then used to build each rate. The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

- Behavioral Supports and Consultation (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Community Based Day Supports (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Support Services)

- Day Habilitation Supplement (set in accordance with 101 CMR 424.00: Rates for Certain Developmental and Support Services)

- Family Training (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services; Family Training rate)

- Group Supported Employment (set in accordance with 101 CMR 419: Rates for Supported Employment Services)

- Individualized Home Supports (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

- Individual Supported Employment (set in accordance with 101 CMR 419: Rates for Supported Employment Services)

- Peer Support (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Respite (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Stabilization (set in accordance with 101 CMR 412.00: Rates for Family Transitional Support Services)

2. Agency-based, per-trip transportation services: Massachusetts has a coordinated statewide Human Service Transportation (HST) brokerage system with six Regional Transit Authorities currently brokering and managing consumer trips throughout the state. Brokers arrange transportation services by subcontracting with local qualified transportation providers. Work volume for transportation providers can be as limited as occasional trips for mid-day medical appointments to long-term, multiple days a week, route-structured program services. For Demand-response trips, contracted providers will be awarded trips on a daily basis based on lowest price, availability and prior performance. Program-Based trips for a specific destination, frequency and time, usually operating on a daily or regularly scheduled basis were procured for a five year period beginning July 1, 2015. Additional routes are added as needed. Contracts are awarded based on lowest price, availability and prior performance.

3. Self-directed services with employer authority are paid through the Fiscal Employer Agent (FEA/FMS) at rates within an established range of payment. Participants may determine staff wages within the established range of payment. The minimum that may be paid is the state’s minimum wage, while the maximum is set as the agency provider rate for the service to be provided. These limits apply to wages for the following self-directed waiver services:

- Adult Companion and Chore(maximum rates set in accordance with 101 CMR 359.00)

- Behavioral Supports and Consultation, Family Training, Peer Support, and Respite (maximum rates set in accordance with 101 CMR 414.00)

- Individualized Home Supports (maximum rate set in accordance with 101 CMR 423.00)

- Individual Supported Employment (maximum rate set in accordance with 101 CMR 419.00)

4. For waiver services in which there is no comparable Medicaid state plan or EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation after public hearing pursuant to Massachusetts General Laws Chapter 118E, Section 13D, and as described below. This approach applies to the following waiver services as described below.

- Rates for Adult Companion and Chore are set in accordance with 101 CMR 359.00: Rates for Home and Community Based Services Waivers, and were established based on data for comparable services provided through the Executive Office of Elder Affairs (EOEA) Home Care Program, which is the largest purchaser of these services. The most current data for SFY 2016 was used, and rates were adjusted to the median rate paid for each of these services under the Home Care Program. The EOEA Home Care Program provides elders in the Commonwealth with long term services and supports that enable them to live in the community. The Home Care Program includes participants in the Frail Elder Waiver as well as other participants served at state cost. Home Care program services include Adult Companion and Chore Services. For these specific services, the median of contracted service prices excluding the outliers was found. Outliers were removed for any pricing in the database that was 2 standard deviations away from the mean for that service. This median is used as the rate for Chore Services. For Adult Companion, however, the methodology yielded a median slightly lower than the previously established rate for Adult Companion, and therefore the previous Adult Companion rate was maintained. The methodology and data sources used in this 2016 analysis were consistent with the method used previously in past analysis. The calculation of the median and exclusion of outliers were performed using SAS statistical software.

5. Purchase of goods as waiver services are paid according to the cost of the good. These are all self-directed waiver services, therefore all payments for purchase of goods are made through the FEA/FMS and purchased through a self-directed budget. This approach applies to the following waiver services:

- Assistive Technology

- Home Modifications

- Individual Goods and Services

- Specialized Medical Equipment and Supplies

- Transportation – transit passes only

- Vehicle Modification

6. Other self-directed services in which there is no comparable Medicaid state plan or EOHHS Purchase of Service (POS) rate are established as described below, specific to the following waiver services:

- Self-directed, per-mile Transportation is paid in accordance with the IRS standard mileage rate.

- Individualized Day Supports are paid through the Fiscal Employer Agent (FEA/FMS) at rates determined by the participant. The minimum that may be paid is the state’s minimum wage, while the maximum is determined by the participant within their individual self-directed budget limit.

All costs that are not eligible for federal financial participation, such as room and board, are excluded from the rate computation. EOHHS establishes the rates for all waiver services that are the basis for the draw of federal funds and claiming of these expenditures on the CMS-64. The rates are presented at a public meeting scheduled by EOHHS and upon approval are entered into the Meditech system and MMIS.

DDS negotiates contracts with service providers and pays providers at the regulated rates of payment. For services with multiple payment rates, claims for FFP are submitted at a provisional rate equal to the average of the contract rates for each service. At the end of each waiver year a final rate is established for each service based on the total costs for and utilization of each waiver service. Claims are then adjusted to account for any differences between the provisional and final rate.

Information about payment rates is available on the DDS website and is shared by service coordinators with waiver participants at the time of the service planning meeting.

Waiver Name:
MA Community Living
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Massachusetts Waiver# 0826.R02.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# 0826.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2591 2691

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# 0826.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Supported Employment 15 minutes 606 2027 $4.00
Day Habilitation Supplement 15 minutes 227 2315 $4.31
Community Based Day Supports 15 minutes 873 3000 $3.76
Individual Supported Employment 15 minutes 538 518 $12.05
Individual Day Supports 15 minutes 61 2421 $5.32

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# 0826.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Supported Employment 15 minutes 629 2027 $4.22
Day Habilitation Supplement 15 minutes 236 2315 $4.55
Community Based Day Supports 15 minutes 907 3000 $3.96
Individual Supported Employment 15 minutes 558 518 $12.71
Individual Day Supports 15 minutes 63 2421 $5.60

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# 0826.R02.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

Additional information on the rate development for waiver service follows.

1. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in POS regulation after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. EOHHS uses the most recent complete state fiscal year UFR available to determine the average across providers of that service for each line item, which are then used to build each rate. The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

- Behavioral Supports and Consultation (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Community Based Day Supports (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Support Services)

- Day Habilitation Supplement (set in accordance with 101 CMR 424.00: Rates for Certain Developmental and Support Services)

- Family Training (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services; Family Training rate)

- Group Supported Employment (set in accordance with 101 CMR 419: Rates for Supported Employment Services)

- Individualized Home Supports (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

- Individual Supported Employment (set in accordance with 101 CMR 419: Rates for Supported Employment Services)

- Peer Support (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Respite (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Stabilization (set in accordance with 101 CMR 412.00: Rates for Family Transitional Support Services)

2. Agency-based, per-trip transportation services: Massachusetts has a coordinated statewide Human Service Transportation (HST) brokerage system with six Regional Transit Authorities currently brokering and managing consumer trips throughout the state. Brokers arrange transportation services by subcontracting with local qualified transportation providers. Work volume for transportation providers can be as limited as occasional trips for mid-day medical appointments to long-term, multiple days a week, route-structured program services. For Demand-response trips, contracted providers will be awarded trips on a daily basis based on lowest price, availability and prior performance. Program-Based trips for a specific destination, frequency and time, usually operating on a daily or regularly scheduled basis were procured for a five year period beginning July 1, 2015. Additional routes are added as needed. Contracts are awarded based on lowest price, availability and prior performance.

3. Self-directed services with employer authority are paid through the Fiscal Employer Agent (FEA/FMS) at rates within an established range of payment. Participants may determine staff wages within the established range of payment. The minimum that may be paid is the state’s minimum wage, while the maximum is set as the agency provider rate for the service to be provided. These limits apply to wages for the following self-directed waiver services:

- Adult Companion and Chore(maximum rates set in accordance with 101 CMR 359.00)

- Behavioral Supports and Consultation, Family Training, Peer Support, and Respite (maximum rates set in accordance with 101 CMR 414.00)

- Individualized Home Supports (maximum rate set in accordance with 101 CMR 423.00)

- Individual Supported Employment (maximum rate set in accordance with 101 CMR 419.00)

- Live-In Caregiver (maximum rate set in accordance with DDS rate methodology described below)

4. For waiver services in which there is no comparable Medicaid state plan or EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation after public hearing pursuant to Massachusetts General Laws Chapter 118E, Section 13D, and as described below. This approach applies to the following waiver services as described below.

- Rates for Adult Companion and Chore are set in accordance with 101 CMR 359.00: Rates for Home and Community Based Services Waivers, and were established based on data for comparable services provided through the Executive Office of Elder Affairs (EOEA) Home Care Program, which is the largest purchaser of these services. The most current data for SFY 2016 was used, and rates were adjusted to the median rate paid for each of these services under the Home Care Program. The EOEA Home Care Program provides elders in the Commonwealth with long term services and supports that enable them to live in the community. The Home Care Program includes participants in the Frail Elder Waiver as well as other participants served at state cost. Home Care program services include Adult Companion and Chore Services. For these specific services, the median of contracted service prices excluding the outliers was found. Outliers were removed for any pricing in the database that was 2 standard deviations away from the mean for that service. This median is used as the rate for Chore Services. For Adult Companion, however, the methodology yielded a median slightly lower than the previously established rate for Adult Companion, and therefore the previous Adult Companion rate was maintained. The methodology and data sources used in this 2016 analysis were consistent with the method used previously in past analysis. The calculation of the median and exclusion of outliers were performed using SAS statistical software.

5. Purchase of goods as waiver services are paid according to the cost of the good. These are all self-directed waiver services, therefore all payments for purchase of goods are made through the FEA/FMS and purchased through a self-directed budget. This approach applies to the following waiver services:

- Assistive Technology

- Home Modifications

- Individual Goods and Services

- Specialized Medical Equipment and Supplies

- Transportation – transit passes only

- Vehicle Modification

6. Other self-directed services in which there is no comparable Medicaid state plan or EOHHS Purchase of Service (POS) rate are established as described below, specific to the following waiver services:

- Rates for Live-In Caregiver are developed and updated annually by DDS based on regional and population-based HUD Fair Market Rent (FMR) and USDA average moderate food cost data, respectively, with a multiplier adjusted to assure individuals are able to obtain fair market value apartments in their chosen town. The rate calculation is updated every January based upon the previous year’s HUD and USDA data. The formulas for computing the maximum per diem and monthly rates for Live-In Caregiver are as follows:

Maximum Live-In Caregiver Monthly Rate = [(HUD FMR for the municipality in which the individual resides x 1.5) ÷ 2] + USDA Cost of Food

Maximum Live-In Caregiver Per Diem Rate = (Maximum Live-In Caregiver Monthly Rate x 12) ÷ 365

The HUD Fair Market Rates for a 2 bedroom home in Massachusetts for Fiscal Year 2018: https://www.huduser.gov/portal/datasets/fmr/fmrs/FY2018_code/2018state_summary.odn

Please note: when using this link, select New State: Massachusetts, select Statewide FMRs, the town to town rates are found on the FY2018 Massachusetts FMR Local Area Summary table.

The Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, November 2017 moderate food plan costs for an individual (male and female) between the ages of 19 and 71+ for the month of November 2017.

https://www.cnpp.usda.gov/sites/default/files/CostofFoodNov2017.pdf

- Self-directed, per-mile Transportation is paid in accordance with the IRS standard mileage rate.

- Individualized Day Supports are paid through the Fiscal Employer Agent (FEA/FMS) at rates determined by the participant. The minimum that may be paid is the state’s minimum wage, while the maximum is determined by the participant within their individual self-directed budget limit.

All costs that are not eligible for federal financial participation, such as room and board, are excluded from the rate computation. EOHHS establishes the rates for all waiver services that are the basis for the draw of federal funds and claiming of these expenditures on the CMS-64. The rates are presented at a public meeting scheduled by EOHHS and upon approval are entered into the Meditech system and MMIS.

DDS negotiates contracts with service providers and pays providers at the regulated rates of payment. For services with multiple payment rates, claims for FFP are submitted at a provisional rate equal to the average of the contract rates for each service. At the end of each waiver year a final rate is established for each service based on the total costs for and utilization of each waiver service. Claims are then adjusted to account for any differences between the provisional and final rate.

Information about payment rates is available on the DDS website and is shared by service coordinators with waiver participants at the time of the service planning meeting.

Waiver Name:
MA Intensive Supports
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Massachusetts Waiver# MA.0827.R02.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.0827.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
10118 11518

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.0827.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Supported Employment 15 minutes 1235 2138 $3.90
Day Habilitation Supplement 15 minutes 1833 2271 $4.31
Community Based Day Supports 15 minutes 2858 3803 $3.77
Individual Supported Employment 15 minutes 680 522 $11.91
Individual Day Supports 15 minutes 76 4160 $5.31

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.0827.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Supported Employment 15 minutes 1406 2138 $4.10
Day Habilitation Supplement 15 minutes 2087 2271 $4.55
Community Based Day Supports 15 minutes 3253 3803 $3.97
Individual Supported Employment 15 minutes 774 522 $12.57
Individual Day Supports 15 minutes 86 4160 $5.59

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.0827.R02.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D and MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

Additional information on the rate development for waiver service follows.

1. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in POS regulation after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations or administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. EOHHS uses the most recent complete state fiscal year UFR available to determine the average across providers of that service for each line item, which are then used to build each rate. The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

- Behavioral Supports and Consultation (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Community Based Day Supports (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Support Services)

- Day Habilitation Supplement (set in accordance with 101 CMR 424.00: Rates for Certain Developmental and Support Services)

- Family Training (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services; Family Training rate)

- Group Supported Employment (set in accordance with 101 CMR 419: Rates for Supported Employment Services)

- Individualized Home Supports (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

- Individual Supported Employment (set in accordance with 101 CMR 419: Rates for Supported Employment Services)

- Peer Support (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Residential Habilitation (set in accordance with 101 CMR 420.00: Rates for Adult Long-Term Residential Services)

- Respite (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

- Stabilization (set in accordance with 101 CMR 412.00: Rates for Family Transitional Support Services)

2. Agency-based, per-trip transportation services: Massachusetts has a coordinated statewide Human Service Transportation (HST) brokerage system with six Regional Transit Authorities currently brokering and managing consumer trips throughout the state. Brokers arrange transportation services by subcontracting with local qualified transportation providers. Work volume for transportation providers can be as limited as occasional trips for mid-day medical appointments to long-term, multiple days a week, route-structured program services. For Demand-response trips, contracted providers will be awarded trips on a daily basis based on lowest price, availability and prior performance. Program-Based trips for a specific destination, frequency and time, usually operating on a daily or regularly scheduled basis were procured for a five year period beginning July 1, 2015. Additional routes are added as needed. Contracts are awarded based on lowest price, availability and prior performance.

3. Self-directed services with employer authority are paid through the Fiscal Employer Agent (FEA/FMS) at rates within an established range of payment. Participants may determine staff wages within the established range of payment. The minimum that may be paid is the state’s minimum wage, while the maximum is set as the agency provider rate for the service. These limits apply to wages for the following self-directed waiver services:

- Adult Companion and Chore (maximum rates set in accordance with 101 CMR 359.00)

- Behavioral Supports and Consultation, Family Training, Peer Support, and Respite (maximum rates set in accordance with 101 CMR 414.00)

- Individualized Home Supports (maximum rate set in accordance with 101 CMR 423.00)

- Individual Supported Employment (maximum rate set in accordance with 101 CMR 419.00)

- 24-Hour Self Directed Home Sharing Support (maximum rate set in accordance with 101 CMR 411.00)

- Live-In Caregiver (maximum rate set in accordance with DDS rate methodology described below)

4. For waiver services in which there is no comparable Medicaid state plan or EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation after public hearing pursuant to Massachusetts General Laws Chapter 118E, Section 13D, and as described below. This approach applies to the following waiver services as described below.

- Rates for Adult Companion and Chore are set in accordance with 101 CMR 359.00: Rates for Home and Community Based Services Waivers, and were established based on data for comparable services provided through the Executive Office of Elder Affairs (EOEA) Home Care Program, which is the largest purchaser of these services. The most current data for SFY 2016 was used, and rates were adjusted to the median rate paid for each of these services under the Home Care Program. The EOEA Home Care Program provides elders in the Commonwealth with long term services and supports that enable them to live in the community. The Home Care Program includes participants in the Frail Elder Waiver as well as other participants served at state cost. Home Care program services include Adult Companion and Chore Services. For these services, the median of contracted service prices excluding the outliers was found. Outliers were removed for any pricing in the database that was 2 standard deviations away from the mean for that service. This median is used as the rate for Chore Services. For Adult Companion, however, the methodology yielded a median slightly lower than the previously established rate for this service, and therefore the previous Adult Companion rate was maintained. The methodology and data sources used in this 2016 analysis were consistent with the method used in past analysis. The calculation of the median and exclusion of outliers were performed using SAS statistical software.

5. Purchase of goods as waiver services are paid according to the cost of the good. These are self-directed services, therefore payments for purchase of goods are made through the FEA/FMS and purchased through a self-directed budget:

-Assistive Technology

-Home Modifications

-Individual Goods and Services

-Specialized Medical Equipment and Supplies

-Transitional Assistance

-Transportation – transit passes

-Vehicle Modification

6. Other self-directed services in which there is no comparable Medicaid state plan or EOHHS Purchase of Service (POS) rate are established as described below:

- Rates for Live-In Caregiver are developed and updated annually by DDS based on regional and population-based HUD Fair Market Rent (FMR) and USDA average moderate food cost data, respectively, with a multiplier adjusted to assure individuals are able to obtain fair market value apartments in their chosen town. The rate calculation is updated every January based upon the previous year’s HUD and USDA data. Formulas for computing the maximum per diem and monthly rates for Live-In Caregiver are as follows:

Maximum Live-In Caregiver Monthly Rate = [(HUD FMR for the municipality in which the individual resides x 1.5) ÷ 2] + USDA Cost of Food

Maximum Live-In Caregiver Per Diem Rate = (Maximum Live-In Caregiver Monthly Rate x 12) ÷ 365

The HUD Fair Market Rates for a 2 bedroom home in Massachusetts for Fiscal Year 2018: https://www.huduser.gov/portal/datasets/fmr/fmrs/FY2018_code/2018state_summary.odn

Note: Select New State: Massachusetts > Statewide FMRs, the town to town rates are found on the FY2018 Massachusetts FMR Local Area Summary table.

The Official USDA Food Plans: Cost of Food at Home at Four Levels, U.S. Average, November 2017 moderate food plan costs for an individual (male and female) between the ages of 19 and 71+ for the month of November 2017.

https://www.cnpp.usda.gov/sites/default/files/CostofFoodNov2017.pdf

- Self-directed, per-mile Transportation is paid in accordance with the IRS standard mileage rate.

- Individualized Day Supports are paid through the Fiscal Employer Agent (FEA/FMS) at rates determined by the participant. The minimum that may be paid is the state’s minimum wage, while the maximum is determined by the participant within their individual self-directed budget limit.

All costs that are not eligible for federal financial participation, such as room and board, are excluded from the rate computation. EOHHS establishes the rates for all waiver services that are the basis for the draw of federal funds and claiming of these expenditures on the CMS-64. The rates are presented at a public meeting scheduled by EOHHS and upon approval are entered into the Meditech system and MMIS.

DDS negotiates contracts with service providers and pays providers at the regulated rates of payment. For services with multiple payment rates, claims for FFP are submitted at a provisional rate equal to the average of the contract rates for each service. At the end of each waiver year a final rate is established for each service based on the total costs for and utilization of each waiver service. Claims are then adjusted to account for any differences between the provisional and final rate.

Information about payment rates is available on the DDS website and is shared by service coordinators with waiver participants at the time of the service planning meeting.

Massachusetts Waiver# MA.1027.R01.00 

MA MFP Community Living

Waiver Name:
MA MFP Community Living
Effective Date:
4/1/2018
Expiration Date:
3/31/2023

Services

List of Services for Massachusetts Waiver# MA.1027.R01.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.1027.R01.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
843 1243

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.1027.R01.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services 15 minutes 25 1307 $9.15
Supported Employment 15 minutes 42 268 $9.15
Community Based Day Supports 15 minutes 42 3061 $5.16
Day Services per diem 33 69 $102.90
Individual Support and Community Habilitation 15 minutes 594 1274 $10.91

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.1027.R01.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services 15 minutes 37 1360 $10.62
Supported Employment 15 minutes 62 279 $10.62
Community Based Day Supports 15 minutes 186 3185 $5.99
Day Services per diem 49 71 $119.45
Individual Support and Community Habilitation 15 minutes 876 1325 $24442.00

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.1027.R01.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. The HCBS rate regulation was last updated effective January 1, 2017. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

The rates for all waiver services in this waiver were established in accordance with the above statutory requirements. Additional information on the rate development for each waiver service follows.

The MFP waiver rates can be found in EOHHS MFP waiver services regulations 101 CMR 359.00 (Rates for Home and Community Based Services Waivers). The regulation can be found on the MassHealth website: www.mass.gov/eohhs/gov/departments/masshealth/

101 CMR 359.00 establishes rates for waiver services based on and tied to existing rate setting methodologies for similar/same services when possible. As such, the rates for waiver services in this waiver are established in one of four ways, as follows:

1. For waiver services in which there is a comparable Medicaid state plan rate, the waiver service rate was established in regulation at the comparable Medicaid state plan rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All Medicaid state plan rates were established in regulation pursuant to this same statutory requirement. Medicaid State Plan rates are developed using provider cost data submitted to the Center for Health Information and Analysis (CHIA) in accordance with provider cost reporting requirements under 957 CMR 6.00: Cost Reporting Requirements. The provider cost data is used to calculate rates that meet the statutory rate adequacy requirements noted above. There are no differences in the rate methodology between these state plan and waiver services. No additional CAF was used for the waiver services using the comparable state plan rate. This applies to the following waiver services:

Skilled Nursing (set in accordance with 114.3 CMR 50.00 Home Health Services; Rates for Skilled Nursing Services) Occupational, Physical and Speech Therapy (114.3 CMR 50.00: Rates for Home Health Services for agency services and

114.3 CMR 39.00 Rehabilitation Center Services out-of-office visit rates for Individual Providers)

Home Health Aide and Supportive Home Care Aide (114.3 CMR 50.00: Rates for Home Health Services) Specialized Medical Equipment (114.3 CMR 22.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment)

Transportation (114.3 CMR 27.00 Ambulance Services)

Non-agency Personal Care (101 CMR 309.00: Independent Living Services for the Personal Care Attendant Program)

2. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation at the comparable POS rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. In determining the rates for Community Family Training, Individual Support and Community Habilitation, and Peer Support, EOHHS used the most recent complete state fiscal year UFR available and determined the average across providers of that service for each line item, which are then used to build each rate.

The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

Family Training (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services; Family Training rate)

Individual Support and Community Habilitation (101 CMR 423.00: Rates for Certain In-Home Basic Living Supports) Peer Support (101 CMR 414.00: Rates for Family Stabilization Services)

Community Based Day Supports (101 CMR 415.00: Rates for Community-Based Day Support Services) Community Behavioral Health Support and Navigation (101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

3. For waiver services in which there is no comparable state plan or EOHHS POS rate, a rate for the waiver service was developed and established under 101 CMR 359.00 after public hearing pursuant to MGL Chapter 118E, Section 13D, and as described below. This applies to the following waiver services: Adult Companion, Chore, Day Services, Homemaker, Independent Living Supports, Orientation and Mobility Services, Agency Personal Care, Pre-Vocational Services, Shared Home Supports and Supported Employment.

For Adult Companion, Agency Personal Care, Chore Services, Homemaker Services, rates were developed using applicable FY2016 agency data for comparable services provided through the Executive Office of Elder Affairs (EOEA) Home Care Program, which provides elders in the Commonwealth with long term services and supports that enable them to live in the community, and is the largest purchaser of these services. Home Care Program services include Adult Companion, Agency Personal Care, Chore Services, and Homemaker Services. For these services, the median of contracted service prices excluding the outliers was found. Outliers were removed for any pricing in the database that was 2 standard deviations away from the mean for that service. For Agency Personal Care, Chore Services, and Homemaker Services, this median was used as the rate. For Adult Companion, however, this methodology yielded a median slightly lower than the previously established rate for Adult Companion; therefore the previous Adult Companion rate was maintained. The methodology and data sources used in this 2016 analysis were consistent with the method used previously in past analysis. Calculations were performed using SAS statistical software.

Rates for Day Services were developed using FY2010 contract data for Community Based Day Support Services purchased by the Department of Developmental Services, and remained unchanged from the prior effective rate period based on provider input gathered during the public hearing process for the proposed updates to the rates established under 101 CMR 359.00. The FY2010 contract data for Community Based Day Support Services was based on model budgets for providers of this service, which included line items for staff salaries (including management and direct care staff), tax and fringe benefits, occupancy, other expenses and administrative allocation. The salaries used to impute direct care resources reflect the weighted average for the applicable job titles. The unit cost elements for the other direct program costs are based on the median for the applicable input. The model budget was based on a provider capacity of 15 clients, operating at 90% of this capacity, with a ratio of 1 staff member for every 3 clients.

Rates for Independent Living Supports and Shared Home Supports were developed from the previously effective MFP Waiver rate regulation at 101 CMR 357.00. The historic rates were based on existing rates for comparable service components (including personal care, skilled nursing visits, and homemaker, supportive home care aide, and individual support/community habilitation, where applicable), and weighted by projected units per week. The rates remained unchanged based on provider input gathered during the public hearing process for the proposed rate updates to the rates established under 101 CMR 359.00.

Rates for Orientation and Mobility services were based on the historic rate for such services from 101 CMR 356.00: Rates for Money Follows the Person Demonstration Services. The rates remained unchanged based on provider input gathered during the public hearing process for the proposed rate updates to the rates established under 101 CMR 359.00.

Rates for Prevocational and Supported Employment Services are based on historic rates for such services from the rate regulation 114.4 CMR 10.00: Rates for Competitive Integrated Employment Services. The rates were then updated with a retrospective CAF of 6.86%. Data for the calculation of the CAF came from Global Insights. The CAF is the percent increase between the base period index number (i.e., the listed index value for 2012Q3) and the effective period index number (i.e., the average of the index numbers over the effective period of the rate regulation [2017Q1 through 2018Q4]). 4. Home Accessibility Adaptations, Respite, Transitional Assistance and Vehicle Modification are paid at Individual Consideration (IC). Where IC rates are designated, the appropriate payment rate is determined in accordance with the following standards and criteria established in 101 CMR 359.00:

(a) the amount of time required to complete the service or item;

(b) the degree of skill required to complete the service or item;

(c) the severity or complexity of the service or item;

(d) the lowest price charged or accepted from any payer for the same or similar service or item, including, but not limited to any shelf price, sale price, advertised price, or other price reasonably obtained by a competitive market for the service or item; and

(e) the established rates, policies, procedures, and practices of any other purchasing governmental unit in purchasing the same or similar services or items.

All costs that are not eligible for federal financial participation, such as room and board, are specifically excluded from the rate computation of any waiver services.

The waiver case manager will inform the participant of the availability of information about waiver services payment rates and 101 CMR 359.00.

Massachusetts Waiver# MA.1028.R01.00 

MA MFP Residential Supports

Waiver Name:
MA MFP Residential Supports
Effective Date:
4/1/2018
Expiration Date:
3/31/2023

Services

List of Services for Massachusetts Waiver# MA.1028.R01.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.1028.R01.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
364 574

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.1028.R01.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services 15 minutes 24 615 $9.15
Supported Employment 15 minutes 33 350 $9.15
Community Based Day Supports 15 minutes 36 3282 $5.16
Day Services per diem 154 102 $102.90
Individual Support and Community Habilitation 15 minutes 7 401 $10.91

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.1028.R01.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services 15 minutes 38 643 $10.62
Supported Employment 15 minutes 52 366 $10.62
Community Based Day Supports 15 minutes 172 3431 $5.99
Day Services per diem 185 107 $119.45
Individual Support and Community Habilitation 15 minutes 11 419 $12.66

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.1028.R01.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. The HCBS rate regulation was last updated effective January 1, 2017. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied.

The rates for all waiver services in this waiver were established in accordance with the above statutory requirements. Additional information on the rate development for each waiver service follows.

The MFP waiver rates can be found in EOHHS MFP waiver services regulations 101 CMR 359.00 (Rates for Home and Community Based Services Waivers). The regulation can be found on the MassHealth website: www.mass.gov/eohhs/gov/departments/masshealth/

101 CMR 359.00 establishes rates for waiver services based on and tied to existing rate setting methodologies for similar/same services when possible. As such, the rates for waiver services in this waiver are established in one of four ways, as follows:

1. For waiver services in which there is a comparable Medicaid state plan rate, the waiver service rate was established in regulation at the comparable Medicaid state plan rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All Medicaid state plan rates were established in regulation pursuant to this same statutory requirement. Medicaid State Plan rates are developed using provider cost data submitted to the Center for Health Information and Analysis (CHIA) in accordance with provider cost reporting requirements under 957 CMR 6.00: Cost Reporting Requirements. The provider cost data is used to calculate rates that meet the statutory rate adequacy requirements noted above. There are no differences in the rate methodology between these state plan and waiver services. No additional CAF was used for the waiver services using the comparable state plan rate.

This applies to the following waiver services:

Skilled Nursing (set in accordance with 114.3 CMR 50.00 Home Health Services; Rates for Skilled Nursing Services)

Occupational, Physical and Speech Therapy (set in accordance with 114.3 CMR 50.00: Rates for Home Health Services for agency services and 114.3 CMR 39.00 Rehabilitation Center Services out-of-office visit rates for Individual Providers)

Specialized Medical Equipment (set in accordance with 114,3 CMR 22.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment)

Transportation (set in accordance with 114.3 CMR 27.00 Ambulance Services)

2. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in regulation at the comparable POS rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. In determining the rates for Residential Habilitation, Shared Living – 24 Hour Supports, Residential Family Training, Individual Support and Community Habilitation, and Peer Support, EOHHS used the most recent complete state fiscal year UFR available and determined the average across providers of that service for each line item, which are then used to build each rate.

The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

Family Training (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services; Family Training rate)

Individual Support and Community Habilitation (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

Peer Support (set in accordance with 101 CMR 414.00: Rates for Family Stabilization Services)

Residential Habilitation (set in accordance with 101 CMR 420.00 Rates for Adult Long-Term Residential Services)

Shared Living – 24 Hour Supports (set in accordance with 101 CMR 411.00 Rates for Certain Placement and Support Services)

Community Based Day Supports (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Support Services)

Community Behavioral Health Support and Navigation (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

3. For waiver services in which there is no comparable state plan or EOHHS POS rate, a rate for the waiver service was developed and established under 101 CMR 359.00 after public hearing pursuant to MGL Chapter 118E, Section 13D, and as described below.

This applies to the following waiver services: Assisted Living, Day Services, Orientation and Mobility Services, Pre-Vocational Services, and Supported Employment.

Rates for Assisted Living were developed from the previously effective MFP Waiver rate regulation at 101 CMR 357.00. The historic rates were based on existing rates for comparable service components (including personal care, skilled nursing visits, and homemaker, supportive home care aide, and individual support/community habilitation, where applicable), and weighted by projected units per week. The rates remained unchanged based on provider input gathered during the public hearing process for the proposed rate updates to the rates established under 101 CMR 359.00.

Rates for Day Services were developed using FY2010 contract data for Community Based Day Support Services purchased by the Department of Developmental Services, and remained unchanged from the prior effective rate period based on provider input gathered during the public hearing process for the proposed updates to the rates established under 101 CMR 359.00. The FY2010 contract data for Community Based Day Support Services was based on model budgets for providers of this service, which included line items for staff salaries (including management and direct care staff), tax and fringe benefits, occupancy, other expenses and administrative allocation. The salaries used to impute direct care resources reflect the weighted average for the applicable job titles. The unit cost elements for the other direct program costs are based on the median for the applicable input. The model budget was based on a provider capacity of 15 clients, operating at 90% of this capacity, with a ratio of 1 staff member for every 3 clients.

Rates for Orientation and Mobility services were based on the historic rate for such services from 101 CMR 356.00: Rates for Money Follows the Person Demonstration Services. The rates remained unchanged based on provider input gathered during the public hearing process for the proposed rate updates to the rates established under 101 CMR 359.00.

Rates for Prevocational and Supported Employment Services are based on historic rates for such services from the rate regulation 114.4 CMR 10.00: Rates for Competitive Integrated Employment Services. The rates were then updated with a retrospective CAF of 6.86%. Data for the calculation of the CAF came from Global Insights. The CAF is the percent increase between the base period index number (i.e., the listed index value for 2012Q3) and the effective period index number (i.e., the average of the index numbers over the effective period of the rate regulation [2017Q1 through 2018Q4]).

4. Home Accessibility Adaptations and Transitional Assistance are paid at Individual Consideration (IC). Where IC rates are designated, the appropriate payment rate is determined in accordance with the following standards and criteria established in 101 CMR 359.00:

(a) the amount of time required to complete the service or item;

(b) the degree of skill required to complete the service or item;

(c) the severity or complexity of the service or item;

(d) the lowest price charged or accepted from any payer for the same or similar service or item, including, but not limited to any shelf price, sale price, advertised price, or other price reasonably obtained by a competitive market for the service or item; and

(e) the established rates, policies, procedures, and practices of any other purchasing governmental unit in purchasing the same or similar services or items.

All costs that are not eligible for federal financial participation, such as room and board, are specifically excluded from the rate computation of any waiver services.

The waiver case manager will inform the participant of the availability of information about waiver services payment rates and 101 CMR 359.00.

Waiver Name:
MA TBI
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Massachusetts Waiver# MA.0359.R04.00

Cost Neutrality

Cost Neutrality for Massachusetts Waiver# MA.0359.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
100 100

Year 1 Waiver Services

List of Year 1 Waiver Services for Massachusetts Waiver# MA.0359.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Individual Support and Community Habilitation 15 minutes 28 478 $12.82
Supported Employment 15 minutes 15 minutes 1 876 $13.01
Supported Employment Intake, Evaluation and Assessment episode 1 1 $865.98
Supported Employment Job-targeted Educational and Skills Training Activities episode 1 1 $2363.34
Supported Employment - Job Development and Placement episode 1 1 $4764.42
Supported Employment - Initial Employment Supports episode 1 1 $1701.36
Day Services 15 minutes 16 2780 $5.96

Year 5 Waiver Services

List of Year 5 Waiver Services for Massachusetts Waiver# MA.0359.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Individual Support and Community Habilitation 15 minutes 28 478 $13.99
Supported Employment 15 minutes 15 minutes 3 876 $14.09
Supported Employment Intake, Evaluation and Assessment episode 4 1 $937.37
Supported Employment Job-targeted Educational and Skills Training Activities episode 4 1 $2558.16
Supported Employment - Job Development and Placement episode 4 1 $5157.16
Supported Employment - Initial Employment Supports episode 4 1 $1841.61
Day Services 15 minutes 16 2780 $6.45

Rate Determination Methods

Rate Determination Methods for Massachusetts Waiver# MA.0359.R04.00

EOHHS is required by state law to develop rates for health services purchased by state governmental units, and which includes rates for waiver services purchased under this waiver. State law further requires that rates established by EOHHS for health services must be “adequate to meet the costs incurred by efficiently and economically operated facilities providing care and services in conformity with applicable state and federal laws and regulations and quality and safety standards and which are within the financial capacity of the commonwealth.” See MGL Chapter 118E Section 13C. This statutory rate adequacy mandate guides the development of all rates described herein.

In establishing rates for health services, EOHHS is required by statute to complete a public process that includes issuance of a notice of the proposed rates with an opportunity for the public to provide written comment, and EOHHS is required to hold a public hearing to provide an opportunity for the public to provide oral comment. See MGL Chapter 118E Section 13D; see also MGL Chapter 30A Section 2. The purpose of this public process is to ensure that the public (and in particular, providers) are given advance notice of proposed rates and the opportunity to provide feedback, both orally and in writing, to ensure that proposed rates meet the statutory rate adequacy requirements noted above.

All rates established in regulation by EOHHS are required by statute to be reviewed biennially and updated as applicable, to ensure that they continue to meet the statutory rate adequacy requirements. See MGL Chapter 118E Section 13D. In updating rates to ensure continued compliance with statutory rate adequacy requirements, a cost adjustment factor (CAF) or other updates to the rate models may be applied. The cost adjustment factor for all rates using such a factor is from the Massachusetts Consumer Price Index optimistic forecast provided by Global Insight, based on an average for the prospective two-year period during which the rate will apply.

Additional information on the rate development for waiver services follows.

1. For waiver services in which there is a comparable Medicaid state plan service and rate, the waiver service rate was established in regulation at the comparable Medicaid state plan rate after public hearing pursuant to MGL Chapter 118E, Section 13D. All Medicaid state plan rates were established in regulation pursuant to this same statutory requirement. Medicaid State Plan rates are developed using provider cost data submitted to the Center for Health Information and Analysis (CHIA) in accordance with provider cost reporting requirements under 957 CMR 6.00: Cost Reporting Requirements. The provider cost data is used to calculate rates that meet the statutory rate adequacy requirements noted above. There are no differences in the rate methodology between these state plan and waiver services. No additional CAF was used for the waiver services using the comparable state plan rate. This applies to the following waiver services:

-Specialized Medical Equipment (set in accordance with 101 CMR 322.00 (formerly 114.3 CMR 22.00): Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment). These regulations establish a process for determining the price of equipment. This same process is used to determine the cost of the specific item being purchased as Specialized Medical Equipment. The rate is determined at the time of purchasing.

For these rates, no productivity expectations and administrative ceiling calculations have been used in establishing the rates.

2. Transportation services: Massachusetts has a coordinated statewide Human Service Transportation (HST) brokerage system with six Regional Transit Authorities currently brokering and managing consumer trips throughout the state. Brokers arrange transportation services by subcontracting with local qualified transportation providers. Work volume for transportation providers can be as limited as occasional trips for mid-day medical appointments to long-term, multiple days a week, route-structured program services. For Demand-response trips, contracted providers will be awarded trips on a daily basis based on lowest price, availability and prior performance. Program-Based trips for a specific destination, frequency and time, usually operating on a daily or regularly scheduled basis were procured for a five year period beginning July 1, 2015. Additional routes are added as needed. Contracts are awarded based on lowest price, availability and prior performance.

3. For waiver services where there is a comparable EOHHS Purchase of Service (POS) rate, the waiver service rate was established in POS regulation after public hearing pursuant to MGL Chapter 118E, Section 13D. All POS rates were established in regulation pursuant to this statutory requirement. In accordance with Massachusetts General Laws (MGL) Chapter 118E, Section 13D Duties of ratemaking authority; criteria for establishing rates, the rates are reviewed every two years. POS rates are developed using Uniform Financial Reporting (UFR) data submitted to the Massachusetts Operational Services Division, in accordance with UFR reporting requirements under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services, which requires providers to submit UFRs on an annual basis. EOHHS uses UFR data to calculate rates that meet statutory adequacy requirements described above. No productivity expectations and administrative ceiling calculations were used in establishing these rates. UFR data demonstrates expenses of providers of a particular service for particular line items. Specifically, UFRs include line items such as staff salaries; tax and fringe benefits; expenses such as training, occupancy, supplies and materials, or other expenses specific to each service; and administrative allocation. EOHHS uses these line items from UFRs submitted by providers as components in the buildup for the rates for particular services by determining the average for each line item across all providers. EOHHS uses the most recent complete state fiscal year UFR available to determine the average across providers of that service for each line item, which are then used to build each rate. When analyzing a variable that is relatively normally distributed, EOHHS considers an outlier as data that falls two or more standard deviations from its mean. In general, outliers belong to one of two categories: a mistake in the data or a true outlier. Depending on the data set being analyzed, an outlier would generally be handled by either excluding the outlier data or capping the outlier data so that the outlier data would not adversely affect the ability of EOHHS to develop rates applicable to providers of a particular service.

The waiver service rate is set at the comparable EOHHS POS rate for the following waiver services:

-Adult Companion and Individual Support and Community Habilitation (set in accordance with 101 CMR 423.00: Rates for Certain In-Home Basic Living Supports)

-Day Services (set in accordance with 101 CMR 415.00: Rates for Community-Based Day Supports)

- Homemaker Services (set in accordance with 101 CMR 422.00: General Programs – Disability Services)

-Residential Habilitation (set in accordance with 101 CMR 420.00 Rates for Adult Long-Term Residential Services)

-Shared Living – 24 Hour Supports (set in accordance with 101 CMR 411.00 Rates for Certain Placement and Support Services)

-Rates for Supported Employment Services (set in accordance with 101 CMR 419: Rates for Supported Employment Services, and 101 CMR 410: Rates for Competitive Integrated Employment Services)

No productivity expectations and administrative ceiling calculations have been used in establishing these rates.

4. Home Accessibility Adaptations, Respite, Transitional Assistance are paid at Individual Consideration (IC). Where IC rates are designated, the appropriate payment rate is determined in accordance with the following standards and criteria:

(a) the amount of time required to complete the service or item;

(b) the degree of skill required to complete the service or item;

(c) the severity or complexity of the service or item;

(d) the lowest price charged or accepted from any payer for the same or similar service or item, including, but not limited to any shelf price, sale price, advertised price, or other price reasonably obtained by a competitive market for the service or item; and

(e) the established rates, policies, procedures, and practices of any other purchasing governmental unit in purchasing the same or similar services or items.

The State does not establish a limit or maximum allowable rate for home accessibility adaptations, respite or transitional assistance services.

All costs that are not eligible for federal financial participation, such as room and board, are specifically excluded from the rate computation of any waiver services.

The waiver case manager informs participants of the availability of information about waiver services payment rates during service planning meetings.

Michigan Waiver# MI.0167.R06.00 

MI Habilitation Supports Waiver

Waiver Name:
MI Habilitation Supports Waiver
Effective Date:
10/1/2019
Expiration Date:
9/30/2024

Services

List of Services for Michigan Waiver# MI.0167.R06.00

Cost Neutrality

Cost Neutrality for Michigan Waiver# MI.0167.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
8268 8268

Year 1 Waiver Services

List of Year 1 Waiver Services for Michigan Waiver# MI.0167.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Out of the Home Non Vocational Habilitation 15 minutes 1489 5477 $4.35
Prevocational Services hour 379 679 $15.19
Supported Employment 15 minutes 496 721 $7.52

Year 5 Waiver Services

List of Year 5 Waiver Services for Michigan Waiver# MI.0167.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Out of the Home Non Vocational Habilitation 15 minutes 1489 5477 $4.71
Prevocational Services hour 379 679 $16.44
Supported Employment 15 minutes 496 721 $8.14

Rate Determination Methods

Rate Determination Methods for Michigan Waiver# MI.0167.R06.00

This §1915(c) waiver operates concurrently with the Michigan 1115 Behavioral Health Demonstration. Please refer to the Michigan's §1115 Waiver application and associated materials.

Minnesota Waiver# MN.0166.R06.00 

MN Community Access for Disabled Disability Inclusion

Waiver Name:
MN Community Access for Disabled Disability Inclusion
Effective Date:
6/1/2016
Expiration Date:
5/31/2021

Services

List of Services for Minnesota Waiver# MN.0166.R06.00

Cost Neutrality

Cost Neutrality for Minnesota Waiver# MN.0166.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
26250 35570

Year 1 Waiver Services

List of Year 1 Waiver Services for Minnesota Waiver# MN.0166.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service Decremental 1856 1161 $6.67
Prevocational Services daily/hour 3037 233 $37.01
Supported Employment 15 minutes 2074 745 $7.10
Employment Development Service 15 minutes 0 0 $10.28
Employment Exploration Service 15 minutes 0 0 $10.24
Employment Support Services 15 minutes 0 0 $10.24

Year 5 Waiver Services

List of Year 5 Waiver Services for Minnesota Waiver# MN.0166.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service Decremental 2516 1000 $7.53
Prevocational Services 15 minutes 91 120 $11.01
Supported Employment 15 minutes 0 641 $8.02
Employment Development Service 15 minutes 885 404 $13.16
Employment Exploration Service 15 minutes 463 404 $10.97
Employment Support Services 15 minutes 3463 1615 $10.97

Rate Determination Methods

Rate Determination Methods for Minnesota Waiver# MN.0166.R06.00

Minnesota pays for services in 3 ways.

1. DHS sets rates for state plan services, including home care, home care nursing & PCA services. These rates are approved in the state plan. Personal care for participants who elect CDCS are not state-set rates.

DHS establishes rates for case management, ext PCA, homemaker, home-delivered meals & chore services. Case management is paid at $24.47/15-min unit. Ext PCA is paid for 1:1, 1:2 and 1:3 ratios at $4.35, $3.26 and $2.86 respectively per 15-min units. For persons eligible for 12 or more hours of daily PCA, ext PCA rates are increased by 7.5% when the service is provided by persons who have completed the required training. Homemaker (home management & w/ADLs) is paid at $4.61/15- min unit, home-delivered meals are paid at $6.53/meal, and chore services are paid at $3.76/15-min unit. These rates are subject to COLA increases as enacted by the Legislature.

2. Market rates are used when services are purchased at the price typically charged on a market basis. Market rate services:

-24-hour emergency assistance

-Caregiver Living Expenses

-Crisis Respite

-Environmental Accessibility Adaptations

-Family Training & Counseling

-Homemaker (cleaning component)

-Respite (daily)

-Specialized Equipment & Supplies

-Transitional Services (Expenses)

-Public Transportation

-Specialist Services

3. For all other waiver services, rate methods are described in MN Stat. 256B.4914 and calculated in the rate management system (RMS). Rate methods are grouped into 4 categories:

Payment for residential support services:

-Customized living

-Foster Care

Payment for day program services:

-Adult Day Service/Adult Day Service Bath

-Prevocational Services

Payments for unit-based services w/programming:

-Independent Living Skills Training

-Individualized Home Supports

-In-Home Family Supports

-Personal Support Services

-Positive Support Services

-Housing Access Coordination

-Employment Exploration

-Employment Development

-Employment Support

Payments for unit-based services w/o programming:

-Respite (15-min unit)

-Adult Companion

-Night Supervision

These rate methods share many similar values, calculations and expense categories with some variations within each. Rates are determined by common calculations and factors.

Rate methods are applied statewide. Online technology is utilized to determine payment rates for all disability waiver services. Using individualized participant information and information collected from providers, lead agencies enter information into RMS that calculates individualized participant payment rates based on the person's service plan. RMS takes into consideration shared and individual staffing.

Information entered into RMS includes: shared and individual staffing hours, direct RN and LPN hours, staffing ratios, information to document variable levels of service qualification for variable levels of reimbursement in each framework, shared or individualized arrangements for unit-based services, and service hours provided thourough monitoring technology.

Provider related expenses include direct service wages, supervision, employee-related cost factors (required tax and benefit obligations), and client and program overhead factors (expenses related to indirect support of service delivery unless otherwise indicated in service specific definition). Provider related costs are multiplied by required service units to provide a rate for each individual waiver participant. These factors are fixed across all providers.

In all rate categories, direct staffing wage costs are the main driver of rates. A base wage index was established using MN-specific wages taken from job descriptions and standard occupational classification codes from the BLS Occupational Handbook. A competitive workforce factor multiplier is applied to the direct staffing wage to address the difference in average wages for direct care staff and other occupations with similar education, training, and experience requirements, as identified by the BLS Occupational Handbook. For the CADI and BI waivers, customized living is not affected by the competitive workforce factor as its rate is determined under a rate-setting framework in state statute for the Elderly Waiver. The framework for customized living, which relies on base wage and additional cost factors based on established data sources, was implemented on January 1, 2019. The Minnesota Legislature did not apply a competitive workforce factor to this newly established framework.

The average wages are adjusted to differentiate between shared and individual staffing. The system takes into account shared staffing, when staff are available to provide services to more than one person and individual staffing, and when direct care staff are available to solely provide support as a one-to-one interaction with a specific individual. Other personnel expenses are added to produce a provider's rate for individuals including a supervisory span of control which accounts for the number of subordinates a supervisor has during the time service is provided and an added customization rate for assisting those in need of deaf/hard of hearing support. All those providers' expenses are multiplied by factors for relief staffing, ancillary staff needs, employee-related taxes and benefits and client programming, including transportation. Client programming costs, including transportation, to provide individuals access to the community or care in their home as defined in a support plan are also considered.

Within the 4 different rates categories, some fixed components, which apply to only one specific category, are added separately. These include: transportation and client programming and support for residential services, facility use factor for day services, and meals and snacks for adult day.

Automatic inflationary adjustments within the model will impact the component values every two years, beginning with 7/1/22. COLAs (after-model rate increases) enacted by the legislature will also impact these component values prior to the implementation of the automatic inflationary adjustments (rebase) within the model. When the inflationary adjustments within the model are updated using BLS and CPI, the COLAs enacted by the legislature will be replaced by the inflationary adjustments within the model. If a legislative COLA occurs in the years between rebasing, they will add to component values prior to and until the next rebase.

DHS maintains a document with these values at mn.gov/dhs/assets/2019-DWRS-component-values_tcm1053-356458.pdf

For individuals who use sign language and do not hear/understand speech and require staff to be fluent signers of ASL Deaf/Hard of hearing (DHOH) customization option is available in the RMS. This customization applies to individuals who meet Long Term Care and screening criteria. Staff who are fluent in ASL must provide the service, and the staff must employ this skill in the provision of service to an individual who meets the screening criteria.

There are circumstances when an individual may have exceptional needs which cannot be met by an increase in service units in RMS. In these cases, lead agencies may submit an exception request to increase an individual's service rate based on the person's service plan, as described in Minn. Stat. 256B.4914, subd. 14. Exception requests will be reviewed on an individual basis and approved or denied by the state. Individuals may appeal any denial of an exception request.

Specific exception policies exist for the following services (see Appendix C): environmental accessibility adaptations, CDCS, extended PCA and remote support.

Implementation of new RMS system began 1/1/14 and was completed in 1 year. All service plans were entered into the RMS during individual annual reviews by 12/31/14.

To mitigate overpayments, rate file limits are set in MMIS. While some services with state established singular rates only allow for payments at an exact, actual rate, framework and market rate services may be billed at varying rates with a rate file limit established to function as a protection in the system. Rate file limits for every service offered under the disability waivers are based on analysis of historic unit rates in the MMIS system. These rate file limits are changed as rate adjustments occur. The department sets rate file limits for all services, regardless of payment methodology, as found in the Long-Term Services & Supports Rate Limits document: www.dhs.state.mn.us/dhs16_151043.pdf

Providers delivering services with rates determined under MN Stat. 256B.4914 are required to report business costs every 5 yrs. The state will analyze data for each service at the individual, provider, lead agency and state levels and provide reports which include rate re-base recommendations to the legislature on 1/15/21 & every 4 yrs thereafter.

DHS uses several methods to monitor functions delegated to lead agencies, to ensure support plans are being met, ensure equitable access to services for participants, and to evaluate purchase. These included lead agency reviews and by regionally assigned staff as outlined in Appdx A.

To monitor rate system integrity, DHS will analyze data & create two types of reports to ensure that lead agencies accurately enter required elements in RMS to produce correct payment rates. An analysis, conducted annually, will identify high and low outliers at the individual service level. A second, annual analysis will be conducted thourough random sample and will assess systems continuity by service and region and identify data trends that may indicate inconsistent RMS utilization. These reports will be issued to lead agencies for analysis and necessary correction. Regional staff will conduct follow-up and assistance to ensure appropriate remediation.

For residential supports and day program services, the licensing process under Chapter 245D will involve a comparison of the staffing hours and staffing ratios used for purposes of the payment rate to the actual staffing hours and ratios in a sampling of case files, as part of ensuring that needs identified in the community support plan have been met. Where staffing hours/ratios are not sufficient to meet identified needs, remediation will occur thourough the licensing process as identified in Chapter 245D. This process began with technical assistance visits in July 2014, with a 2-yr licensing review cycle beginning January 2015.

For residential supports and day services, the lead agency review process will be modified to review individual needs identified in the support plan in comparison to the staffing hours/ratios identified for purposes of the payment rates. This review may be used to inform the determination in the licensing process as to whether needs identified in the support plan have been met.

Beginning 2012 and every 2 yrs thereafter, the state conducts a gaps analysis and reports to the Legislature on the capacity and gaps in long-term care services and supports.

All reports are available upon request.

Minnesota Waiver# MN.4128.R07.03 

Community Alternative Care (CAC) Waiver

Waiver Name:
Community Alternative Care (CAC) Waiver
Effective Date:
4/1/2018
Expiration Date:
3/31/2023

Services

List of Services for Minnesota Waiver# MN.4128.R07.03

Cost Neutrality

Cost Neutrality for Minnesota Waiver# MN.4128.R07.03

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
736 991

Year 1 Waiver Services

List of Year 1 Waiver Services for Minnesota Waiver# MN.4128.R07.03

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service decremental 1 1142 $7.15
Supported Employment 15 minutes 1 566.04 $8.68
Employment Development Services 15 minutes 5 400 $12.46
Employment Exploration Services 15 minutes 5 400 $10.39
Employment Support Services 15 minutes 15 1600 $10.39

Year 5 Waiver Services

List of Year 5 Waiver Services for Minnesota Waiver# MN.4128.R07.03

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service decremental 1 1142 $8.24
Supported Employment day 0 0 $10.00
Employment Development Services 15 minutes 10 400 $14.35
Employment Exploration Services 15 minutes 10 400 $11.96
Employment Support Services 15 minutes 28 1600 $11.96

Rate Determination Methods

Rate Determination Methods for Minnesota Waiver# MN.4128.R07.03

Minnesota pays for services in 3 ways.

1. DHS sets rates for state plan services, including home care services, home care nursing & PCA services. These rates are approved in the state plan. Personal care for participants who elect CDCS are not state-set rates.

DHS establishes rates for case management, ext PCA, homemaker, home-delivered meals and chore services. Case management is paid at $24.47 per 15-min unit. Ext PCA is paid for 1:1, 1:2 and 1:3 ratios at $4.35, $3.26 and $2.86 respectively per 15-min units. For persons eligible for 12 or more hours of daily PCA, ext PCA rates are increased by 7.5% when the service is provided by persons who have completed the required training. Homemaker (home management w/ADLs) is paid at $4.61/15- min unit, home-delivered meals are paid at $6.53/meal, and chore services are paid at $3.76/15 min unit. These rates are subject to COLA increases as enacted by the Legislature.

2. Market rates are used when services are purchased at the price typically charged on a market basis. Market rate services:

-24 hour emergency assistance

-Caregiver Living Expenses

-Crisis Respite

-Environmental Accessibility Adaptations

-Family Training and Counseling

-Homemaker (cleaning component)

-Respite (daily)

-Specialized Equipment & Supplies

-Transitional Services

-Transportation

-Specialist Services

3. For all other waiver services, rate methods are described in MN Stat. 256B.4914 and calculated in the rate management system (RMS). Rate methods are grouped into 4 categories:

Payment for residential support services:

-Foster Care

Payment for day program services:

-Adult Day Service

Payments for unit-based services with programming:

-Independent Living Skills Training

-Individualized Home Supports

-In-Home Family Supports

-Personal Support

-Positive Support

-Housing Access Coordination

-Employment Exploration

-Employment Development

-Employment Support

And payments for unit-based services w/o programming:

-Night Supervision

-Respite (15-min unit)

-Adult Companion

These rate methods share many similar values, calculations and expense categories with some variations within each. Rates are determined by common calculations and factors.

Rate methods are applied statewide. Online technology is utilized to determine payment rates for all waiver services. Using individualized participant information and information collected from providers, lead agencies enter information into the RMS that calculates individualized payment rates based on the person's service plan. RMS takes into consideration shared and individual staffing. Information entered into RMS includes: shared and individual staffing hours, direct RN & LPN hours, staffing ratios, information to document variable levels of service qualification for variable levels of reimbursement in each framework, shared or individualized arrangements for unit-based services, and service hours provided thourough monitoring technology.

Provider related expenses include direct service wages, supervision, employee-related cost factors (required tax and benefit obligations), and client and program overhead factors (expenses related to indirect support of service delivery unless otherwise indicated in service specific definition). Provider related costs are multiplied by required service units to provide a rate for each waiver participant. These factors are fixed across all providers.

In all rate categories, direct staffing wage costs are the main driver of rates. A base wage index was established using MN-specific wages taken from job descriptions and standard occupational classification codes from the BLS Occupational Handbook. A competitive workforce factor multiplier is applied to the direct staffing wage to address the difference in average wages for direct care staff and other occupations with similar education, training, and experience requirements, as identified by the BLS Occupational Handbook. The average wages are adjusted to differentiate between shared and individual staffing. The system takes into account shared staffing, when staff are available to provide services to more than one person and individual staffing, and when direct care staff are available to solely provide support as a one-to-one interaction with a specific individual. Other personnel expenses are added to produce a provider's rate for individuals including a supervisory span of control which accounts for the number of subordinates a supervisor has during the time service is provided and an added customization rate for assisting those in need of deaf/hard of hearing support. All those provider's expenses are multiplied by factors for relief staffing, ancillary staff needs, employee-related taxes and benefits and client programming, including transportation. Client programming costs, including transportation to provide individuals access to the community or care in their home as defined in a support plan are also considered.

Within the 4 rates categories, some fixed components, which apply to only one specific category, are added separately. These include: transportation & client programming and support for residential services, facility use factor for day services, meal & snacks for adult day.

Automatic inflationary adjustments within the model will impact the component values every two years, beginning 7/1/22. COLAs (after-model rate increases) enacted by the legislature will also impact these component values prior to the implementation of the automatic inflationary adjustments (rebase) within the model. When the inflationary adjustments within the model are updated using BLS and CPI, the COLAs enacted by the legislature will be replaced by the inflationary adjustments within the model. If a legislative COLA occurs in the years between rebasing, they will add to component values prior to and until the next rebase.

DHS maintains a document with these values at https://mn.gov/dhs/assets/2019-DWRS-component-values_tcm1053- 356458.pdf

For individuals who use sign language and do not hear/understand speech and require staff to be fluent signers of ASL Deaf/Hard of hearing (DHOH) customization option is available in the RMS. This customization applies to individuals who meet Long Term Care and screening criteria. Staff who are fluent in ASL must provide the service, and the staff must employ this skill in the provision of service to an individual who meets the screening criteria.

There are circumstances when an individual may have exceptional needs which cannot be met by an increase in service units in RMS. In these cases, lead agencies may submit an exception request to increase an individual's service rate based on the person's service plan as described in 256B.4914, subd. 14. Exception requests will be reviewed on an individual basis and approved or denied by the state. Individuals may appeal any denial of an exception request.

Specific exception policies exist for the following services (see Appendix C, service definitions): environmental accessibility adaptations, CDCS, extended PCA and remote support.

Implementation of new RMS system began 1/1/14 and was completed in 1 year. All service plans were entered into the RMS during individual annual reviews by 12/31/14.

To mitigate overpayments, rate file limits are set in MMIS. While some services with state established singular rates only allow for payments at an exact, actual rate, framework and market rate services may be billed at varying rates with a rate file limit established to function as a protection in the system. Rate file limits for every service offered under the disability waivers are based on analysis of historic unit rates in the MMIS system. These rate file limits are changed as rate adjustments occur. DHS sets rate file limits for all services, regardless of payment methodology, as found in the Long-Term Services and Supports Rate Limits document:

https://edocs.dhs.state.mn.us/lfserver/Public/DHS-3945-ENG

Providers delivering services with rates determined under MN Stat. 256B.4914 are required to report business costs every 5 yrs. The state will analyze data for each service at the individual, provider, lead agency and state levels and provide reports which include rate re-base recommendations to the legislature on 1/15/21 and every 4 yrs thereafter.

DHS uses several methods to monitor waiver functions delegated to lead agencies, to ensure support plans are being met, ensure equitable access to services for participants, and to evaluate purchase. These include lead agency reviews and regionally assigned staff as outlined in Appdx A.

To monitor rate system integrity, DHS will analyze data and create 2 types of reports to ensure that lead agencies accurately enter required elements in RMS to produce correct payment rates. An analysis, conducted annually, will identify high and low outliers at the individual service level. A second, annual analysis will be conducted thourough random sample and will assess systems continuity by service and region and identify data trends that may indicate inconsistent RMS utilization. These reports will be issued to lead agencies for analysis and necessary correction. Regional staff will conduct follow-up and assistance to ensure appropriate remediation.

For residential supports and day program services, the licensing process under chapter 245D will involve a comparison of the staffing hours and staffing ratios used for purposes of the payment rate to the actual staffing hours and ratios in a sampling of case files, as part of ensuring that needs identified in the community support plan have been met. Where staffing hours/ratios are not sufficient to meet identified needs, remediation will occur thourough the licensing process as identified in chapter 245D. This process began with technical assistance visits in 07/14, with a 2-yr licensing review cycle beginning 01/15.

For residential supports and day program services, the lead agency review process will be modified to review individual needs identified in the support plan in comparison to the staffing hours/ratios identified for purposes of the payment rates. This review may be used to inform the determination in the licensing process as to whether needs identified in the support plan have been met.

Beginning 2012 and every 2 years thereafter, the state conducts a gaps analysis and reports to the Legislature on the capacity and gaps in long-term care services and supports.

All reports are available upon request.

Minnesota Waiver# MN.0061.R07.07 

MN Developmental Disabilities

Waiver Name:
MN Developmental Disabilities
Effective Date:
10/27/2017
Expiration Date:
10/26/2022

Services

List of Services for Minnesota Waiver# MN.0061.R07.07

Cost Neutrality

Cost Neutrality for Minnesota Waiver# MN.0061.R07.07

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
20432 25154

Year 1 Waiver Services

List of Year 1 Waiver Services for Minnesota Waiver# MN.0061.R07.07

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service decremental 428 1691.92 $8.14
Day Training and Habilitation decremental 11393 243.82 $72.77
Prevocational Services decremental 353 170.82 $47.31
Supported Employment 15 minutes 1356 810.97 $7.83
Employment Development Services 15 minutes 126 228.57 $10.24
Employment Exploration Services 15 minutes 126 228.57 $10.24
Employment Support Services 15 minutes 441 1.48 $5953.59

Year 5 Waiver Services

List of Year 5 Waiver Services for Minnesota Waiver# MN.0061.R07.07

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service decremental 527 1598.51 $9.10
Day Training and Habilitation decremental 14026 157.65 $81.29
Prevocational Services decremental 0 162.5 $44.89
Supported Employment 15 minutes 0 766.19 $8.75
Employment Development Services 15 minutes 974 430 $13.72
Employment Exploration Services 15 minutes 693 430 $11.43
Employment Support Services 15 minutes 5369 1722 $6.58

Rate Determination Methods

Rate Determination Methods for Minnesota Waiver# MN.0061.R07.07

Minnesota pays for services in 3 ways.

1. DHS sets rates for state plan services, including PCA services. These rates are approved in the state plan. Personal care for participants who elect CDCS are not state-set rates.

DHS establishes rates for case management, ext PCA, homemaker, home-delivered meals & chore services. Case management is paid at $23.19/15-min unit. Ext PCA is paid for 1:1, 1:2 and 1:3 ratios at $4.35, $3.26 and $2.86 respectively per 15-min units. For persons eligible for 12 or more hours of daily PCA, ext PCA rates are increased by 7.5%, when the service is provided by persons who have completed the required training. Homemaker (home management & w/ADLs) is paid at $4.61/15- min unit, home-delivered meals are paid at $6.53/meal, and chore services are paid at $3.76/15 min unit. These rates are subject to COLA increases as enacted by the Legislature.

2. Market rates are used when services are purchased at the price typically charged on a market basis.

Market rate services:

24 hour emergency assistance Assistive technology Caregiver Living Expenses Crisis Respite

Environmental Accessibility Adaptations Family Training & Counseling Homemaker (cleaning component) Specialized Equipment & Supplies Respite (daily)

Transitional Services Transportation Specialist Services

3. For all other services, rate methods are described in MN Stat. 256B.4914 and calculated in the rate management system (RMS). Rate methods are grouped into 4 categories:

Payment for residential support services:

Residential Habilitation (SLS in foster care)

Payment for day program services:

Adult Day Service/Adult Day Service Bath Prevocational Services

Day Training & Habilitation

Payments for unit-based services w/programming:

Independent Living Skills Training Positive supports

Personal supports

Housing Access Coordination

Residential Habilitation (In-Home Family Support & SLS own home) Employment Exploration

Employment Development Employment Support

Payments for unit-based services w/o programming:

Night Supervision Respite (15-min unit)

These rate methods share many similar values, calculations and expense categories with some variations within each. Rates are determined by common calculations & factors.

Rate methods are applied statewide. Online technology is utilized to determine payment rates for all services. Using individualized participant information and information collected from providers, lead agencies enter information into the RMS that calculates individualized payment rates based on the person's service plan. RMS takes into consideration shared & individual staffing.

Information entered into RMS includes: shared and individual staffing hours, direct RN & LPN hours, staffing ratios, information to document variable levels of service qualification for variable levels of reimbursement in each framework, shared or individualized arrangements for unit-based services, number of miles for DT&H transportation services & service hours provided thourough monitoring technology.

Provider related expenses include direct service wages, supervision, employee-related cost factors (required tax & benefit obligations), & client and program overhead factors (expenses related to indirect support of service delivery unless otherwise indicated in service specific definition). Provider related costs are multiplied by required service units to provide a rate for each participant. These factors are fixed across all providers.

In all rate categories, direct staffing wage costs are the main driver of rates. A base wage index was established using MN-specific wages taken from job descriptions and standard occupational classification codes from the BLS Occupational Handbook. A competitive workforce factor multiplier is applied to the direct staffing wage to address the difference in average wages for direct care staff and other occupations with similar education, training, and experience requirements, as identified by the BLS Occupational Handbook. The average wages are adjusted to differentiate between shared and individual staffing. The system takes into account shared staffing, when staff are available to provide services to more than 1 person and individual staffing, and when direct care staff are available to solely provide support as a 1- to-1 interaction with a specific individual. Other personnel expenses are added to produce a provider's rate for individuals including a supervisory span of control which accounts for the number of subordinates a supervisor has during the time service is provided and an added customization rate for assisting those in need of deaf/hard of hearing support. These provider expenses are multiplied by factors for relief staffing, ancillary staff needs, employee-related taxes & benefits & client programming, including transportation. Client programming costs, including transportation to provide individuals access to the community or care in their home as defined in a support plan are also considered.

Within the 4 rates categories, some fixed components which apply to only 1 specific category, are added separately. These include: transportation & client programming & support for residential services, facility use factor for day services, meal, snacks & bath for adult day, transportation for DT&H.

Automatic inflationary adjustments within the model will impact the component values every two years, beginning with 7/1/22. COLAs (after-model rate increases) enacted by the legislature will also impact these component values prior to the implementation of the automatic inflationary adjustments (rebase) within the model. When the inflationary adjustments within the model are updated using BLS and CPI, the COLAs enacted by the legislature will be replaced by the inflationary adjustments within the model. If a legislative COLA occurs in the years between rebasing, they will add to component values prior to and until the next rebase.

DHS maintains a document with these values at mn.gov/dhs/assets/2019-DWRS-component-values_tcm1053-356458.pdf

For individuals who use sign language and do not hear/understand speech & require staff to be fluent signers of ASL, Deaf/Hard of Hearing (DHOH) customization option is available in the RMS. This customization applies to individuals who meet DD screening criteria. Staff who are fluent signers of ASL must provide the service, and the staff must employ this skill in the provision of service to an individual who meets the screening criteria.

There are circumstances when an individual may have exceptional needs which cannot be met by an increase in service units in RMS. In these cases, lead agencies may submit an exception request to increase an individual's service rate based on the person's service plan as described in 256B.4914 subd. 14. Exception requests will be reviewed on an individual basis and approved or denied by the state. Individuals may appeal any denial of an exception request.

Specific exception policies exist for the following services (see Appdx C): environmental accessibility adaptations, CDCS, extended PCA and remote support.

Implementation of new RMS system began 1/1/14 and was completed in 1 year. All service plans were entered into the RMS during individual annual reviews by 12/31/14. To mitigate overpayments, rate file limits are set in MMIS. While some services with state established singular rates only allow for payments at an exact, actual rate, framework and market rate services may be billed at varying rates with a rate file limit established to function as a protection in the system. Rate file limits for every service offered under the disability waivers are based on analysis of historic unit rates in the MMIS system. These rate file limits are changed as rate adjustments occur. DHS sets rate file limits for all services, regardless of payment methodology, as found in the Long-Term Services & Supports Service Rate Limits document: http://mn.gov/dhs-stat/images/historicrates.pdf

Providers delivering services with rates determined under MN Stat. 256B.4914 are required to report business costs every 5 yrs. The state will analyze data for each service at the individual, provider, lead agency & state levels and provide reports which include rate re-base recommendations to the legislature on 1/15/21 and every 4 yrs thereafter.

DHS uses several methods to monitor functions delegated to lead agencies, to ensure support plans are being met and equitable access to services for participants and to evaluate purchase. These included lead agency reviews by regionally assigned staff as outlined in Appdx A.

To monitor rate system integrity, DHS will analyze data and create 2 types of reports to ensure that lead agencies accurately enter required elements in RMS to produce correct payment rates. An analysis, conducted annually, will identify high and low outliers at the individual service level. A second, annual analysis will be conducted thourough random sample & will assess systems continuity by service and region and identify data trends that may indicate inconsistent RMS utilization. These reports will be issued to lead agencies for analysis & necessary correction. Regional staff will conduct follow-up & assistance to ensure appropriate remediation.

For residential supports & day program services, the licensing process under 245D will involve a comparison of the staffing hours & staffing ratios used for purposes of the payment rate to the actual staffing hours and ratios in a sampling of case files, as part of ensuring that needs identified in the community support plan have been met. Where staffing hours/ratios are not sufficient to meet identified needs, remediation will occur thourough the licensing process as identified in 245D. This process began with technical assistance visits in 7/14, with a 2-yr licensing review cycle beginning 01/15.

For residential supports & day services, the lead agency review process will be modified to review individual needs identified in the support plan in comparison to the staffing hours/ratios identified for purposes of the payment rates. This review may be used to inform the determination in the licensing process as to whether needs identified in the support plan have been met.

Beginning 2012 and every 2 yrs thereafter, the state conducts a gaps analysis and reports to the Legislature on the capacity & gaps in long-term care services & supports.

All reports are available upon request.

Minnesota Waiver# MN.4169.R05.06 

MN Brain Injury Waiver

Waiver Name:
MN Brain Injury Waiver
Effective Date:
4/1/2016
Expiration Date:
3/30/2021

Services

List of Services for Minnesota Waiver# MN.4169.R05.06

Cost Neutrality

Cost Neutrality for Minnesota Waiver# MN.4169.R05.06

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1547 1600

Year 1 Waiver Services

List of Year 1 Waiver Services for Minnesota Waiver# MN.4169.R05.06

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service Decremental 123 1106 $6.99
Prevocational Services daily/hour 328 230 $36.84
Supported Employment day 107 1153 $6.67
Employment Development Service 15 minutes 0 0 $10.28
Employment Exploration Service 15 minutes 0 0 $10.24
Employment Support Services 15 minutes 0 0 $10.24

Year 5 Waiver Services

List of Year 5 Waiver Services for Minnesota Waiver# MN.4169.R05.06

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Service 15 minutes 127 1106.31 $8.05
Prevocational Services daily/hour 123 230.12 $42.43
Supported Employment 15 minutes 0 0 $7.50
Employment Development Service 15 minutes 57 433 $13.73
Employment Exploration Service 15 minutes 38 433 $11.45
Employment Support Services 15 minutes 233 1730 $11.45

Rate Determination Methods

Rate Determination Methods for Minnesota Waiver# MN.4169.R05.06

Minnesota pays for services in 3 ways.

1. DHS sets rates for state plan services, including home care services, home care nursing & PCA. These rates are approved in the state plan. Personal care for participants who elect CDCS are not state-set rates.

DHS establishes rates for case management, ext PCA, homemaker, home-delivered meals & chore services. Case management is paid at $24.47/15-min unit. Ext PCA is paid for 1:1, 1:2 and 1:3 ratios at $4.35, $3.26 and $2.86 respectively per 15-min units. For persons eligible for 12 or more hours of daily PCA, ext PCA rates are increased by 7.5% when the service is provided by persons who have completed required training. Homemaker (home management & w/ADLs) is paid at $4.61/15-min unit, home-delivered meals are paid at $6.53/meal, and chore services are paid at $3.76/15-min unit. These rates are subject to COLA increases as enacted by the Legislature.

2. Market rates are used when services are purchased at the price typically charged on a market basis. Market rate services:

24 hour emergency assistance Caregiver Living Expenses Crisis Respite

Environmental Accessibility Adaptations Family Training & Counseling Homemaker (cleaning component)

ILS Therapies Respite (daily)

Specialized Equipment & Supplies Transitional Services (Expenses) Public Transportation

Specialist Services

3. For all other waiver services, rate methods are described in MN Stat. 256B.4914 and calculated in the rate management system (RMS). Rate methods are grouped into 4 categories:

Payment for residential support services:

Customized living Foster Care

Payment for day program services:

Adult Day Service/Adult Day Service Bath Prevocational Services

Structured Day Programs

Payments for unit-based services w/programming:

Independent Living Skills (ILS) Training Individualized Home Supports

In-Home Family Supports Personal Support Positive Support

Housing Access Coordination Employment Exploration Employment Development Employment Support

And payments for unit-based services w/o programming:

-Night Supervision

-Respite (15-min unit)

-Adult Companion

These rate methods share many similar values, calculations and expense categories with some variations within each. Rates are determined by common calculations and factors. Rate methods are applied statewide. Online technology is utilized to determine payment rates for all disability waiver services. Using individualized participant information and information collected from providers, lead agencies enter information into RMS that calculates individualized participant payment rates based on the person's service plan. RMS takes into consideration shared and individual staffing.

Information entered into RMS includes: shared and individual staffing hours, direct RN and LPN hours, staffing ratios, information to document variable levels of service qualification for variable levels of reimbursement in each framework, shared or individualized arrangements for unit-based services, and service hours provided thourough monitoring technology.

Provider related expenses include direct service wages, supervision, employee-related cost factors (required tax and benefit obligations), and client and program overhead factors (expenses related to indirect support of service delivery unless otherwise indicated in service-specific definition). Provider related costs are multiplied by required service units to provide a rate for each participant. These factors are fixed across all providers.

In all rate categories, direct staffing wage costs are the main driver of rates. A base wage index was established using MN-specific wages taken from job descriptions and standard occupational classification codes from the BLS Occupational Handbook. A competitive workforce factor multiplier is applied to the direct staffing wage to address the difference in average wages for direct care staff and other occupations with similar education, training, and experience requirements, as identified by the BLS Occupational Handbook. For the CADI and BI waivers, customized living is not affected by the competitive workforce factor as its rate is determined under a rate-setting framework in state statute for the Elderly Waiver. The framework for customized living, which relies on base wage and additional cost factors based on established data sources, was implemented on January 1, 2019. The Minnesota Legislature did not apply a competitive workforce factor to this newly established framework.

The average wages are adjusted to differentiate between shared & individual staffing. The system takes into account shared staffing, when staff are available to provide services to more than one person and individual staffing, and when direct care staff are available to solely provide support as a 1-to-1 interaction with a specific individual. Other personnel expenses are added to produce a provider's rate for individuals including a supervisory span of control which accounts for the number of subordinates a supervisor has during the time service is provided and an added customization rate for assisting those in need of deaf/hard of hearing support. All those providers' expenses are multiplied by factors for relief staffing, ancillary staff needs, employee-related taxes and benefits and client programming, including transportation.

Client programming costs, including transportation, to provide individuals access to the community or care in their home as defined in a support plan are also considered.

Within the 4 different rates categories, some fixed components, which apply to only one specific category, are added separately. These include: transportation & client programming & support for residential services, facility use factor for day services, & meals & snacks for adult day.

Automatic inflationary adjustments within the model will impact the component values every two years, beginning with 7/1/22. COLAs (after-model rate increases) enacted by the legislature will also impact these component values prior to the implementation of the automatic inflationary adjustments (rebase) within the model. When the inflationary adjustments within the model are updated using BLS and CPI, the COLAs enacted by the legislature will be replaced by the inflationary adjustments within the model. If a legislative COLA occurs in the years between rebasing, they will add to component values prior to and until the next rebase.

DHS maintains a document with these values at mn.gov/dhs/assets/2019-DWRS-component-values_tcm1053-356458.pdf

For individuals who use sign language and do not hear/understand speech and require staff to be fluent signers of ASL Deaf/Hard of hearing (DHOH) customization option is available in the RMS. This customization applies to individuals who meet Long Term Care screening criteria. Staff who are fluent signers of ASL must provide the service, and the staff must employ this skill in the provision of service to an individual who meets the screening criteria.

There are circumstances when an individual may have exceptional needs which cannot be met by an increase in service units in the RMS. In these cases, lead agencies may submit an exception request to increase an individual's service rate based on the person's service plan, as described in 256B.4914 subd. 14. Exception requests will be reviewed on an individual basis and approved or denied by the state. Individuals may appeal any denial of an exception request. Specific exception policies exist for the following services (see Appendix C): environmental accessibility adaptations, CDCS, extended PCA and remote support.

Implementation of new RMS began 1/1/14 and was completed in 1 year. All service plans were entered into the RMS during individual annual reviews by 12/31/14.

To mitigate overpayments, rate file limits are set in MMIS. While some services with state established singular rates only allow for payments at an exact, actual rate, framework and market rate services may be billed at varying rates with a rate file limit established to function as a protection in the system. Rate file limits for every service offered under the disability waivers are based on analysis of historic unit rates in the MMIS system. These rate file limits are changed as rate adjustments occur. The department sets rate file limits for all services, regardless of payment methodology, as found in the Long-Term Services and Supports Service Rate Limits document: http://www.dhs.state.mn.us/dhs16_151043.pdf

Providers delivering services with rates determined under MN Stat. 256B.4914 are required to report business costs every 5 years. The state will analyze data for each service at the individual, provider, lead agency and state levels and provide reports which include rate rebase recommendations to the legislature on 1/15/21 and every 4 years thereafter.

DHS uses several methods to monitor waiver functions delegated to lead agencies, to ensure support plans are being met, ensure equitable access to services for participants, and to evaluate purchase. These included lead agency reviews and by regionally assigned staff as outlined in Appdx A.

To monitor rate system integrity, DHS will analyze data and create 2 types of reports to ensure that lead agencies accurately enter required elements in RMS to produce correct payment rates. An analysis, conducted annually, will identify high and low outliers at the individual service level. A second, annual analysis will be conducted thourough random sample and will assess systems continuity by service and region and identify data trends that may indicate inconsistent RMS utilization. These reports will be issued to lead agencies for analysis and necessary correction. Regional staff will conduct follow-up and assistance to ensure appropriate remediation.

For residential supports and day services, the licensing process under MN Statutes, chapter 245D will involve a comparison of the staffing hours and staffing ratios used for purposes of the payment rate to the actual staffing hours and ratios in a sampling of case files, as part of ensuring that needs identified in the support plan have been met. Where staffing hours/ratios are not sufficient to meet identified needs, remediation will occur thourough the licensing process as identified in MN Statutes, chapter 245D. This process began with technical assistance visits in 07/14, with a 2-yr licensing review cycle beginning 01/15.

For residential supports and day services, the lead agency review process will be modified to review individual needs identified in the support plan in comparison to the staffing hours/ratios identified for purposes of the payment rates. This review may be used to inform the determination in the licensing process as to whether needs identified in the support plan have been met.

Beginning 2012 and every 2 yrs thereafter, the state conducts a gaps analysis and reports to the Legislature on the capacity and gaps in long-term care services and supports.

All reports are available upon request.

Mississippi Waiver# MS.0282.R05.00 

Intellectual Disabilities/ DD

Waiver Name:
Intellectual Disabilities/ DD
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Mississippi Waiver# MS.0282.R05.00

Cost Neutrality

Cost Neutrality for Mississippi Waiver# MS.0282.R05.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
3150 4150

Year 1 Waiver Services

List of Year 1 Waiver Services for Mississippi Waiver# MS.0282.R05.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Services - Adult Low Support 15 minutes 316 3065.27 $3.78
Day Services - Adult Medium Support 15 minutes 536 3457.59 $4.10
Day Services -Adult High Support 15 minutes 446 3964.88 $4.66
Prevocational Services Low Support 1/2 15 minutes 657 3461.29 $3.12
Prevocational Services Medium Support 3 15 minutes 493 3409.97 $3.32
Prevocational Services High Support 4/5 15 minutes 89 2716.24 $3.66
Supported Employment Job Development 15 minutes 155 655.74 $8.80
Supported Employment Job Maintenance 15 minutes 179 1890.25 $8.35
Supported Employment Job Maintenance 2 person 15 minutes 68 324.83 $5.22
Supported Employment Job Maintenance 3 person 15 minutes 25 130.14 $4.17
Job Discovery 15 minutes 85 39.39 $11.16

Year 5 Waiver Services

List of Year 5 Waiver Services for Mississippi Waiver# MS.0282.R05.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Services - Adult Low Support 15 minutes 416 3065.27 $3.78
Day Services - Adult Medium Support 15 minutes 706 3457.59 $4.10
Day Services -Adult High Support 15 minutes 587 3964.88 $4.66
Prevocational Services Low Support 1/2 15 minutes 865 3461.29 $3.12
Prevocational Services Medium Support 3 15 minutes 650 3409.97 $3.32
Prevocational Services High Support 4/5 15 minutes 118 2716.24 $3.66
Supported Employment Job Development 15 minutes 204 655.74 $8.80
Supported Employment Job Maintenance 15 minutes 236 1890.25 $8.35
Supported Employment Job Maintenance 2 person 15 minutes 90 324.83 $5.22
Supported Employment Job Maintenance 3 person 15 minutes 33 130.14 $4.17
Job Discovery day 112 39.39 $11.16

Rate Determination Methods

Rate Determination Methods for Mississippi Waiver# MS.0282.R05.00

Both DMH and the State are responsible for rate setting and oversight.

The rate models were the same as the ones revised in October 2015 that were submitted in the ID/DD Waiver Amendment with an effective date of 5/1/17 Providers have indicated to DMH that the rates have improved their ability to provide more assistance to people receiving services, thus allowing them additional staff to adequately meet the Final Rule requirements for community access and choice.

Burns & Associates reviewed the rate models in the fall of 2017 and calculated what the rate would be using up-to-date information from published data sources for wages, benefits, and mileage costs and making minor methodological refinements. Burns & Associates found that, for nearly every service, the updated calculations were within plus-or-minus three percent of the current rate. Based upon these results, no changes were made to the October 2015 rates

DMH engaged Burns & Associates, Inc., a national consultant experienced in developing provider reimbursement rates to establish independent rate models that are intended to reflect the costs that providers face in delivering a given service. Specific assumptions are made for each of the category of costs outlined below. These assumptions, however, are not prescriptive and providers have the flexibility within the total rate to design programs that meet people's needs consistent with service requirements and each person's individual support plan.

Both DMH and the State participated in the rate study conducted in 2014. The Memorandum of Understanding between the State and DMH states that rate adjustments can be made as agreed upon by DMH and the State.

The rate-setting process for each service included:

• Conducting a series of focus groups with providers for each category of services (for example, there was a series of groups for

residential habilitation providers, for case management providers, etc.)

• Inviting all providers to complete a survey related to their service design and costs

• Identification of benchmark data, including Bureau of Labor Statistics cross-industry wage and benefit data as well as rates

for comparable services in other CMS Region 4 states

• Development of rate models that include the specific assumptions related to the cost of delivering each service, including

direct care worker wages, benefits, and ‘productivity’ (i.e., billable time); staffing ratios; mileage; facility expenses; and

agency program support and administration

• Incorporating Inventory for Client and Agency Planning assessment data to create ‘tiered’ rates for residential and day

habilitation services to recognize the need for more intensive staffing for individuals with more significant needs

• Emailing proposed rate models and supporting documentation, inviting the parties to submit comments, preparing written

responses to all comments received, and revising the rates based on these comments

Rate models were developed for all waiver services with a few exceptions. Rates for Crisis Support and Nursing Respite were maintained at previous levels, based on an earlier rate study. Therapy services and medical supplies rates are aligned with the rates paid for those services in other Medicaid programs. Transition services are reimbursed based on actual costs.

The rates are the same for all providers. There are no variations based on provider type.

On February 5-6, 2014, the process for the proposed rate determination method was presented to providers of all services as well as advocacy organizations. Interested parties were given one month to submit comments to a dedicated email account. Department of Mental Health considered these comments and compiled a comprehensive document detailing responses. Comments were considered and appropriately incorporated in the rate methodology. The rates revised in 2017 will be available for public comment during the required 30-day comment period for the renewal.

To make waiver participants aware of reimbursement rates, waiver payment rates are available on the State’s website. Current rates are available at https://medicaid.ms.gov/providers/fee-schedules-and-rates/. The rates in the proposed waiver amendment were sent to all county Health Department offices, all IDD advocacy organizations, and all waiver providers. Additionally, when Support Budgets are implemented, participants will be made aware of rates by virtue of calculation of their Support Budget.

Missouri Waiver# MO.0841.R02.01 

Partnership for Hope

Waiver Name:
Partnership for Hope
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Missouri Waiver# MO.0841.R02.01

Cost Neutrality

Cost Neutrality for Missouri Waiver# MO.0841.R02.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
3220 3220

Year 1 Waiver Services

List of Year 1 Waiver Services for Missouri Waiver# MO.0841.R02.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Medical Exception 15 minutes 14 550 $8.10
Day Habilitation Behavioral Exception 15 minutes 14 550 $7.52
Day Habilitation Group 15 minutes 282 1323 $5.46
Prevocational Individual 15 minutes 42 288 $9.50
Prevocational Group 15 minutes 76 1275 $4.70
Supported Employment Individual 15 minutes 42 376 $11.48
Supported Employment Group 15 minutes 18 654 $4.75
Career Planning 15 minutes 13 357 $9.50
Community Integration Individual 15 minutes 823 656 $8.63
Community Integration Group 15 minutes 252 386 $5.46
Job Development 15 minutes 27 250 $9.50

Year 5 Waiver Services

List of Year 5 Waiver Services for Missouri Waiver# MO.0841.R02.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Medical Exception 15 minutes 14 550 $8.73
Day Habilitation Behavioral Exception 15 minutes 14 550 $8.10
Day Habilitation Group 15 minutes 282 1323 $5.89
Prevocational Individual 15 minutes 42 288 $10.24
Prevocational Group 15 minutes 76 1275 $5.07
Supported Employment Individual 15 minutes 42 376 $12.37
Supported Employment Group 15 minutes 18 654 $5.12
Career Planning 15 minutes 13 357 $10.24
Community Integration Individual 15 minutes 823 656 $9.31
Community Integration Group 15 minutes 252 386 $5.88
Job Development 15 minutes 27 250 $10.24

Rate Determination Methods

Rate Determination Methods for Missouri Waiver# MO.0841.R02.01

Each Division of DD regional office has Provider Relations staff assigned to work with Division of DD waiver providers. The Division of DD is responsible for rate development. The rate methodology for each group of services is described below. A maximum allowable for each service is calculated and is applied across all areas of the State. All maximum allowable rates are approved by MO HealthNet. Service rates may be adjusted prospectively based on State budget appropriations.

Rates are developed for each waiver service using one of the following rate methodologies:

1. The fee schedule methodology is utilized for the following services: day habilitation — behavioral, day habilitation

— medical, applied behavior analysis, supported employment, prevocational, job development, career planning, and family peer support. One statewide fee schedule rate is developed for each service and paid to all providers.

To develop the fee schedule rates, the following key cost components were considered for each service:

A. Staff wages

B. Employee benefits and other employee-related expenses

C. Productivity

D. Other service-related expenses

E. Administrative expenses

To model the cost components, various market data sources were reviewed including Bureau of Labor Statistics, Missouri-specific staff wages and Missouri-specific health exchange costs. The market assumptions for each cost component were factored together to develop an overall hourly rate, which was then converted to a “per unit” rate using the specific unit definition for each service (e.g., per 15 minute unit).

2. The negotiated market price methodology is utilized for the following services: environmental accessibility adaptations, specialized medical equipment and supplies, assistive technology, community transition, dental and transportation. For environmental accessibility adaptations, specialized medical equipment and supplies and assistive technology services, bids or cost estimates for a job/equipment/supply are obtained from two or more providers. The regional office reviews the quotes for reasonability and then authorizes a service price based on the provider with the lowest and best price. For community transition, dental and transportation services, a provider supplies cost information to the regional office for review and approval. For all these services, the authorized amount cannot exceed the maximum allowed rate set by the State for the service.

3. The Appropriated Fee Schedule is utilized for the following services: Day Habilitation, Community Integration, and Individualized Skill Development. Provider rates are based on actual historical state costs, which have been adjusted by appropriation passed by the Missouri General Assembly specifically to raise the lowest rates to a minimum fee schedule across all providers to stabilize provider capacity. Rates are adjusted as cost of living funds are appropriated.

4. The self-directed methodology is used for the following services: self-directed personal assistance, self-directed medical personal assistance and team collaboration personal assistance. Employers (families, individuals, guardians) are given a budget based on the necessary hours determined for the individual and the statewide average rate for agency personal assistance. The employer sets the actual wage of the direct care staff based on their budget authority and must stay within the budget. The per unit cost cannot exceed the maximum allowable rate set by the State.

5. Professional Services such as personal assistant, personal assistant – medical, professional assessment and monitoring, person centered strategies consultation, physical therapy, occupational therapy, speech therapy, support broker, community specialist, and temporary residential reimbursement rates were established based on the expertise required of the professional/semi-professional and are comparable to rates that exist for similar services with comparable requirements.

The State re-examines rates at least once every five years, upon renewal of its waivers. Methods for reviewing rates include periodic market surveys, cost analysis and price comparison. At any time during the five-year period, re- evaluation of pricing and rate increases are considered as warranted based upon provider inquiries, service access and budgetary considerations. DDD monitors the number of providers delivering each waiver service, reviews participant complaints regarding ability to select/find a qualified provider, and considers participant feedback on service quality. Rate increases are determined by the State based on the outcomes of the periodic rate reviews performed by the State and available budget appropriations. Individuals, providers, and other stakeholders have an opportunity to make public comments to the Division of DD, MHD, and elected officials on rates and methodology for rate setting during annual legislative hearings in preparation for the appropriation process. Many of the Medicaid maximum allowable rates have been adjusted over the years for COLA funding appropriated by the General Assembly. Individual rates may be adjusted for market or programmatic changes. For waiver submissions that impact rates, interested parties are notified by email blasts, online postings, postings in Regional Offices, and newspaper advertisements statewide informing of the 30 day public comment period and stakeholder forums. Additionally, providers and other stakeholders may provide comment to the Division of DD Director or DMH Director at any time regarding rates by writing a letter or during public meetings.

During the person centered planning process when service providers are selected, the participant is informed of provider rates. Individuals in all areas of the state receive services based on their needs as indicated in the ISP (person-centered service plan), regardless of the cost per unit. Also, participants are given a copy of their approved budget which contains the rate for each service they are approved to receive.

All fee schedules are located at https://apps.dss.mo.gov/fmsFeeSchedules/maindisclaimer.shtml.

Waiver Name:
DD Comprehensive
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Missouri Waiver# MO.0178.R06.04

Cost Neutrality

Cost Neutrality for Missouri Waiver# MO.0178.R06.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
8782 9182

Year 1 Waiver Services

List of Year 1 Waiver Services for Missouri Waiver# MO.0178.R06.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Behavioral 15 minutes 142 2253.61 $7.59
Day Habilitation Medical 15 minutes 214 2253.61 $8.18
Day Habilitation 15 minutes 2070 3919.53 $3.53
Prevocational Individual 15 minutes 64 488.93 $9.40
Prevocational Group 15 minutes 260 1680.47 $4.71
Supported Employment Individual 15 minutes 133 956.23 $9.39
Supported Employment Group 15 minutes 252 2502.74 $4.71
Career Planning 15 minutes 8 230.04 $9.40
Community Integration Individual 15 minutes 1452 1057.75 $6.01
Community Integration Group 15 minutes 892 1101.11 $4.02
Job Development 15 minutes 6 276.05 $9.40

Year 5 Waiver Services

List of Year 5 Waiver Services for Missouri Waiver# MO.0178.R06.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Behavioral 15 minutes 152 2253.61 $7.90
Day Habilitation Medical 15 minutes 228 2253.61 $8.51
Day Habilitation 15 minutes 2195 3919.53 $3.67
Prevocational Individual 15 minutes 68 488.93 $9.78
Prevocational Group 15 minutes 276 1680.47 $4.90
Supported Employment Individual 15 minutes 141 956.23 $9.77
Supported Employment Group 15 minutes 267 2502.74 $4.90
Career Planning 15 minutes 8 230.04 $9.78
Community Integration Individual 15 minutes 1540 1057.75 $6.25
Community Integration Group 15 minutes 946 1101.11 $4.18
Job Development 15 minutes 6 276.05 $9.78

Rate Determination Methods

Rate Determination Methods for Missouri Waiver# MO.0178.R06.04

Each Division of DD Regional Office has Provider Relations (PR) staff assigned to work with Division of DD Waiver Providers. The rate methodology for each group of services is described below. All services may be adjusted for inflation, cost and/or utilization. A maximum allowable for each service is calculated and is applied across all areas of the State. If a maximum allowable is not sufficient in one part of the state it is adjusted for the entire state.

Residential Habilitation Services: Group home settings, Individualized Supported Living (ISL) and Shared Living models are based on level of supports needed based on the individual’s Rate Allocation Score derived from the Support Intensity Scale, (SIS)licensed by the American Association on Intellectual and Developmental Disabilities, or other state approved assessment tool; herein referred to an “assessment” as it relates to residential rates.

Rates for residential services do not include room and board charges. The provider has a separate contract daily rate for Room and Board costs. Room and Board is paid directly to the provider by Department of Mental Health using State only funds or is collected directly from the consumer/conservator by the provider. No FFP is used for room and board.

Group Home (GH) Residential Habilitation rates are based on the individual’s rate allocation score. Target GH rates have been established by the state for each rate allocation score for small and large GH settings. Rates for new participants are individualized and not based on the GH's historical rates. If a participant does not yet have a rate allocation score, they are budgeted at the lowest score until an assessment can be completed.

ISL daily rates are based on a budget that is developed for each waiver participant which utilizes a staffing pattern and an hourly rate determined by the individual’s rate allocation score. Hourly direct care rates for each rate allocation score have been established by the state. If a participant does not yet have a rate allocation score, they are budgeted at the lowest score until an assessment can be completed. The provider develops this budget based on the individual’s needs as described in the individual support plan. The regional office reviews the proposed budget, makes adjustments if needed, and approves the final budget which is developed to a daily rate.

Shared Living rates are based on the level of supervisory oversight needed plus a supplementary payment based on the individual’s score from the Support Intensity Scale, (SIS), or other state approved assessment tool. Room and board costs are excluded from the host home rates.

Shared Living rates are based on three levels: Level 1:Less than 24 Hour Supervision; Level 2:24 Hour Supervision; Level 3:24 Hour Comprehensive Support

A Basic Assessment supplement(Level 1 – 5)is added to the rate based on supports as reflected in the person’s Individual Support Plan and the level of support as indicated in the assessment.

Day Services: This includes Community Integration, Day Habilitation, Individualized Skill Development and agency- based Personal Assistance (PA). Division PR staff work with interested providers on completing their current or projected costs detail. The forms in the packet allow the potential provider to report its cost to provide a specific waiver service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code.

Personal Assistance-Self Directed: This includes individual personal assistance, medical personal assistance, and team collaboration personal assistance.

Employers(families, individuals, guardians) are given a budget that is based on the determined hours needed of the individual at the statewide average for agency personal assistance. The employer sets the actual wage of the direct care staff based on local wages and other factors so long as they stay within their budget. The per-unit cost cannot exceed the maximum allowable set by the state.

Respite Care In Home rates are set by Division PR staff who work with interested providers on completing a their current or projected costs detail. The forms in the packet allow the potential provider to report its cost to provide a specific respite service and are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code.

Out of home respite: Division PR staff work with interested providers on completing their current or projected costs. The forms in the packet allow the potential provider to report its cost to provide a specific waiver service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code. The maximum allowable rate is based on previous experience and existing waiver residential provider rates where the services are delivered most frequently.

Day Habilitation Behavioral is paid a flat rate to all providers statewide. The methodology to establish this rate is as follows: The hourly rate is calculated by using an average salary for a registered behavior technician plus an amount for fringe to cover health exchange Gold plan,7.65% FICA and 10 leave days. Agency overhead equal to 15% of base salary is added to the total salary to cover the physical plant and administration. An additional amount is added to the direct staff cost for Licensed Behavior Analyst oversight. The total compensation package is divided by a number of hours for a full time equivalent adjusted by a utilization factor to account for non-billable hours.

Day Habilitation Medical is paid a flat rate to all providers statewide. The methodology to establish this rate is as follows: The hourly rate is calculated by using the US median salary for an LPN adjusted slightly for Missouri. Fringe of approximately 29% is added to the base salary to cover health exchange Gold plan,7.65% FICA, 10 leave days, and CNA certification expenses. Agency overhead equal to 15% of base salary is added to the total salary to cover the physical plant and administration. The total compensation package is divided by 2,080 hours to develop the hourly cost of the CNA/LPN.An additional per hour cost for RN oversight is added to the CNA/LPN rate and the new total is divided by the annual average per person units of day habilitation based on actual utilization. The hourly rate is divided into four 15 minute increments for billing purposes.

Transportation rates are set based on cost-based bids submitted by providers who for specific routes and regions.PR staff use these costs to establish a rate per unit. The unit may be computed as per mile, per trip or some other unit but are billed as a monthly total based on actual utilization so long as the total monthly amount does not exceed the maximum allowable set by the state.

Behavior Services: Includes Behavior Identification Assessment, Observational Behavioral Follow-Up Assessment, Exposure Behavioral Assessment, Exposure Behavior Follow-Up Assessment, Adaptive Behavior Treatment with Protocol Modification, Exposure Adaptive Behavior Treatment with Protocol Modification, Adaptive Behavior Treatment by Protocol by Technician, Family Behavior Treatment Guidance, and Behavior Treatment Social Skills.

The unit rate for services provided by a licensed behavior analyst(LBA),a psychologist, or other Qualified Health Care Professional was calculated at an amount for 30 minutes of service.

This calculation is based on a combined highest range of salary of Licensed Behavior Analysts per MO Office of Administration Merit Classification) and the highest range of salary for Psychologists II MO Office of Administration Merit Classification),adding an administrative fee rate used by the University of MO for fringe benefits, calculated 50 billable hours for psychologists and 44% billable hours for Licensed Behavior Analysts(6% difference from psychologist’s billable hours attributed to travel)using a full time equivalent work year of 2080 hours.

The unit rate for services provided by a licensed assistant behavior analyst or a registered behavior technician was calculated at an amount for 30 minutes of service.

This calculation is commensurate with a rate set for behavioral personal assistance(discontinued with this waiver renewal).The education and experience required for behavioral personal assistance is similar to that required for the registered behavior technician.

Supported Employment reimbursement rates are a flat rate paid to all providers statewide. The rate was established based on the costs associated with increased staff training.

Prevocational Services, Job Development and Career Planning reimbursement rates are a flat rate paid to all providers statewide. These rates were established based on the costs associated with increased staff training. The state included costs associated with employment service professional salaries from other state agencies, adding an administrative fee rate used by the University of MO for fringe benefits, training fees and training hours, billable hours including travel time. Professional Services such as Professional Assessment and Monitoring, Physical Therapy, Occupational Therapy, Speech Therapy, Support Broker, Community Specialist, and Counseling reimbursement rates are set at the Medicaid Waiver cap. These rates were established based on the expertise required of the professional/semi-professional and comparable to rates of existing similar state plan counseling services.

Crisis Intervention rates are set by Division PR who work with interested providers on completing their current or projected costs detail. The forms in the packet allow the potential provider to report its cost to provide the service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code.

Community Transition is the actual cost of one-time services that meet the service definition presented by the provider of residential services and approved by the regional office.

Special Equipment, Supplies and Services: For environmental accessibility adaptations, specialized medical equipment and supplies and Assistive Technology a flat rate is not used. Bids or estimates of cost for a job, equipment, or supplies are obtained from two or more providers the individual chooses. A dollar amount is authorized for the provider with the lowest and best price if the price is reasonable based on the purchase experience of the regional office of similar jobs, equipment or supplies and does not exceed the annual maximum allowed for the service.

Individuals, providers, and other stakeholders have an opportunity to make public comments to the Division of DD, MO Healthnet, and elected officials on rates and methodology for rate setting during annual legislative hearings in preparation for the appropriation process. Providers and other stakeholders may provide comment to the Division of DD Director or Department of Mental Health Director at any time regarding rates by writing a letter or during public meetings.

During the person centered planning process when service providers are selected, the participant is informed of provider rates. Also participants are given a copy of their approved budget which contains the rate for each service they are approved to receive.

For non-residential services, if an individual requests a provider that has a higher rate, a new budget is prepared for the individual. The new budget is sent to the UR Committee.

All maximum allowable rates are approved by MO Healthnet.

Missouri Waiver# MO.0404.R03.02 

Division of DD Community Support

Waiver Name:
Division of DD Community Support
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Missouri Waiver# MO.0404.R03.02

Cost Neutrality

Cost Neutrality for Missouri Waiver# MO.0404.R03.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
3404 5604

Year 1 Waiver Services

List of Year 1 Waiver Services for Missouri Waiver# MO.0404.R03.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Behavioral 15 minutes 117 1761.24 $7.59
Day Habilitation Medical 15 minutes 107 1414.22 $8.18
Day Habilitation 15 minutes 942 3317.14 $3.57
Prevocational Individual 15 minutes 22 626.05 $9.22
Prevocational Group 15 minutes 98 1437.94 $4.50
Supported Employment Individual 15 minutes 46 742.8 $9.13
Supported Employment Group 15 minutes 72 1559.16 $4.72
Career Planning 15 minutes 3 8.76 $10.79
Community Integration Individual 15 minutes 764 991.24 $5.88
Community Integration Group 15 minutes 397 774.73 $4.20
Job Development 15 minutes 10 240 $9.31

Year 5 Waiver Services

List of Year 5 Waiver Services for Missouri Waiver# MO.0404.R03.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Behavioral 15 minutes 160 1761.24 $7.90
Day Habilitation Medical 15 minutes 180 1414.22 $8.51
Day Habilitation 15 minutes 1602 3317.58 $3.72
Prevocational Individual 15 minutes 34 626.05 $9.59
Prevocational Group 15 minutes 159 1437.94 $4.69
Supported Employment Individual 15 minutes 74 742.8 $9.50
Supported Employment Group 15 minutes 124 1559.16 $4.91
Career Planning 15 minutes 4 8.76 $11.23
Community Integration Individual 15 minutes 1197 991.24 $6.12
Community Integration Group 15 minutes 642 774.73 $4.37
Job Development 15 minutes 21 240 $9.68

Rate Determination Methods

Rate Determination Methods for Missouri Waiver# MO.0404.R03.02

Each Division of DD Regional Office has Provider Relations staff assigned to work with Division of DD Waiver Providers. The rate methodology for each group of services is described below. All services may be adjusted for inflation, cost and/or utilization. A maximum allowable for each service is calculated and is applied across all areas of the State. If a maximum allowable is not sufficient in one part of the state, it is adjusted for the entire state.

Day Services: This includes Community Integration, Day Habilitation, Individualized Skill Development and agency- based Personal Assistance. Division provider relations staff work with interested providers on completing their current or projected costs detail. The forms in the packet allow the potential provider to report its cost to provide a specific waiver service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code.

Personal Assistance-Self Directed: This includes individual personal assistance, medical personal assistance, and team collaboration personal assistance.

Employers(families, individuals, guardians) are given a budget that is based on the determined hours needed of the individual at the statewide average for agency personal assistance. The employer sets the actual wage of the direct care staff based on local wages and other factors so long as they stay within their budget. The per-unit cost cannot exceed the maximum allowable set by the state.

Respite Care In Home rates are set by Division provider relations staff who work with interested providers on completing their current or projected costs detail. The forms in the packet allow the potential provider to report its cost to provide a specific respite service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code.

Out of home respite: Division provider relations staff work with interested providers on completing their current or projected costs. The forms in the packet allow the potential provider to report its cost to provide a specific waiver service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code. The maximum allowable rate is based on previous experience and existing waiver residential provider rates where the services are delivered most frequently.

Day Habilitation Behavioral is paid a flat rate to all providers statewide. The methodology to establish this rate is as follows: The hourly rate is calculated by using an average salary for a Registered behavior technician plus an amount for fringe to cover health exchange Gold plan, 7.65% FICA and 10 leave days. Agency overhead equal to 15% of base salary is added to the total salary to cover the physical plant and administration. An additional amount is added to the direct staff cost for Licensed Behavior Analyst oversight. The total compensation package is divided by a number of hours for a full time equivalent adjusted by a utilization factor to account for non-billable hours.

Day Habilitation Medical is paid a flat rate to all providers statewide. The methodology to establish this rate is as follows: The hourly rate is calculated by using the US median salary for an LPN adjusted slightly for Missouri. Fringe of approximately 29% is added to the base salary to cover health exchange Gold plan, 7.65% FICA, 10 leave days, and CNA certification expenses. Agency overhead equal to 15% of base salary is added to the total salary to cover the physical plant and administration. The total compensation package is divided by 2,080 hours to develop the hourly cost of the CNA/LPN. An additional per hour cost for RN oversight is added to the CNA/LPN rate and the new total is divided by the annual average per person units of day habilitation based on actual utilization. The hourly rate is divided into four 15 minute increments for billing purposes.

Transportation rates are set based on cost-based bids submitted by providers who for specific routes and regions. Provider Relations staff use these costs to establish a rate per unit. The unit may be computed as per mile, per trip or some other unit but are billed as a monthly total based on actual utilization so long as the total monthly amount does not exceed the maximum allowable set by the state.

Behavior Services: Includes Behavior Identification Assessment, Observational Behavioral Follow-Up Assessment, Exposure Behavioral Assessment, Exposure Behavior Follow-Up Assessment, Adaptive Behavior Treatment with Protocol Modification, Exposure Adaptive Behavior Treatment with Protocol Modification, Adaptive Behavior Treatment by Protocol by Technician, Family Behavior Treatment Guidance, and Behavior Treatment Social Skills.

The unit rate for services provided by a licensed behavior analyst (LBA), a psychologist, or other Qualified Health Care Professional was calculated at an amount for 30 minutes of service.

This calculation is based on a combined highest range of salary of Licensed Behavior Analysts per MO Office of Administration Merit Classification) and the highest range of salary for Psychologists II MO Office of Administration Merit Classification), adding an administrative fee rate used by the University of MO for fringe benefits, calculated 50 billable hours for psychologists and 44% billable hours for Licensed Behavior Analysts (6% difference from psychologist’s billable hours attributed to travel) using a full time equivalent work year of 2080 hours.

The unit rate for services provided by a licensed assistant behavior analyst or a registered behavior technician was calculated at an amount for 30 minutes of service.

This calculation is commensurate with a rate set for behavioral personal assistance (discontinued with this waiver renewal). The education and experience required for behavioral personal assistance is similar to that required for the registered behavior technician.

Supported Employment reimbursement rates are a flat rate paid to all providers statewide. The rate was established based on the costs associated with increased staff training.

Prevocational Services, Job Development and Career Planning reimbursement rates are a flat rate paid to all providers statewide. These rates were established based on the costs associated with increased staff training. The state included costs associated with employment service professional salaries from other state agencies, adding an administrative fee rate used by the University of MO for fringe benefits, training fees and training hours, billable hours including travel time.

Professional Services such as Professional Assessment and Monitoring, Physical Therapy, Occupational Therapy, Speech Therapy, Support Broker, Community Specialist, and Counseling reimbursement rates are set at the Medicaid Waiver cap. These rates were established based on the expertise required of the professional/semi-professional and comparable to rates of existing similar state plan counseling services.

Crisis Intervention rates are set by Division provider relations who work with interested providers on completing their current or projected costs detail. The forms in the packet allow the potential provider to report its cost to provide the service. The reported costs are reviewed by staff. Each provider’s rate is set based on reported costs with the condition the rate must not exceed the maximum allowable set by the state for that particular service code.

Community Transition is the actual cost of one-time services that meet the service definition presented by the provider of residential services and approved by the regional office.

Special Equipment, Supplies and Services: For environmental accessibility adaptations, specialized medical equipment and supplies and Assistive Technology a flat rate is not used. Bids or estimates of cost for a job, equipment, or supplies are obtained from two or more providers the individual chooses. A dollar amount is authorized for the provider with the lowest and best price if the price is reasonable based on the purchase experience of the regional office of similar jobs, equipment or supplies and does not exceed the annual maximum allowed for the service.

Individuals, providers, and other stakeholders have an opportunity to make public comments to the Division of DD, MO Healthnet, and elected officials on rates and methodology for rate setting during annual legislative hearings in preparation for the appropriation process. Providers and other stakeholders may provide comment to the Division of DD Director or Department of Mental Health Director at any time regarding rates by writing a letter or during public meetings.

During the person centered planning process when service providers are selected, the participant is informed of provider rates. Also, participants are given a copy of their approved budget which contains the rate for each service they are approved to receive.

For non-residential services, if an individual requests a provider that has a higher rate, a new budget is prepared for the individual. The new budget is sent to the UR Committee.

All maximum allowable rates are approved by MO Healthnet.

Waiver Name:
Big Sky
Effective Date:
1/1/2018
Expiration Date:
12/31/2022

Services

List of Services for Montana Waiver# MT.0148.R06.02

Cost Neutrality

Cost Neutrality for Montana Waiver# MT.0148.R06.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2580 2580

Year 1 Waiver Services

List of Year 1 Waiver Services for Montana Waiver# MT.0148.R06.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Health 15 minutes 23 1405.73 $2.20
Prevocational Services hour 25 627.51 $7.81
Day Habilitation 9 67.34 $80.12
Supported Employment 15 minutes 7 91.16 $13.09

Year 5 Waiver Services

List of Year 5 Waiver Services for Montana Waiver# MT.0148.R06.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Health day 23 1405.73 $2.20
Prevocational Services hour 25 627.51 $7.81
Day Habilitation 9 67.34 $80.12
Supported Employment 15 minutes 7 91.16 $13.09

Rate Determination Methods

Rate Determination Methods for Montana Waiver# MT.0148.R06.02

Payments for waiver services will be consistent with efficiency, economy and quality of care and will be enough to enlist enough providers. Services will be reimbursed via fee for service; there will be no interim rates, no prospective payments, and no cost settlements.

*The Department’s Senior and Long Term Care (SLTC) Division has operated a home and community based waiver program for elderly and physically disabled consumers since the early 1980s. SDMI HCBS waiver service descriptions that are the same or similar as the SLTC HCBS waiver, will use the established fee schedule. Many of the same service providers provide waiver services to both waivers participants and having the same fee schedule will ensure uniformity of rates. The Senior and Long Term Services Division and the Addictive and Mental Disorders Division waiver programs share the majority of the providers and services. Following is the list of services the two Divisions share: Adult Day Care; Community Transition Services; Consultative Clinic and Therapeutic Services; Environmental Accessibility Modifications; Health and Wellness; Homemaker; Homemaker Chore; Nutrition (Meals); Pain and Symptom Management; Personal Assistance Attendant – Agency Based; Personal Attendant – Self-Direction; Personal Emergency Response System, Rental and Installation; Prevocational Services; Private Duty Nursing; Residential Habilitation; Respite Care; Specialized Medical Equipment and Supplies; Specially Trained Attendant; Supported Employment; and Non-Medical Transportation. These rates were originally determined by surveying current providers.

*Private Duty Nursing rate calculation included the following steps: 1) determine the number of PDN providers across the state and how the number of providers impacts access, 2) review entry level nursing salaries in a cross cutting sample of hospitals across the state, 3) estimate the employment and provider agency costs in addition to salaries, and 4) calculate a rate that would reasonably cover employing nurses at a minimally competitive entry salary level.

*There are three (3) PDN provider agencies enrolled in Montana Medicaid. Analysis of the three PDN provider agencies determined the RN and LPN staffing shortage for PDN services estimates 275 to 670 direct care nursing hours unfilled on a biweekly basis. If the state were to lose one of the three remaining PDN agencies, a total of 3,631 direct care nursing hours offered through SDMI HCBS waiver and Big Sky Waiver would be unfilled monthly. A review of hourly wages for LPNs and RNs gathered from hospitals across the state range from $24.30 to $27.39 per hour.

*The department analyzed data from multiple hospitals across the state ensuring the sample represented large, medium, and small hospitals to ensure payments for PDN services are consistent with the 1902(a)30(A) of the social security act and determine the prevailing wage rate for LPNs and RNs.

*Montana analyzed the following data elements to determine the provider agency costs: current staff salaries, benefits, taxes, number of hours approved for current members requiring PDN services, number of members receiving PDN, overhead administrative costs, and total charge for PDN related procedures to determine RVU (relative value unit) and the cost per RVU. Using this information, the state developed an hourly salary calculation based on a weighted hourly rate less 38% to account for benefits and overhead.

*The department estimated the percentage in the response above for employer taxes, benefits and organizational overhead. We determined the desired average starting salary and applied the overhead percentage to the calculation.

*The new rate was calculated by utilizing the estimated taxes and benefits for state government employees’ salaries at

$60,000 plus the current state of Montana standard overhead of 10% and determined a 28% increase was required to align with the average starting wage for RNs and LPNs.

*The department used the following data sources in the rate setting process:

• Wage Study

• Provider discussions regarding overhead and benefits

• Projected units of service

• Additional budget authority of $400,000

*The proposed hour values are a result of the basic wage study completed by the department. Wage data was collected from five hospitals of different sizes and locals on RN starting wages. The average was calculated for setting the rates

*Currently 80% of private duty nursing is completed by LPNs due to the inability to recruit RNs. This can leave a gap in care due to the licensure/educational differences of the two levels of nursing. This differential adjustment is to attract RNs for in private duty nursing and begin to close the gaps in services. In addition, this split addresses the wage needs to the 3 providers, who are critical to waiver operations and services to children under 19 in both rural and urban areas within the state. Montana believes that access to waiver PDN services is now comparable to access for the general population in the geographic area and comparable to the Medicaid rates in similar state Medicaid programs because of the PDN rate increase.

*As per question a, $37.52 is the average wage paid plus employer costs base on survey and discussion with providers. The actual calculated rate, $37.67, is the result of current spend, plus an additional $400,000 and trended units.

*The providers of private duty nursing are not governmental agencies. Montana does not have a standard overhead rate for non-governmental agencies. The 38% represents taxes, employer benefits and overhead. Our consultation with providers in this instance indicated this overhead is necessary to maintain services in a rural and frontier state

*Although the loss of the first PDN provider agency did not significantly impact SDMI HCBS waiver members, the loss of the second PDN provider agency would have placed a hardship on members being served in the community. Even though Montana Medicaid authorized the direct care worker hours for members, PDN services were either denied or reduced because providers were not able to cover the approved hours due to the growing impact of staffing shortages. If the second PDN provider were to voluntarily terminate their enrollment with Medicaid, the effectiveness of the state’s three HCBS waivers would be severely impacted. This precarious situation prompted the state to seriously consider PDN reimbursement rate increases to avoid deterioration of health and safety of enrolled HCBS members and proactively take steps to keep members in their communities to avoid institutionalization.

*Montana solicited feedback from all PDN provider providers using multiple methods including: interested party notification, public notice through Montana Administrative rules process, newspaper, *posted on the department’s website, public hearing, waiver public notice, tribal consultation, Montana Health Coalition notice, and meetings the department held with PDN provider agencies.

*All feedback received from PDN providers was positive. The provider who contemplated exiting the program has committed to providing home and community based services. The department raising the rate demonstrates the commitment to providers and HCBS.

*The department did not receive additional feedback during the rules or waiver comment period for the new LPN and RN rates.

*Montana was not required to seek legislative approval for rate increase as the increase is within legislative appropriations.

*The PDN provider that withdrew as a Medicaid provider did not provide the department with feedback as to why they opted out of the program.

The PDN provider agency who reached out to the department to discuss PDN rate concerns has committed to serving the HCBS waiver population as a Medicaid provider if the reimbursement rates are increased.

*The department did not request feedback from all PDN providers between SFY2016 and SFY2017.

*The department did not request provider feedback from the PDN providers. There was not a great impact to SDMI HCBS waiver members when the first PDN provider withdrew.

*The department reviewed feedback by multiple sources identified indicating the struggles PDN agencies have had with staffing.

*AMDD does not have a geographical (rural) differential currently. The Self-direction program may assist waiver participants that live in rural areas to access providers in their areas.

*The Case Management Team and the waiver participant develop the person centered recovery plan. The cost sheet is made available to the waiver participant as the services are identified. The waiver participant is aware of the reimbursement rate for each of their services identified in the person centered recovery plan.

*The SLTC and AMDD review the rates annually to ensure shared services remain consistent and are within our Montana Legislative appropriation. Proposed fee schedules are posted as part of the Administrative Rule of Montana process for public comment when fees are changed, added or deleted. Services are reimbursed according to fee schedule. The fee schedule identifies the maximum allowable rate.

*AMDD and SLTC meet annually to review information received through multiple sources including: number of providers, feedback received from providers and members, member complaints, legislative appropriation, and the state of Montana’s Access Plan.

*In addition, AMDD and SLTC will review claim history of all providers for trends in the amount of services utilized and monitor the number of provider enrollments and compare previous state fiscal year to current year to determine whether there has been a significant reduction of providers. Montana will research trend if the overall provider network decreases by 10 percent.

Montana Waiver# MT.0208.R06.02 

HCBW for Individuals w/DD

Waiver Name:
HCBW for Individuals w/DD
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Montana Waiver# MT.0208.R06.02

Cost Neutrality

Cost Neutrality for Montana Waiver# MT.0208.R06.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2880 2880

Year 1 Waiver Services

List of Year 1 Waiver Services for Montana Waiver# MT.0208.R06.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports and Activities hour 1375 740 $23.30
Supported Employment Follow Along hour 415 130 $37.88
Supported Employment Coworker Support day 5 63 $10.40
SE Individual Support hour 40 40 $37.88
Supported Employment Group Support hour 90 170 $23.51

Year 5 Waiver Services

List of Year 5 Waiver Services for Montana Waiver# MT.0208.R06.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports and Activities hour 1560 627 $22.67
Supported Employment Follow Along hour 385 130 $36.75
Supported Employment Coworker Support day 3 63 $10.09
SE Individual Support hour 8 19 $36.75
Supported Employment Group Support hour 98 157 $22.22

Rate Determination Methods

Rate Determination Methods for Montana Waiver# MT.0208.R06.02

The DDP rates methodology system applies to all DDP waiver contracts. The contracts do not change significantly from year to year by provider, any increases/decreases to rates are due to the Legislature and the current practice for rate adjustments do not include provider costs or BLS information. The rate-setting process is designed to allow adjustment to any of the 4 cost components exclusive of the others. So we have the ability to specifically adjust the direct care wage, and to adjust other components of the rate if funding allows. Increases/decreases to rates are due to the Legislature.

Montana ARM Title 37. chapter 34 subchapter 30 outlines the rates and documentation requirements for reimbursement. A brief history of the rate setting project follows:

In the fall of 2000, CMS regional office reviewers noted that rates paid for services were not consistent across providers for the similar services. In response to CMS requests for justification of the various rates paid to providers for similar services, DDP solicited input from providers, who elected to establish a fee-for-service rate reimbursement system. A consulting firm, Mercer Government Human Services (later Davis Deshaies LLC), was retained to collect cost data from providers and recommend standardized reimbursement rates based upon a comparison of these historical costs to national reimbursement benchmarks, as well as consideration of limitations due to Montana legislative appropriation and budget neutrality. The contractor held regional training and transition sessions across the state, as well as frequent feedback sessions with stakeholders in the first phases of the project.

HB2 of the 2005 Legislative Session supported the gradual implementation of standardized rates. The Montana Developmental Disabilities Program fully converted its provider reimbursement approach from a negotiated rate system to a standardized fee-for-service system for its Medicaid Home and Community-Based Services (HCBS) waiver program which became effective 7/1/08. This conversion was initiated in response to direction from the Montana State legislature and guidance from the federal Centers for Medicare and Medicaid.

In 2004, DDP created the Rates Advisory Committee (for approximately five years) which provided feedback on establishing the rates methodology for waiver services. The rates advisory committee was the primary entity responsible for reviewing data and assisting the DDP in providing feedback and approval for setting rates. The rates advisory committee comprised of DDP staff, the rates contractor, providers, a family member, a Legislator, as well as members from advocacy groups such as Disability Rights Montana, People First, and Montana Council on Developmental Disabilities. Lastly, the rates advisory committee included the liaison of the Montana Association of Contractors of Developmental Disabilities Services provider group. The rates advisory committee generally met monthly until 2007, and quarterly in 2008 until full implementation. After the creation of the methodology and standardized rates were established, the Department now solicits public comments at hearings when rules related to waiver services or rates are amended. The public may submit feedback in written format as well, per Montana Rule processes and timelines. The most frequent reason for changes to waiver rates has been fluctuations in Legislative appropriation to the Division.

Outside of the formal rule process, the DD Program conducts monthly calls with contractors to provide information, provide training, and solicit feedback on a variety of topics/issues,

The established methodology is incorporated into DDP’s rates manual, which is referenced in Montana ARM, and is available to the public on the DDP website.

The Department of Public Health and Human Services (department) has determined that an increase to the private duty nursing fees is necessary to serve high-needs Montana Medicaid members in the least costly setting. According to the Montana Medicaid 2017 Access Monitoring Plan, one private duty nursing provider withdrew as a Medicaid provider between state fiscal years 2016 and 2017, leaving four providers available to serve Montana's Medicaid population. In 2018, one of the four remaining providers notified the department that it could no longer provide private duty nursing at the reimbursement rate currently paid by the Medicaid program and that it would discontinue services within three months. In response, the department analyzed the Medicaid population served, the number of private duty nursing agencies across the state, the existing labor market for nurses, the cost of providing private duty nursing benefits to Medicaid members, and the higher level of care costs avoided by providing the private duty nursing benefit. Therefore, the department now proposes to reimburse private duty nursing providers at the rates of $8.95 per 15 minutes of care by a licensed practical nurse (LPN) and $11.28 per 15 minutes by a registered nurse (RN). The rates are currently $7.38 for LPN services and $8.69 for RN services.

The private duty nursing (PDN) rate calculation included the following steps: 1) determine the number of PDN providers across the state and how the number of providers impacts access, 2) review entry level nursing salaries in a cross cutting sample of hospitals across the state, 3) estimate the employment and provider agency costs in addition to salaries, and 4) calculate a rate that would reasonably cover employing nurses at a minimally competitive entry salary level.

There is no established ‘rate’ for some services such as Individual Goods and Services, Environmental Modifications, Community Transition Services, Personal Emergency Response Systems, and Specialized Medical Equipment and Supplies where rates do not apply. In these instances, actual cost is used. For others, during the process to implement standardized rates the following was identified:

1. Direct Care Staff Time is the Billable Unit for most HCBS services. Most provider reimbursement is based upon the amount of direct care staff time delivered to or on behalf of the HCBS individual by the provider. In order to meet the conditions for payment, the HCBS individual must be Medicaid eligible, enrolled, attend, and receive a HCBS Waiver Service; and the direct care staff must be actively employed and present to provide the HCBS Waiver Service. In addition, the service provided must be consistent with the individual's plan of care.

2. Direct care staff is defined to be those individuals whose primary responsibility is the day to day, hands-on, direct support of people with disabilities, training and instruction, and assistance with and management of activities of daily living.

Standardized Cost Centers: Per the process creating fee-for-service rates, most provider reimbursement rates consist of four cost centers. These cost centers are:

---Direct Care Staff Compensation

---Employee-Related Expenses – Mandatory and non-mandatory expenses and benefits.

---Program Supervision and Indirect Expenses – Expenses, travel, supervision and indirect costs of running the program.

---General & Administrative Expenses – Upper level management and operating costs.

In addition to the standardized cost centers, geographical factors are applied for residential habilitation and day habilitation services; economy-of-scale are applied to residential habilitation. These factors are as follow:

• Geographical factor: Geographical cost adjustment factors consider the cost of living, employment compensation, cost of housing, and labor market trends.

• Economy-of-Scale factor: Economy-of-scale factors are used to adjust provider reimbursement for general & administrative (G&A) and program-related (PR) costs for agencies of different sizes.

All waiver services are pre-authorized through the person’s Individual Cost Plan, and are based on the person’s Plan of Care. The member’s cost plan identifies each service, the providers to deliver each service, and either the units identified as necessary or maximum cost allowable. System edits are in place that do not allow a provider to attempt to invoice for anything that is not authorized in the cost plan.

It is specified in the waiver service descriptions that reimbursement should not be sought from the DD waiver if another source (most commonly IDEA or Vocational Rehabilitation) is available to pay for the service. The burden is on the planning teams to potentially identify alternatives, as well as on provider agencies to appropriately seek payment from other potential sources and obtain appropriate documentation. The vast majority of individuals in this waiver have aged out of eligibility for school services. Planning team members and providers have demonstrated due diligence in exploring all potential funding sources for needed services prior to committing waiver cost plan dollars.

There are no co-pays imposed on services provided through the DD waiver, but members may be responsible for co- payment of other services reimbursed with Medicaid monies.

In September 2016, Montana submitted the state’s attached Access Monitoring Review Plan (AMRP) to assess Medicaid member access to medical services and determine if Montana’s reimbursement rates are sufficient so medical providers will enroll and participate in Montana Medicaid. Montana also included language within the attached AMRP addendum, submitted to CMS in January 2018, that stated Montana will monitor the number of provider enrollments and compare previous state fiscal year to current year to determine whether there has been a significant reduction of providers.

Montana will research trend if the overall provider network decreases by 10 percent. Finally, in 2016, a JAMA study was completed that showed access to primary care services in Montana is comparable to access for private insurance. This study was provided to CMS on February 13, 2018, after a CMS inquiry was received by Montana related to this question.

Since rate adjustments are the result of the legislative sessions, the rules for public comment and testimony during the legislative process provide opportunity for feedback. In addition, when DDP formalizes the rates based on changes in appropriation, the rule process to implement the new rates is also an avenue for public comments. We do consider comments at other times, including but not limited to: testimony made at interim committee hearings; emails or calls we receive from stakeholders; surveys that DDP sends; and/or workgroups with providers to note possible areas of ongoing concern as we prepare funding proposals for future legislative sessions.

Montana Waiver# 0455.R02.00 

Severe and Disabling Mental Illness Home and Community Based Services

Waiver Name:
Severe and Disabling Mental Illness Home and Community Based Services
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for Montana Waiver# 0455.R02.00

Cost Neutrality

Cost Neutrality for Montana Waiver# 0455.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
600 750

Year 1 Waiver Services

List of Year 1 Waiver Services for Montana Waiver# 0455.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Health 15 minutes 8 2039 $2.26
Supported employment 15 minutes 25 223 $13.45

Year 5 Waiver Services

List of Year 5 Waiver Services for Montana Waiver# 0455.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Adult Day Health 15 minutes 11 2039 $2.40
Supported employment 15 minutes 32 223 $14.28

Rate Determination Methods

Rate Determination Methods for Montana Waiver# 0455.R02.00

The Home and Community Based Service, Severe and Disabling Mental Illness (SDMI) waiver utilizes Fee-for-Service (FFS), negotiated market price, and public pricing rate methodologies. Each rate has a unit designation and reimbursement is equal to the rate multiplied by the number of units utilized. SDMI FFS rate schedules are published and posted to the Departments website. There will be no interim rates, no prospective payments, and no cost settlements.

Montana’s Senior and Long-Term Care (SLTC) Division operates a home and community based waiver program for elderly and physically disabled consumers, this program was implemented in the early 1980s. AMDD's waiver uses the established fee schedule for service descriptions that are the same or similar as the SLTC's waiver. These rates were originally determined by surveying current providers.

Many of the same service providers provide waiver services to both waivers and having the same fee schedule will ensure uniformity of rates. Following is the list of services the two Divisions share: Adult Day Care, Community Transition Services, Consultative Clinic and Therapeutic Services, Environmental Accessibility Modifications, Health and Wellness, Homemaker Chore, Nutrition (Meals), Pain and Symptom Management, Personal Assistance Attendant – Agency Based, Personal Attendant – Self-Direction, Personal Emergency Response System, Private Duty Nursing, Residential Habilitation, Respite Care, Specialized Medical Equipment and Supplies, Supported Employment, and Non-Medical Transportation.

AMDD has adopted a rate methodology that incorporates the following factors for Behavioral Intervention Assistant services:

BASE WAGE

Salary expectations for direct and indirect care workers is based on the Montana mean wage or the livable wage for Montana, whichever is higher, for each position, direct and indirect care hours for each position, productivity/capacity adjustments, the full-time equivalency required for the delivery of services to Medicaid members, and necessary staffing ratios. Finally, collaboration with policy staff ensures the salaried positions, wage, and hours required conform to the program or service design.

PRODUCTIVITY

Communication with stakeholders, providers, and members aids in the determination of direct and indirect care hours required and the full-time equivalent of each position. In addition, a review of claims history aides in determining provider capacity.

BENEFITS FACTOR

The benefits factor is consistent with Montana State’s benefit package and includes paid time off, medical benefits, and trainings.

ADMINISTRATIVE COSTS/OVERHEAD

This is set at 18% based on common practice for Medicaid services.

Private Duty Nursing (PDN) rate calculation included the following steps:

(1) Determine the number of PDN providers across the state and how the number of providers impacts access;

(2) Review entry level nursing salaries in a cross cutting sample of hospitals across the state;

(3) Estimate the employment and provider agency costs in addition to salaries; and

(4) Calculate a rate that would reasonably cover employing nurses at a minimally competitive entry salary level.

AMDD does not have a geographical (rural) differential currently. The Self-direction program may assist waiver participants that live in rural areas to access providers in their areas.

The case management team and the waiver participant develop the Person Centered Recovery Plan (PCRP). The cost sheet is made available to the member as the services are identified. The member is aware of the reimbursement rate for each of their services identified in the PCRP.

AMDD and SLTC review the rates annually to ensure shared services remain consistent and are within our Montana Legislative appropriation. Proposed fee schedules are posted as part of the Administrative Rule of Montana process for public comment when fees are changed, added or deleted. Services are reimbursed according to fee schedule. The fee schedule identifies the maximum allowable rate.

AMDD and SLTC meet annually to review information received through multiple sources including: number of providers, feedback received from providers and members, member complaints, legislative appropriation, and the state of Montana’s Access Plan. In addition, AMDD and SLTC will review claim history of all providers for trends in the amount of services utilized and monitor the number of provider enrollments and compare previous state fiscal year to current year to determine whether there has been a significant reduction of providers. Montana will research trend if the overall provider network decreases by 10 percent.

Nebraska Waiver# NE.4154.R06.07 

Comprehensive Developmental Disabilities Services

Waiver Name:
Comprehensive Developmental Disabilities Services
Effective Date:
6/1/2017
Expiration Date:
5/31/2022

Services

List of Services for Nebraska Waiver# NE.4154.R06.07

Cost Neutrality

Cost Neutrality for Nebraska Waiver# NE.4154.R06.07

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4200 4500

Year 1 Waiver Services

List of Year 1 Waiver Services for Nebraska Waiver# NE.4154.R06.07

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services Agency 1:1 hour 507 364 $30.81
Prevocational Services Agency Small Group hour 0 0 $0.01
Prevocational Services Agency Large Group hour 0 0 $0.01
Prevocational Services Independent 1:1 hour 0 0 $0.01
Supported Employment - Individual, Agency hour 41 122 $41.32
Supported Employment - Individual, Independent hour 0 0 $0.01
Adult Day Services hour 0 0 $12.61
Enclave Agency hour 0 0 $12.70
Supported Employment - Enclave hour 92 1382 $12.70
Habilitative Community Inclusion Agency, Daily day 0 0 $0.01
Habilitative Community Inclusion Agency, hourly hour 2030 1048 $17.21
Habilitative Community Inclusion - Independent, hourly hour 0 0 $0.01
Habilitative Workshop, Agency, Daily day 0 0 $0.01
Habilitative Workshop, Agency, Hourly hour 1881 1535 $18.37
Supported Employment - Follow Along, Agency, Quarter Hour 15 minutes 41 486 $10.31
Supported Employment - Follow Along, Agency, Hourly hour 0 0 $41.50
Supported Employment - Follow Along, Independent, Quarter Hour 15 minutes 0 0 $0.01
Supported Employment - Follow Along, Independent, Hourly 15 minutes 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Nebraska Waiver# NE.4154.R06.07

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services Agency 1:1 hour 129 58 $42.28
Prevocational Services Agency Small Group hour 22 71 $9.39
Prevocational Services Agency Large Group hour 11 327 $16.91
Prevocational Services Independent 1:1 hour 0 0 $0.01
Supported Employment - Individual, Agency hour 685 182 $46.92
Supported Employment - Individual, Independent hour 47 385 $27.35
Adult Day Services hour 128 593 $8.82
Enclave Agency hour 465 469 $10.33
Supported Employment - Enclave hour 0 0 $0.01
Habilitative Community Inclusion Agency, Daily day 2377 77 $154.75
Habilitative Community Inclusion Agency, hourly hour 2377 17 $21.95
Habilitative Community Inclusion - Independent, hourly hour 217 439 $19.89
Habilitative Workshop, Agency, Daily day 2687 137 $133.80
Habilitative Workshop, Agency, Hourly hour 2687 31 $19.12
Supported Employment - Follow Along, Agency, Quarter Hour 15 minutes 0 0 $0.01
Supported Employment - Follow Along, Agency, Hourly hour 148 16 $44.29
Supported Employment - Follow Along, Independent, Quarter Hour 15 minutes 0 0 $0.01
Supported Employment - Follow Along, Independent, Hourly 15 minutes 4 140 $25.87

Rate Determination Methods

Rate Determination Methods for Nebraska Waiver# NE.4154.R06.07

Current rates for services on this waiver were last reviewed in 2017. CMS approved the renewal of this waiver in 2017 with the condition that the state complete a comprehensive rate methodology study. In December 2016, the Division of Developmental Disabilities (DDD) contracted with Optumas Consulting to develop a rate methodology process for fee- for-service rates for DDD’s HCBS waivers. DDD built the proposed rates by estimating the total costs incurred by providers to deliver developmental disabilities (DD) services. Each DD service has its own individual rate model. The models begin with an estimate of the cost of direct labor required to provide the specific service. The rate that accounts for the total cost of the service is determined by applying factors to this direct labor cost.

Rate factors were determined by a few mechanisms including the review of actual costs documented in the general ledgers (GL) of the accounting systems of 12 providers. The GL data reviewed included actual revenue and expense data for a representative sample of DD service providers for Nebraska state fiscal year 2016 (July 1, 2015 – June 30, 2016). DDD commenced the review in March 2017 and completed it in September 2017. All costs were categorized into the rate factors and care was taken to identify unallowable expenses, including room and board and fundraising expenses, and exclude these from consideration in the rate factors. Other activities used for determining rate factors were completed concurrently with the GL review and included:

- A staff training survey administered to members of the Provider Advisory Group (PAG, description below),

- A review of payroll data submitted by a representative sample of 12 providers, and

- A residential group home staffing survey.

These reviews were conducted for the purpose of studying and, if necessary, rebasing rates for providers. DDD intends to perform comparable reviews on an on-going, periodic basis for the purpose of determining the adequacy of rates. DDD intends to study rates and, if necessary, rebase rates every 5 years. The frequency of the reviews will be at least every 5 years for rate rebasing purposes but may be more frequent depending on availability of resources.

The methodology for estimating the direct labor cost and all of the factors in the rate model are explained below:

1) Direct Labor Cost:

The cost of direct labor for each service is based on the staffing requirements for the service and the classification of the employee. For each classification, an appropriate employment classification from the 2016 Bureau of Labor Statistics (BLS) was selected. Most of the services use the classification of Social and Human Service Assistants for direct care staff. Wages are inflated from the BLS data using the Consumer Price Index to account for inflation from the time when this data was collected to the anticipated implementation of this rate model.

2) Employee Related Expenses (ERE):

This includes costs associated with employees of DD service providers. These costs include FICA, retirement, unemployment compensation, health/dental/life insurance, and short and long term disability insurance. The ERE factor is based on actual costs in general ledger (GL) data submitted by providers.

3) Availability Factor:

This factor compensates providers for paid direct care staff time for non-billable activities including recordkeeping, reporting, training, and meetings. Additionally, it also compensates providers for paid time off for direct staff (holidays, sick, vacation) and overtime hours. The factor is based on payroll data submitted by a representative sample of DD service providers for Nebraska state fiscal year 2016 and a training survey administered to the PAG.

4) Mileage:

This factor compensates providers for mileage while transporting the individual as part of waiver services. The rate is based on the 2018 rate published by the Internal Revenue Service for reimbursement of employees for personal vehicle usage.

5) Program Support:

This factor is intended to cover the supports around direct care specific to the provision of services (as opposed to general and administrative expenses). Examples include clinical supports, nursing costs, and rent/maintenance associated with a building used for the delivery of service. It does not include costs for staff who have direct contact with the waiver participant as these costs are accounted for in the direct labor cost component. This factor was estimated based on GL data submitted by providers.

Rent expense included in the rate model were categorized based on how they were recorded in the GL data. For buildings that housed both program activities and support staff, the expense was split into program support and administration.

1) Administration:

This factor is intended to cover general and administrative expenses for the providers. These include indirect costs such as rent/depreciation, salaries & benefits, & background checks for staff for functions such as human resources, finance and accounting, and quality improvement. This factor was estimated based on GL data submitted by providers.

DDD solicited feedback from stakeholders via the following three structured mechanisms:

1) Establishment of a Provider Advisory Group (PAG) consisting of agency providers of DD services

This group consisted of 12 Agency providers that volunteered to provide feedback to DDD during the rate development process. DDD solicited feedback from the PAG via recurring meetings and requests for feedback following major milestones in the rate development process (e.g. introduction of new service definitions, presentation of draft rate models, etc.). The feedback provided by the PAG helped to inform assumptions in the rate model including staffing ratios in group homes, training requirements for direct care staff, and “sloping” (i.e. adjusting the magnitude) of factors in the rate model for tiered services based on participant acuity level.

2) Independent Provider Meetings

Meetings were held with Independent Providers on March 27, 2018. Two sessions (afternoon and evening) were held to provide flexibility for attending these meetings. Independent providers could attend in-person in Lincoln, NE or via WebEx. DDD presented draft rate methodology and service definitions and solicited feedback from independent providers in these sessions.

3) Public Stakeholder Meeting

A two-hour public stakeholder meeting was held on June 19, 2018. Participants in this meeting included parents & guardians of waiver participants, service providers, and representatives from advocacy groups for individuals with developmental disabilities. The meeting provided an opportunity to present information about the rate development process to this audience and solicit feedback on the process.

DDD developed rates specific to independent providers based on stakeholder feedback and the goal of providing participants with additional options. DDD established independent provider rates to reflect additional habilitation opportunities for self-directed services and provider qualifications for habilitative services. The rate models for independent providers have different assumptions to compensate for differences compared to agency providers. The ERE, staff availability factor, mileage, administration and program support factors are all lower for independent providers.

The ERE factor for independent providers is set lower to cover only FICA taxes. The staff availability factor includes allowances for only training, attending ISP/Planning meetings, and recordkeeping/reporting requirements. The mileage factor assumes lower transportation expenses incurred than agency providers. And the administration factor is intended to cover only basic requirements for billing of services and electronic case management such as an internet and phone connection.

Many of the services incorporate a tiered rate structure to compensate providers based on the acuity of the participant. The following services have tiered rates: Habilitative Workshop, Habilitative Community Inclusion, and Residential Habilitation. The reimbursement for these services are tiered based on participant’s level of service need as determined by the ICAP assessment. The five reimbursement tiers are:

o Basic-ICAP score 65+.

o Intermediate-ICAP score 37-64.

o High–ICAP score 12-36.

o Advanced–ICAP score 1-11.

o Behavioral Risk Tier – based on results of a behavioral risk screen assessment by DDD clinical staff

Rate factors are adjusted for tiered services to account for different costs within the tiers. The assumed staffing ratios for direct labor are lowest for the basic tier and are increased to 1:1 for the behavioral risk tier, including overnight hours. Program support, administration, and the wage percentile of the BLS classification are also graduated to account for the different cost structures within the tiers.

Other services have rate structures to accommodate service delivery one-on-one or in a group setting. This structure provides waiver participants the flexibility to purchase the services in a group setting at a lower cost. Prevocational, Independent Living, and Supported Family Living services are structured with both individual and group rates. Rates for these services are adjusted by changing the assumed staffing ratio for direct labor based on the setting.

Rates established in accordance with this methodology may be adjusted at the direction of the Nebraska State Legislature.

The following services use an alternative rate methodology:

Transitional Services, Environmental Modification Assessment, Home Modification, Assistive Technology, Personal Emergency Response System, and Vehicle Modification are provided at a market rate and approved on a per case basis. The service cap limits were established based on historical precedence in the state. The caps have been adequate over the past several years to enable waiver participants to receive the services at market prices.

Reimbursement for Transportation service is based on the Nebraska standard for mileage reimbursement, pursuant to Neb. Rev. Stat. 81-1176.

Information about payment rates is made available verbally and in writing to waiver participants and providers by state DHHS staff. The waivers and rate study are posted on the DHHS public website at http://dhhs.ne.gov/developmental_disabilities/Pages/RateRebasing.aspx.

To ensure rates remain consistent with the provisions of §1902(a)(30)(A), DDD monitors utilization of waiver services on a monthly basis via reporting. This reporting calculates many of the statistics required on the CMS 372 reports and provides assurance that the cost neutrality requirement of the waiver is being met. DDD intends to review rates paid to providers on an annual basis. The review will determine the number of providers, both independent and agency, providing services in the Metropolitan Statistical Areas within Nebraska and compare this figure to prior years to identify trends in provider availability. In addition, DDD will review on an annual basis the number of participants served on the waiver, including new participants, and the reserve capacity slots utilized for new entrants.

Nebraska Waiver# NE.0394.R03.02 

NE Day Services Waiver for Adults w/DD

Waiver Name:
NE Day Services Waiver for Adults w/DD
Effective Date:
3/1/2017
Expiration Date:
2/28/2022

Services

List of Services for Nebraska Waiver# NE.0394.R03.02

Cost Neutrality

Cost Neutrality for Nebraska Waiver# NE.0394.R03.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1055 1055

Year 1 Waiver Services

List of Year 1 Waiver Services for Nebraska Waiver# NE.0394.R03.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Daily day 559 41 $106.04
Day Habilitation Hourly hour 203 11 $17.59
Prevocational Services, Agency, 1:1 hour 176 179 $32.44
Prevocational Services, Agency, Small Group hour 0 0 $0.01
Prevocational Services, Agency, Large Group hour 0 0 $0.01
Prevocational Services, Independent, 1:1 hour 0 0 $0.01
Supported Employment - Individual, Agency, Hourly hour 10 111 $41.31
Supported Employment - Individual, Independent, Hourly hour 0 0 $0.01
Adult Day hour 0 0 $12.80
Enclave hour 0 0 $0.01
Supported Employment Enclave hour 61 850 $12.70
Habilitative Community Inclusion, Independent, Hourly hour 373 671 $14.10
Habilitative Community Inclusion, Agency, Daily day 0 0 $0.01
Habilitative Community Inclusion, Agency, Hourly hour 0 0 $0.01
Habilitative Workshop - Hourly hour 346 848 $14.87
Habilitative Workshop - Day day 0 0 $0.01
Integrated Community Employment hour 20 34 $40.27
Supported Employment - Follow Along, Agency, Quarter Hour 15 minutes 10 443 $10.31
Supported Employment - Follow Along, Agency, Hourly hour 0 0 $0.01
Supported Employment - Follow Along, Independent, Quarter Hour 15 minutes 0 0 $0.01
Supported Employment - Follow Along, Independent, Hourly hour 0 0 $0.01
Vocational Planning Habilitation Services Hourly hour 176 56 $39.39
Vocational Planning Habilitation Services - Daily day 2 10 $39.19
Workstation Habilitation Services - Daily daily 59 40 $77.59
Workstation Habilitation Services - Hourly hour 17 46 $9.86

Year 5 Waiver Services

List of Year 5 Waiver Services for Nebraska Waiver# NE.0394.R03.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Daily day 0 0 $0.01
Day Habilitation Hourly hour 0 0 $0.01
Prevocational Services, Agency, 1:1 hour 54 58 $42.28
Prevocational Services, Agency, Small Group hour 8 54 $16.91
Prevocational Services, Agency, Large Group hour 9 505 $9.39
Prevocational Services, Independent, 1:1 hour 0 0 $0.01
Supported Employment - Individual, Agency, Hourly hour 171 127 $41.97
Supported Employment - Individual, Independent, Hourly day 14 272 $22.43
Adult Day hour 25 362 $8.82
Enclave hour 130 416 $10.33
Supported Employment Enclave hour 0 0 $0.01
Habilitative Community Inclusion, Independent, Hourly hour 143 45 $16.62
Habilitative Community Inclusion, Agency, Daily day 595 67 $106.44
Habilitative Community Inclusion, Agency, Hourly hour 595 48 $15.71
Habilitative Workshop - Hourly hour 615 75 $12.99
Habilitative Workshop - Day day 615 106 $90.90
Integrated Community Employment hour 0 0 $0.01
Supported Employment - Follow Along, Agency, Quarter Hour 15 minutes 0 0 $0.01
Supported Employment - Follow Along, Agency, Hourly hour 44 16 $44.29
Supported Employment - Follow Along, Independent, Quarter Hour 15 minutes 0 0 $0.01
Supported Employment - Follow Along, Independent, Hourly Hour 0 0 $0.01
Vocational Planning Habilitation Services Hourly hour 0 0 $0.01
Vocational Planning Habilitation Services - Daily day 0 0 $0.01
Workstation Habilitation Services - Daily daily 0 0 $0.01
Workstation Habilitation Services - Hourly hour 0 0 $0.01

Rate Determination Methods

Rate Determination Methods for Nebraska Waiver# NE.0394.R03.02

Current rates for services on this waiver were last reviewed in 2017. CMS approved the renewal of this waiver in 2017 with the condition that the state complete a comprehensive rate methodology study. In December 2016, the Division of Developmental Disabilities (DDD) contracted with Optumas Consulting to develop a rate methodology process for fee- for-service rates for DDD’s HCBS waivers. DDD built the proposed rates by estimating the total costs incurred by providers to deliver developmental disabilities (DD) services. Each DD service has its own individual rate model. The models begin with an estimate of the cost of direct labor required to provide the specific service. The rate that accounts for the total cost of the service is determined by applying factors to this direct labor cost.

Rate factors were determined by a few mechanisms including the review of actual costs documented in the general ledgers (GL) of the accounting systems of 12 providers. The GL data reviewed included actual revenue and expense data for a representative sample of DD service providers for Nebraska state fiscal year 2016 (July 1, 2015 – June 30, 2016). DDD commenced the review in March 2017 and completed it in September 2017. All costs were categorized into the rate factors and care was taken to identify unallowable expenses, including room and board and fundraising expenses, and exclude these from consideration in the rate factors. Other activities used for determining rate factors were completed concurrently with the GL review and included:

- A staff training survey administered to members of the Provider Advisory Group (PAG, description below),

- A review of payroll data submitted by a representative sample of 12 providers, and

- A residential group home staffing survey.

These reviews were conducted for the purpose of studying and, if necessary, rebasing rates for providers. DDD intends to perform comparable reviews on an on-going, periodic basis for the purpose of determining the adequacy of rates. DDD intends to study rates and, if necessary, rebase rates every 5 years. The frequency of the reviews will be at least every 5 years for rate rebasing purposes but may be more frequent depending on availability of resources.

The methodology for estimating the direct labor cost and all of the factors in the rate model are explained below:

1) Direct Labor Cost:

The cost of direct labor for each service is based on the staffing requirements for the service and the classification of the employee. For each classification, an appropriate employment classification from the 2016 Bureau of Labor Statistics (BLS) was selected. Most of the services use the classification of Social and Human Service Assistants for direct care staff. Wages are inflated from the BLS data using the Consumer Price Index to account for inflation from the time when this data was collected to the anticipated implementation of this rate model.

2) Employee Related Expenses (ERE):

This includes costs associated with employees of DD service providers. These costs include FICA, retirement, unemployment compensation, health/dental/life insurance, and short and long term disability insurance. The ERE factor is based on actual costs in general ledger (GL) data submitted by providers.

3) Availability Factor:

This factor compensates providers for paid direct care staff time for non-billable activities including recordkeeping, reporting, training, and meetings. Additionally, it also compensates providers for paid time off for direct staff (holidays, sick, vacation) and overtime hours. The factor is based on payroll data submitted by a representative sample of DD service providers for Nebraska state fiscal year 2016 and a training survey administered to the PAG.

4) Mileage:

This factor compensates providers for mileage while transporting the individual as part of waiver services. The rate is based on the 2018 rate published by the Internal Revenue Service for reimbursement of employees for personal vehicle usage.

5) Program Support:

This factor is intended to cover the supports around direct care specific to the provision of services (as opposed to general and administrative expenses). Examples include clinical supports, nursing costs, and rent/maintenance associated with a building used for the delivery of service. It does not include costs for staff who have direct contact with the waiver participant as these costs are accounted for in the direct labor cost component. This factor was estimated based on GL data submitted by providers.

Rent expense included in the rate model were categorized based on how they were recorded in the GL data. For buildings that housed both program activities and support staff, the expense was split into program support and administration.

1) Administration:

This factor is intended to cover general and administrative expenses for the providers. These include indirect costs such as rent/depreciation, salaries & benefits, & background checks for staff for functions such as human resources, finance and accounting, and quality improvement. This factor was estimated based on GL data submitted by providers.

DDD solicited feedback from stakeholders via the following three structured mechanisms:

1) Establishment of a Provider Advisory Group (PAG) consisting of agency providers of DD services

This group consisted of 12 Agency providers that volunteered to provide feedback to DDD during the rate development process. DDD solicited feedback from the PAG via recurring meetings and requests for feedback following major milestones in the rate development process (e.g. introduction of new service definitions, presentation of draft rate models, etc.). The feedback provided by the PAG helped to inform assumptions in the rate model including staffing ratios in group homes, training requirements for direct care staff, and “sloping” (i.e. adjusting the magnitude) of factors in the rate model for tiered services based on participant acuity level.

2) Independent Provider Meetings

Meetings were held with Independent Providers on March 27, 2018. Two sessions (afternoon and evening) were held to provide flexibility for attending these meetings. Independent providers could attend in-person in Lincoln, NE or via WebEx. DDD presented draft rate methodology and service definitions and solicited feedback from independent providers in these sessions.

3) Public Stakeholder Meeting

A two-hour public stakeholder meeting was held on June 19, 2018. Participants in this meeting included parents & guardians of waiver participants, service providers, and representatives from advocacy groups for individuals with developmental disabilities. The meeting provided an opportunity to present information about the rate development process to this audience and solicit feedback on the process.

DDD developed rates specific to independent providers based on stakeholder feedback and the goal of providing participants with additional options. DDD established independent provider rates to reflect additional habilitation opportunities for self-directed services and provider qualifications for habilitative services. The rate models for independent providers have different assumptions to compensate for differences compared to agency providers. The ERE, staff availability factor, mileage, administration and program support factors are all lower for independent providers.

The ERE factor for independent providers is set lower to cover only FICA taxes. The staff availability factor includes allowances for only training, attending ISP/Planning meetings, and recordkeeping/reporting requirements. The mileage factor assumes lower transportation expenses incurred than agency providers. And the administration factor is intended to cover only basic requirements for billing of services and electronic case management such as an internet and phone connection.

Many of the services incorporate a tiered rate structure to compensate providers based on the acuity of the participant. The following services have tiered rates: Habilitative Workshop, Habilitative Community Inclusion, and Residential Habilitation. The reimbursement for these services are tiered based on participant’s level of service need as determined by the ICAP assessment. The five reimbursement tiers are:

o Basic-ICAP score 65+.

o Intermediate-ICAP score 37-64.

o High–ICAP score 12-36.

o Advanced–ICAP score 1-11.

o Behavioral Risk Tier – based on results of a behavioral risk screen assessment by DDD clinical staff

Rate factors are adjusted for tiered services to account for different costs within the tiers. The assumed staffing ratios for direct labor are lowest for the basic tier and are increased to 1:1 for the behavioral risk tier, including overnight hours. Program support, administration, and the wage percentile of the BLS classification are also graduated to account for the different cost structures within the tiers.

Other services have rate structures to accommodate service delivery one-on-one or in a group setting. This structure provides waiver participants the flexibility to purchase the services in a group setting at a lower cost. Prevocational, Independent Living, and Supported Family Living services are structured with both individual and group rates. Rates for these services are adjusted by changing the assumed staffing ratio for direct labor based on the setting.

Rates established in accordance with this methodology may be adjusted at the direction of the Nebraska State Legislature.

The following services use an alternative rate methodology:

Transitional Services, Environmental Modification Assessment, Home Modification, Assistive Technology, Personal Emergency Response System, and Vehicle Modification are provided at a market rate and approved on a per case basis. The service cap limits were established based on historical precedence in the state. The caps have been adequate over the past several years to enable waiver participants to receive the services at market prices.

Reimbursement for Transportation service is based on the Nebraska standard for mileage reimbursement, pursuant to Neb. Rev. Stat. 81-1176.

Information about payment rates is made available verbally and in writing to waiver participants and providers by state DHHS staff. The waivers and rate study are posted on the DHHS public website at http://dhhs.ne.gov/developmental_disabilities/Pages/RateRebasing.aspx.

To ensure rates remain consistent with the provisions of §1902(a)(30)(A), DDD monitors utilization of waiver services on a monthly basis via reporting. This reporting calculates many of the statistics required on the CMS 372 reports and provides assurance that the cost neutrality requirement of the waiver is being met. DDD intends to review rates paid to providers on an annual basis. The review will determine the number of providers, both independent and agency, providing services in the Metropolitan Statistical Areas within Nebraska and compare this figure to prior years to identify trends in provider availability. In addition, DDD will review on an annual basis the number of participants served on the waiver, including new participants, and the reserve capacity slots utilized for new entrants.

Nevada Waiver# NV.0125.R07.00 

NV HCBS Waiver for Individuals with Intellectual and Developmental Disabilities

Waiver Name:
NV HCBS Waiver for Individuals with Intellectual and Developmental Disabilities
Effective Date:
10/1/2018
Expiration Date:
9/30/2023

Services

List of Services for Nevada Waiver# NV.0125.R07.00

Cost Neutrality

Cost Neutrality for Nevada Waiver# NV.0125.R07.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2603 3075

Year 1 Waiver Services

List of Year 1 Waiver Services for Nevada Waiver# NV.0125.R07.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation hour 1011 582 $25.87
Prevocational Services hour 1082 329 $25.87
Supported Employment hour 370 345 $25.87
Career Planning 15 minutes 193 60 $7.81

Year 5 Waiver Services

List of Year 5 Waiver Services for Nevada Waiver# NV.0125.R07.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation hour 1194 582 $27.25
Prevocational Services hour 1278 329 $27.25
Supported Employment hour 437 345 $27.25
Career Planning 15 minutes 228 60 $8.22

Rate Determination Methods

Rate Determination Methods for Nevada Waiver# NV.0125.R07.00

The DHCFP and the ADSD are the responsible entities for rate determination; however, the DHCFP rates units, will be the lead to perform all rates and cost study. Once rate is determined, it is presented to the legislature for approval. All approved rates are then entered MMIS for oversight to ensure providers are paid uniformly and based on their provider type. Rate study will be conducted every four (4) years per Assembly Bill 108.

The DHCFP and the ADSD conduct public workshop, attend advisory council meetings to gather public input. Additionally, each provider type has representatives and present their concerns or issues to the DHHS, state agencies, and attend legislative sessions. The DHCFP website is also an avenue to solicit public input as well as through mail, fax or email.

The DHCFP rate staff uses DSS Reporting and periodically analyze number of claims paid, net payments to billing providers, service count, the number of patients, total expenditures and estimated cost per patient. If the report indicates a drop in the number of claims, patients or billing providers by 25%, the DHCFP will first verify that it is not due to a seasonal phenomenon and if it is a local or statewide impact. If it is not related to a seasonal phenomenon, the DHCFP will query the District Offices and the Fiscal Agent staff to determine if access issues are being reported. If no access issues are being reported, the DHCFP will continue to track the data and make ongoing public inquiries through public forums, workshops, council meetings which also address provider issues/concerns.

The state also monitors billed claims for fluctuations in utilization of waiver services through reports obtained from MMIS and financial reviews conducted by DHCFP Quality Assurance (QA) unit annually. ADSD’s QA unit certifies and monitors applicants who want to enroll as PT 38, before an applicant can become Medicaid provider; and, reviews ID waiver providers to ensure compliance with the approved waiver, Medicaid policies and licensure/certification requirements. Recipients are surveyed annually utilizing the Participant Experience Survey (PES) to ensure their health, safety and welfare. Any discrepancies found are reported to the state’s licensure agency, or DHCFP Surveillance Utilization Review unit and copies of reported discrepancies are also provided to LTSS unit for tracking and trending.

In 2/2017, ADSD implemented a new Serious Occurrence Report (SOR) database called Harmony for reporting complaints/grievances. The ADSD has one (1) working business day to respond to all complaints. The DHCFP staff also has access to Harmony for tracking and trending all complaints/grievances through ADSD.

Private Provider Rates – The ADSD is the billing agent for private providers for the following services: Day Habilitation; Prevocational Services; Residential Support Services; Supported Employment; Behavioral Consultation, Training and Intervention services; Career Planning; Counseling Services; Non-Medical Transportation; Nursing Services; Nutritional Counseling Services and Residential Support Management. The ADSD pays the private providers the total computable amount and then bills the DHCFP for the federal share of expenditures. Rates paid to the private providers for: Day Habilitation; Prevocational Services; Residential Support Services; Supported Employment; and, Residential Support Management were set in 2002 by the Nevada Provider Rates Task Force. EP&P consultant was contracted by the DHCFP to conduct an analysis of provider rates and make recommendations on rate-setting. The base rate for these services were developed and adopted by the DHCFP using a provider cost survey and market analysis. The rates are comprised of level of staffing (FTEs) per billing unit; the wage level for supervisor and direct care staff using wage information from the Bureau of Labor Statistics; employee related expenses at 27% which includes benefits such as paid vacation, paid sick leave, holiday pay, health insurance, etc.; amount of non-billable time spent by staff (productivity adjustment at 30 minutes per day) as well as staff training time; 15% was added to the hourly direct care and ERE cost for non-direct care activities. This is the base rate for these services. The EP&P study further recommended allowing for cost of living adjustments/inflation in future years. Rate adjustments for inflation increased the base rate by 29.6% since 2002. The Division proposed rate increases at each bi-annual legislative session; however, there had been no approved rate increase for SFY 08 and thereafter due to the state’s economic situation until SFY 16. The increase for each year was based on availability of funds. Public testimony is allowed during the Legislative process when rate increases are proposed through the budget process. The Base rate is the same for all private providers.

Other Waiver services such as: Behavioral Consultation, Training and Intervention services; Counseling Services; Nursing services; and, Nutritional Counseling Services are reimbursed at the DHCFP approved rate for like services using the State Plan reimbursement methodology. For example, reimbursement rates for nursing services are set using the rate for Home Health Nursing services fee schedule approved in the Medicaid State Plan Attachment 4.19 - B. These rates can be found on the DHCFP website at http://dhcfp.nv.gov/Resources/Rates/FeeSchedules. Changes to the reimbursement methodology for State Plan services require a public hearing with a 30-day advance notice process and a Tribal notice 60-days in advance. The same rate is paid to all private providers providing these waiver services.

The non-medical transportation maximum rate is $100.00 per month; however, the average monthly payment per recipient is $79.16 per month. The Non-Medical Transportation rate is comparable to other states. As Career Planning was a new service, it was not part of the EP&P study and the DHCFP does not cover these services for any other provider type, so the reimbursement rate was established by evaluating surrounding state’s reimbursement rates. The same rate is paid to all private providers for these waiver services.

The ADSD communicates the rates through the development of a PCP. This plan provides the service, individual to staffing ratio, type, scope, duration and frequency of services to be provided. The provider of service enters into a written provider contract with the ADSD. A service authorization for each recipient is developed in Harmony in accordance with their PCP. A review of service provision is required annually. If changes to the plan are needed, which result in changes to what is reimbursed, a special PCP team meeting is held, and correspondence sent to each provider to communicate future service authorization and billing changes due to staff ratio and/or service units.

Waiver service expenditures listed in Appendix J were calculated using the SFY 2017 actual expenditures (reported from the CMS 372 report), divided by the SFY 2017 actual number of recipients, divided by the estimated number of working days to determine the average unit cost. The average unit cost is reflected in Appendix J. Rate increases to the private servicing providers were not approved in the State's 2018 to 2019 budget cycle, so the inflation factor was not applied until year three of this waiver on Schedule J. For purposes of this renewal, the base rate is increased by the CPI of 1.3%for each year of the waiver. The inflation factor is from the U.S. Department of Labor, Bureau of Labor Statistics, Consumer Price Index – All Urban Consumers (not seasonally adjusted), 12 month percent increase change, U.S. City by expenditure category. The latest analysis is from January 1, 2016 through December 31, 2016. Public Provider Rates - In addition to the private providers, the ADSD staff provides direct medical services for the following: Behavioral Consultation, training and intervention; Counseling Services and Nursing Services. These services are a cost based rate utilizing Certified Public Expenditure (CPE) funding.

An Interim Rate is established on an interim basis for direct medical services per unit of service at the lesser of the ADSD billed charges or the provider-specific interim rate. The provider-specific interim rate is an annual rate for the specific services for a period that is provisional in nature, pending the completion of cost reconciliation and a cost settlement for that period. Interim rates are normally based on program experience and cost data during the prior fiscal year. However, in the case of the ADSD, who is the new operating agency for this waiver, current fiscal year budgeted expenditures were also considered in setting the interim rate for the first year of operation.

Annual Cost Report Process:

The ADSD will complete an annual cost report for all medical services delivered during the previous state fiscal year covering July 1 through June 30. The primary purpose of the cost report is to document the ADSD's total Medicaid-allowable cost for delivering the medical services, including direct costs and indirect costs, based on the methodologies/steps described below and to reconcile its interim payments to the total Medicaid-allowable costs. The annual Medicaid Cost Report includes a certification of funds statement to be completed, certifying the ADSD's actual, incurred allocable and allowable costs/expenditures. All filed annual Cost Reports are subject to audit by the DCHFP or its designee. To determine the Medicaid-allowable direct and indirect costs of providing covered services to Medicaid-eligible clients, the following steps are performed: Direct costs for covered services include unallocated payroll costs and other unallocated costs that can be directly charged to covered medical services. Direct payroll costs include total compensation (i.e., salaries and benefits and contract compensation) of direct care staff. Other direct costs include costs directly related to the delivery of covered services, such as supervision, materials and supplies, professional and contracted services, capital outlay, and travel. These costs must be in compliance with Medicaid non-institutional reimbursement policy and are accumulated on the annual cost report, resulting in total direct costs.

A CMS approved time study is required when providers of service do not spend 100% of their time providing the Medical services and is used to determine the percentage of time that medical service personnel spend on direct medical services, general and administrative time, and all other activities to account for 100 percent of the time to assure that there is no duplicate claiming. This CMS approved time study methodology will be used to separate administrative activities and direct services. The direct medical services time study percentage is applied against the net direct and indirect costs. Total Medicaid allowable costs is reduced by any revenue, e.g. Medicaid copayments, TPL, received for the same services to arrive at the total Medicaid net allocable and allowable costs.

Cost Reconciliation Process:

The ADSD will be responsible for reconciling total allowable computable costs reported on the cost report to the Medicaid interim payments for Medicaid services delivered during the reporting period as document in the MMIS, resulting in cost reconciliation.

Cost Settlement Process:

If the ADSD interim payments exceed the actual, certified costs for services to Medicaid clients, the DHCFP will recoup the federal share of the overpayment. If the actual, certified costs exceed the interim Medicaid payments, the DHCFP will pay the federal share of the difference to the ADSD.

Continued in Main Module

New Hampshire Waiver# NH.0053.R06.01 

NH Developmental Disabilities Waiver

Waiver Name:
NH Developmental Disabilities Waiver
Effective Date:
9/1/2016
Expiration Date:
8/31/2021

Services

List of Services for New Hampshire Waiver# NH.0053.R06.01

Cost Neutrality

Cost Neutrality for New Hampshire Waiver# NH.0053.R06.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4763 5303

Year 1 Waiver Services

List of Year 1 Waiver Services for New Hampshire Waiver# NH.0053.R06.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Services 15 minutes 2379 6000 $3.87
Supported Employment 15 minutes 481 3242 $4.60
Community Support Services 15 minutes 562 1329 $6.15

Year 5 Waiver Services

List of Year 5 Waiver Services for New Hampshire Waiver# NH.0053.R06.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Services 15 minutes 2748 6000 $3.87
Supported Employment 15 minutes 555 3245 $4.60
Community Support Services 15 minutes 649 1333 $6.15

Rate Determination Methods

Rate Determination Methods for New Hampshire Waiver# NH.0053.R06.01

The New Hampshire Department of Health & Human Services (NH-DHHS), New Hampshire’s single state Medicaid agency, is responsible for the development of statewide rates for waiver services. The rate methodology development process includes input from stakeholders. Once approved by NH-DHHS, this methodology will be incorporated into the New Hampshire Administrative Code, which includes a period for public comment according to relevant state and federal requirements as well as a public hearing process that allows for public testimony before New Hampshire’s Joint Legislative Committee on Administrative Rules (JLCAR).

The baseline for all Intellectual Disabilities/Developmental Disabilities (ID/DD) waiver services Rates will be the rates in effect on July 1, 2017; and, which have been in effect since 2007. From this base, NH-DHHS will make adjustments, using a combination of the following indices and factors as applicable and necessary: Health Risk & Support Needs adjustment;

CMS Home Health Agency PPS Market Basket Update; and, Access and availability adjustment. In establishing the rates the Department desires to provide fair and equal compensation for comparable service delivery while maintaining the flexibility to meet individual needs as required and ensure adequate access to services.

The rates for waiver services will be set subject to funds appropriated by the New Hampshire State Legislature. NH-DHHS is responsible for the final review and approval of all rates once each biennium. NH-DHHS periodically reviews the rate setting model to determine if the model accurately reflects the adjustment items listed above. Ensure the direct support professional wages in the applicable service market are sufficient to ensure adequate access to services for waiver members.

Information about rate methodology was made available to waiver participants and other stakeholders as part of the State’s public input process. Information about rates and rate setting methodology was included in the waiver renewal public notice and in the PowerPoint presentation used as part of the in-person public presentations. The state requires, via Administrative Rule He-M 503, that all participants be offered the opportunity to self direct their services. This includes discussions regarding available funding, rates and individualized budgeting opportunities.

New Hampshire Waiver# NH.0060.R07.01 

NH Choices for Independence Waiver

Waiver Name:
NH Choices for Independence Waiver
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for New Hampshire Waiver# NH.0060.R07.01

Cost Neutrality

Cost Neutrality for New Hampshire Waiver# NH.0060.R07.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4170 5652

Year 1 Waiver Services

List of Year 1 Waiver Services for New Hampshire Waiver# NH.0060.R07.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 40 2829.49 $4.60

Year 5 Waiver Services

List of Year 5 Waiver Services for New Hampshire Waiver# NH.0060.R07.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 minutes 65 2829.49 $4.60

Rate Determination Methods

Rate Determination Methods for New Hampshire Waiver# NH.0060.R07.01

The following approach is taken by the State Medicaid Agency regarding Rate Setting Methodology for all CFI Waiver services: (a) The rate setting methodology shall use baseline rates in effective on June 30, 2017.

(b) All CFI rates shall be adjusted each Biennium to be effective July 1 of the even State Fiscal year (For example, for State Fiscal Year 2018 and 2019 Biennium, rates will be adjusted to be effective on July 1, 2017).

(c) Rates shall be calculated by adjusting the rate in effect the prior July 1 of the even State Fiscal Year of the previous biennium by applying the Centers for Medicare and Medicaid Services (CMS) Federal Register, Actual Regulation Market Basket Update for Home Health Agency Prospective Payment System (PPS) Market Basket Update (For example, the federal fiscal year 2017, or calendar year 2017 on the Home Health Agency PPS table, will be used to calculate the July 1, 2017 rates).

(d) The calculated rates in (c) above shall be multiplied by an estimated utilization by service to reach an aggregate estimated expenditure for all CFI services.

(e) Using the aggregate estimated expenditure, calculated in (c) and (d) above, rates for CFI waiver services may be subject to a budget neutrality provision.

(f) When the New Hampshire Legislature approves CFI rate increases in a state budget, the rate increases rather than the rate adjustments established in (c) above, shall be applied as required by the budget legislation. The Department shall apply the procedures in (d) and (e), for rates not established by the New Hampshire Legislature, above to align the aggregate estimated expenditures with the legislative appropriation.

(g) No updated rates shall be in excess of the usual and customary charge for the service as provided to the general public as required by RSA 126-A:3III.(b).

New Hampshire Waiver# NH.4177.R05.01 

NH Acquired Brain Disorder Waiver

Waiver Name:
NH Acquired Brain Disorder Waiver
Effective Date:
11/1/2016
Expiration Date:
10/31/2021

Services

List of Services for New Hampshire Waiver# NH.4177.R05.01

Cost Neutrality

Cost Neutrality for New Hampshire Waiver# NH.4177.R05.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
287 307

Year 1 Waiver Services

List of Year 1 Waiver Services for New Hampshire Waiver# NH.4177.R05.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Services 15 minutes 109 6003 $3.87
Supported Employment 15 minutes 3 2574 $5.59
Community Support Services 15 minutes 11 3796 $6.74

Year 5 Waiver Services

List of Year 5 Waiver Services for New Hampshire Waiver# NH.4177.R05.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Services 15 minutes 117 6003 $3.87
Supported Employment 15 minutes 3 2574 $5.59
Community Support Services 15 minutes 11 3796 $6.74

Rate Determination Methods

Rate Determination Methods for New Hampshire Waiver# NH.4177.R05.01

The New Hampshire Department of Health & Human Services (NH-DHHS), New Hampshire’s single state Medicaid agency, is responsible for the development of statewide rates for waiver services. The rate methodology development process includes input from stakeholders. Once approved by NH-DHHS, this methodology will be incorporated into the New Hampshire Administrative Code, which includes a period for public comment according to relevant state and federal requirements as well as a public hearing process that allows for public testimony before New Hampshire’s Joint Legislative Committee on Administrative Rules (JLCAR).

The baseline for all Acquired Brain Disorder (ABD) waiver services Rates will be the rates in effect on July 1, 2017; and, which have been in effect since 2007. From this base, NH-DHHS will make adjustments, using a combination of the following indices and factors as applicable and necessary: Health Risk & Support Needs adjustment;

CMS Home Health Agency PPS Market Basket Update; and, Access and availability adjustment. In establishing the rates the Department desires to provide fair and equal compensation for comparable service delivery while maintaining the flexibility to meet individual needs as required and ensure adequate access to services.

The rates for waiver services will be set subject to funds appropriated by the New Hampshire State Legislature. NH-DHHS is responsible for the final review and approval of all rates once each biennium. NH-DHHS periodically reviews the rate setting model to determine if the model accurately reflects the adjustment items listed above. Ensure the direct support professional wages in the applicable service market are sufficient to ensure adequate access to services for waiver members.

The Rate Methodology, listed below, is applied the same for all services.

ABD Rate Setting Methodology

The New Hampshire Department of Health & Human Services (NH-DHHS), New Hampshire’s single state Medicaid agency, is responsible for the development of statewide rates for waiver services. The rate methodology development process includes input from stakeholders. Once approved by NH-DHHS, this methodology will be incorporated into the New Hampshire Administrative Code, which includes a period for public comment according to relevant state and federal requirements as well as a public hearing process that allows for public testimony before New Hampshire’s Joint Legislative Committee on Administrative Rules (JLCAR).

The baseline for all Acquired Brain Disorder (ABD) waiver services rates will be the rates in effect on July 1, 2017; and, which have been in effect since 2007. From this base, NH-DHHS will make adjustments, using a combination of the following indices and factors as applicable and necessary: • Health Risk & Support Needs adjustment;

• CMS Home Health Agency PPS Market Basket Update; and,

• Access and availability adjustment. In establishing the rates the department desires to provide fair and equal compensation for comparable service delivery while maintaining the flexibility to meet individual needs as required and ensure adequate access to services.

The rates for waiver services will be set subject to funds appropriated by the New Hampshire State Legislature. NH-DHHS is responsible for the final review and approval of all rates once each biennium. NH-DHHS periodically reviews the rate setting model to determine if the model accurately reflects the adjustment items listed above and to make sure that the direct support professional wages in the applicable service market are sufficient to ensure adequate access to services for waiver members.

New Jersey Waiver# NJ.0031.R06.00 

NJ Community Care Waiver

Waiver Name:
NJ Community Care Waiver
Effective Date:
7/1/2017
Expiration Date:
6/30/2021

Services

List of Services for New Jersey Waiver# NJ.0031.R06.00

Cost Neutrality

Cost Neutrality for New Jersey Waiver# NJ.0031.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
11878 13678

Year 1 Waiver Services

List of Year 1 Waiver Services for New Jersey Waiver# NJ.0031.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation - Daily daily 6938 210 $127.24
Day Habilitation - Hourly hour 500 1001 $20.25
Day Habilitation - Tier A 15 minutes 0 0 $0.01
Day Habilitation - Tier A, Acuity 15 minutes 0 0 $0.01
Day Habilitation - Tier B 15 minutes 0 0 $0.01
Day Habilitation - Tier B, Acuity 15 minutes 0 0 $0.01
Day Habilitation - Tier C 15 minutes 0 0 $0.01
Day Habilitation - Tier C, Acuity 15 minutes 0 0 $0.01
Day Habilitation - Tier D 15 minutes 0 0 $0.01
Day Habilitation - Tier D, Acuity 15 minutes 0 0 $0.01
Day Habilitation - Tier E 15 minutes 0 0 $0.01
Day Habilitation - Tier E, Acuity 15 minutes 0 0 $0.01
Prevocational Services 15 minutes 0 0 $0.01
Supported Employment Hourly hour 375 156 $53.00
Supported Employment FFS 15 minutes 0 0 $0.01
Career Planning 15 minutes 0 0 $0.01
Supported Employment Small Group 15 minutes 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for New Jersey Waiver# NJ.0031.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation - Daily daily 94 240 $68.43
Day Habilitation - Hourly hour 0 0 $0.01
Day Habilitation - Tier A 15 minutes 801 4006 $2.36
Day Habilitation - Tier A, Acuity 15 minutes 26 4006 $3.43
Day Habilitation - Tier B 15 minutes 990 4006 $2.99
Day Habilitation - Tier B, Acuity 15 minutes 102 4006 $4.35
Day Habilitation - Tier C 15 minutes 1978 4006 $3.73
Day Habilitation - Tier C, Acuity 15 minutes 325 4006 $5.43
Day Habilitation - Tier D 15 minutes 1985 4006 $5.60
Day Habilitation - Tier D, Acuity 15 minutes 610 4006 $8.15
Day Habilitation - Tier E 15 minutes 773 4006 $7.46
Day Habilitation - Tier E, Acuity 15 minutes 368 4006 $10.87
Prevocational Services 15 minutes 3417 198 $12.73
Supported Employment Hourly Hour 0 0 $0.01
Supported Employment FFS 15 minutes 8488 624 $13.25
Career Planning 15 minutes 3417 46 $13.25
Supported Employment Small Group 15 minutes 0 0 $0.01

Rate Determination Methods

Rate Determination Methods for New Jersey Waiver# NJ.0031.R06.00

Addendum A contains the various reimbursement methodologies for provider reimbursement for waiver services. This Addendum A identifies the waiver reimbursement methodologies in place as of July 1, 2016 identified by the State as the “Current System”, There is also reference to a “Proposed System”, also identified by the State as the “FFS” system which will replace some of the Current System methodologies, details regarding reimbursement of the FFS system are included in Addendum B.

Under the new fee-for-service payment method, DDD establishes all payment rates for services, distributes the rates to support coordination agencies, and publishes the rate schedule on its website for public access. With a few limited exceptions, the standardized rate schedule was set in consultation with the consulting firm JVGA using its BrickTM Method, a component-driven methodology. This architecture has been, or is being, implemented in ten other states.

The services set using this methodology are: Behavioral supports; Career planning; Day habilitation; Individual supports; Occupational therapy; Physical therapy; Prevocational training; Respite; Speech, language and hearing therapy; Support coordination, Supported employment, and Transportation.

The detailed rate models are included in Addendum B.

The BrickTM Method Rate Study

In New Jersey, JVGA participated in conference calls, on-site meetings, on-site presentations, and webinars throughout the project with DDD, an advisory and a fiscal workgroup (both including community stakeholders), providers (though general-invite events as well as analysis of over forty provider agency cost studies), and a family and self-advocate workgroup.

Organization and Analysis of the Data

The study began with a cost study analysis using general ledger information supplied by providers in the sample group. This group was initially selected to ensure a representative sample in several areas, including provider agency size, geographic location and service scope. After establishing the initial group, the study was opened to other providers that wished to participate, resulting in over forty general ledgers for analysis. Cost information was organized so that the components could be calculated as a percentage of DCS wages and compared consistently across providers.

First, each account line was assigned to a component category based on the cost type and use within each program. After summing the components within each general ledger and program, the total for each component was calculated as a percentage of the aggregate DCS wage. The ledgers were returned to the providers for review of the calculations. Feedback was provided through individual phone calls with provider finance and program staff to discuss both the accuracy of cost component assignment and their specific relationships to program operation. For new services, meaning those not currently offered by DDD providers or included in the waiver, JVGA used component percentages from its extensive database of general ledgers that were collected for similar rate studies.

For example, assume two-year old data for a DCS position yields a hourly wage of $10.00. If compound inflation over that time period was equal to 3.5%, the base wage would be $10.35 ($10.00 * 3.5%). If PS and ERE were computed at 20% and 40%, respectively, the value of those components would be $2.07 ($10.35 * 20%) and $4.14 ($10.25 * 40%). At this stage, the rate would be $16.56 ($10.35 + $2.07 + $4.14). The last component is application of G&A – assuming 10%, the grossed up value of a DCS hour would be $18.40 ($16.56 / [1 – 10%]). This rate can then be divided into units for billing purposes, such as fifteen or thirty minute increments, or using DCS-to-consumer ratios.

Non BrickTM Method Rates

The following services are prior-authorized based on individual need, DDD review or third-party evaluation, and analysis of usual and customary rates: Assistive technology, Environmental modifications, Personal emergency response system (PERS), and Vehicle modifications.

Self-Directed Employees

The following services permit individuals to hire self-directed employees (i.e., the individual is the employer of record, with employment documentation managed by the VF/EA: Individual Supports, Respite, and Transportation.

The rate established in the standardized rate schedule is the maximum amount that the consumer-employer can set for the employee wage, with the wage floor established by federal and State labor laws and regulations.

The Department provides information regarding the rate determination methods upon request from the public. In addition, the federal cost of waiver services is identified annually in the State budget.

Consumers who participate in the self-directed option are informed of the maximum rates for services available under the waiver at the time of enrollment onto the waiver.

Continued From: Appendix I: Financial Accountability, I-1: Financial Integrity and Accountability, Financial Integrity:

Through June 30, 2017 DHS Office of Auditing has conducted at least five audits on an annual basis for select agencies that provide services for NJDDD as an additional line of oversight beyond the required annual independent audit. The audit findings are reviewed when calculating final Community Care Waiver (CCW) rates. Required single audit (section P7.06 of the Contract Policy Manual) performed in accordance with federal OMB circular A-133 and Department policy by a licensed accounting firm on an annual basis, ascertain that the financial statements fairly represent the financial position of the organization including a review of the Final Report of Expenditures (FROE). Posted provider service utilization and reports of expenditure (ROE) data in the DDD systems are reviewed by DDD staff to correct potential errors and omissions. Effective July 1, 2017 DHS Office of Auditing will audit 10% of service provider FROE’s annually. The sample will be a stratified random sample in which 33% of the service providers with the highest contract dollar amount will be strata 1, 33% of the service providers with the mid-range contract ceilings will be strata 2, and finally 33% of the service providers with the lowest contract ceiling will be strata 3. For Waiver Year 1 there will be 156 providers in the universe. Each stratum consists of 52 providers. Strata 1 providers have a contract dollar amount between 8,364,661(lowest contracted amount) and 75,683,440 (highest contract amount), strata 2 have a contract dollar amount between 8,093,690-1,486,888, and strata 3 have a contract dollar amount between 63,166 and 1,410,942.

CMS and DDD have agreed to exceptions for certain requirements regarding compliance with Medicare Publication 15-1 and Fixed Rate FROEs. The effective date for compliance is 7/1/17. The exceptions are identified in the Attached Addendum A Section II F.

Within 12 months of this waiver renewal being approved agencies will begin to move away from contracting with DHS and move to becoming the Medicaid Provider (Fee for Service Model) and will begin to submit their claims through MOLINA directly. DDD imposes financial reporting and audit requirements on provider agencies as they shift to the Fee for Service model as a condition of program participation: a) Providers will be required to submit projections to DDD twice each year. The projections will provide anticipated waiver claim volume by service type; b) Providers will be required to submit Interim Financial Statements due after the close of the provider’s second fiscal quarter; and c) Providers will be required to submit Audited Financial Statements annually within 90 days of the close of the agency’s fiscal year. The reporting requirements are described in Addendum B. At this time, the provider agency must also submit a “rate component report” using a template developed by DDD. The report will detail the rate component values for each service and program operated during the fiscal year, allowing DDD to compare actual provider costs to the factors used in the development of the standardized rate schedule.

Under the Fee for Service system, the QMU Comprehensive Audit will continue.

The New Jersey Comprehensive Assessment Tool (NJ CAT) is comprised of the Functional Criteria Assessment (FCA) and the Developmental Disabilities Resource Tool (DDRT), which combined, is a comprehensive tool used to establish: (a) that an individual has met the functional criteria of three or more substantial limitations in areas of major activities of daily living (to establish functional criteria to receive DDD services); (b) that at least one of the deficits is in self-care (to establish whether an individual meets the ICF-ID level of care); and (c) the needs an individual has for services and supports (which will ultimately tie to a budget level). The seven areas that are assessed to determine the budget level include: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; and economic self-sufficiency. The responses to these questions range from “has not done;” “lots of assistance;” “mainly supervision;” or “independent.” Each response below “independent” indicates that assistance by another person is needed.

The NJ CAT is completed by an informant knowledgeable with regard to the waiver participant. The informant is the individual, or someone who knows the individual best and should be the one to complete the assessment. This individual may include a family member or a paid caregiver who can best describe the abilities and needs of the individual. The completed tool is reviewed by a QIDP to ensure the assessment is consistent with both the QIDP’s observations and the skills/needs presented in the individual’s Service Plan. If there are significant changes in the participant’s health and safety, behavior, medical circumstance a re-evaluation of the NJ CAT may occur otherwise a full NJ CAT is competed every 5 years. In addition to providing a direct statistical basis for allocating funds based on assigned levels of need, the NJ CAT assisted DDD in promoting an allocation policy that is fair and equitable instead of just relying on the principle of “first come, first served.” DDD had an objective basis for providing equal amounts of resources for all participants classified at the same level. Besides promoting fairness within similar levels of need, the results of the NJ CAT analysis also promoted equity between tiers. There are five base tiers: A, B, C, D, & E (as well as an exception tier – Tier F – to be utilized in very rare cases). Persons with Tier E needs received more resources from DDD because their level of independence was much lower than those at the other Tiers (A-D). In addition, those at Tier C received more resources than those with A or B Tiers. The same standardized tool is used for every participant receiving services from DDD and persons scoring the same receive the same amount of funding. In addition, an acuity differentiated factor will be added to the tier for individuals with high clinical support needs based on medical and/or behavioral concerns. The acuity-based tiers include: Aa, Ba, Ca, Da, Ea.

New Mexico Waiver# NM.0173.R06.01 

NM Developmental Disabilities Waiver Program

Waiver Name:
NM Developmental Disabilities Waiver Program
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for New Mexico Waiver# NM.0173.R06.01

Cost Neutrality

Cost Neutrality for New Mexico Waiver# NM.0173.R06.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4618 4759

Year 1 Waiver Services

List of Year 1 Waiver Services for New Mexico Waiver# NM.0173.R06.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment, Intensive (New) hour 195 136.86 $42.16
Supported Employment Job Development (New) 15 minutes 152 72.44 $8.97
Supported Employment, Level 3, Group (Old) 15 minutes 3 1603.74 $2.04
Supported Employment Job Developer (Old) each 1 3.08 $807.36
Supported Employment, Level 2, Group (Old) 15 minutes 6 1260.49 $2.54
Supported Employment, Group, Category 2 (New) 15 minutes 51 2542.93 $2.94
Supported Employment/Self Employment (New) 15 minutes 42 440.95 $6.70
Supported Employment, Level 1, Group, Exception (Old) 15 minutes 0 0 $0.01
Supported Employment, Individual, Exception (Old) hour 7 15.76 $188.66
Supported Employment/Self- Employment (Old) 15 minutes 1 634.86 $6.92
Supported Employment, Level 3, Group, Exception (Old) 15 minutes 2 728.78 $2.04
Supported Employment Job Aide (New) hour 17 179.14 $17.06
Supported Employment, Intensive, Exception (Old) hour 77 179.02 $37.65
Supported Employment- Individual Job Maintenance Per Month month 503 5.52 $954.05
Supported Employment, Intensive (Old) hour 5 129.39 $37.51
Supported Employment, Level 1, Group (Old) 15 minutes 1 1175.52 $3.57
Supported Employment, Group, Category 1 (New) 15 minutes 277 2009.42 $1.95
Supported Employment, Individual (Old) hour 20 14.24 $198.86
Supported Employment, Individual Job Maintenance (New) 15 minutes 541 582 $8.16
Supported Employment, Level 2, Group, Exception (Old) 15 minutes 1 689.6 $2.54
Customized Community Supports Adult Habilitation Level 2 (Old) 15 minutes 43 1538.53 $2.70
Customized Community Supports Fiscal Management of Educational Opportunities (FMEO) der dollar 346 302.52 $1.03
Customized Community Supports, Center 15 minutes 0 0 $0.01
Customized Community Supports Adult Habilitation Level 3 (Old) 15 minutes 6 868.03 $2.19

Year 5 Waiver Services

List of Year 5 Waiver Services for New Mexico Waiver# NM.0173.R06.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment, Intensive (New) hour 201 151.07 $43.00
Supported Employment Job Development (New) 15 minutes 157 79.96 $9.14
Supported Employment, Level 3, Group (Old) 15 minutes 3 1770.23 $2.08
Supported Employment Job Developer (Old) each 1 3.39 $823.50
Supported Employment, Level 2, Group (Old) 15 minutes 6 1391.35 $2.59
Supported Employment, Group, Category 2 (New) 15 minutes 52 2806.92 $2.99
Supported Employment/Self Employment (New) 15 minutes 43 486.73 $6.83
Supported Employment, Level 1, Group, Exception (Old) 15 minutes 0 0 $3.69
Supported Employment, Individual, Exception (Old) hour 7 17.4 $192.43
Supported Employment/Self- Employment (Old) 15 minutes 1 700.77 $7.05
Supported Employment, Level 3, Group, Exception (Old) 15 minutes 1 804.43 $2.08
Supported Employment Job Aide (New) hour 18 197.73 $17.40
Supported Employment, Intensive, Exception (Old) hour 77 197.61 $38.40
Supported Employment- Individual Job Maintenance Per Month month 518 6.09 $973.13
Supported Employment, Intensive (Old) Hour 5 142.82 $38.26
Supported Employment, Level 1, Group (Old) 15 minutes 1 1297.55 $3.64
Supported Employment, Group, Category 1 (New) 15 minutes 285 2218.02 $1.98
Supported Employment, Individual (Old) hour 20 15.71 $202.83
Supported Employment, Individual Job Maintenance (New) 15 minutes 558 642.41 $8.32
Supported Employment, Level 2, Group, Exception (Old) 15 minutes 1 761.19 $2.59
Customized Community Supports Adult Habilitation Level 2 (Old) 15 minutes 43 1698.25 $2.75
Customized Community Supports Fiscal Management of Educational Opportunities (FMEO) per dollar 357 333.93 $1.00
Customized Community Supports, Center 15 minutes 0 0 $0.01
Customized Community Supports Adult Habilitation Level 3 (Old) 15 minutes 6 958.15 $2.23
Customized Community Supports, Individual (New) 15 minutes 1160 1129.91 $7.40
Customized Community Supports Adult Habilitation Level, 3, Outlier (Old) 15 minutes 1 2932.61 $3.67
Customized Community Supports, Group, Category 2 (New) 15 minutes 883 3315.3 $4.02
Customized Community Supports, Group, Community Only (New) 15 minutes 219 1106.63 $4.11
Customized Community Supports Adult Habilitation Level 2, Outlier (Old) 15 minutes 2 2842.81 $3.32
Customized Community Supports, Individual, Intense Behavioral Supports (New) 15 minutes 83 4090.74 $8.65
Customized Community Supports, Group, Category 1 (New) 15 minutes 1378 2670.18 $2.68
Community Inclusion Aide (New) hour 14 188.62 $15.14
Customized Community Supports, Community 15 minutes 0 0 $0.01
Customized Community Supports Adult Habilitation Level 1, Outlier (Old) 15 minutes 13 2818.92 $2.28
Customized Community Supports Community Access (Old) 15 minutes 36 782.18 $6.15
Customized Community Supports Adult Habilitation Level 1 (Old) 15 minutes 60 2671.09 $3.84

Rate Determination Methods

Rate Determination Methods for New Mexico Waiver# NM.0173.R06.01

Rate determination and oversight is a joint responsibility between the Department of Health’s Developmental Disabilities Supports Division (DDSD) and the Human Services Department (HSD). The State can increase rates based on Legislative appropriation, however, HSD must approve all rates and any changes to these rates. Most waiver services are reimbursed on a prospective, fee-for-service basis, with the exceptions noted below for items that are reimbursed based on cost. Rates do not vary by provider type.

In 2011, DDSD engaged Burns & Associates, Inc. (B&A), a national consultant experienced in developing provider payment rates for 1915(c) waivers, to establish independent rate models for most waiver services. The rate models are based on specific assumptions related to providers’ costs, including:

• Direct support professionals’ wages, benefits, and productivity (to account for non-billable responsibilities)

• Other direct care costs, such as transportation and program supplies

• Indirect costs such as program support and administration

In addition to cost assumptions, the rate models incorporate programmatic assumptions, such as staffing ratios. The individual assumptions within the rate models are not prescriptive to service providers; for example, providers are not required to pay the wages assumed in the rate models. Rather, providers have the flexibility within the total rate to design programs that meet members’ needs, consistent with service requirements and members’ individual service plans.

Constructing the rate models involved a number of tasks, including several opportunities for public input and periodic review:

• Service definitions and policies were reviewed in order to ensure that the rate models reflect these requirements.

• A provider advisory group was convened several times during the rate-setting process to serve as a ‘sounding board’ to discuss project goals and materials. The group included a diverse mix of providers in terms of services provided, size, and areas served.

• All providers were invited to complete a survey related to the services they provide and their costs.

• Benchmark data was identified and researched, such as the Bureau of Labor Statistics’ cross-industry wage and benefit data.

• Analysis was conducted to use Supports Intensity Scale (SIS) assessment data and other data related to individuals with high behavioral and high medical need to create ‘tiered’ rates for Supported Living, Customized Community Support-Group, and Community Integrated Employment-Group to recognize the need for more intensive staffing for individuals with more significant needs. Specifically, each adult member has been assigned to one of seven groups based on assessment results in the areas of home living support needs, community living support needs, health and safety needs, medically-related support needs, and behaviorally-related support needs. These seven groups, in turn, are cross-walked to two or three rate categories.

• During this Waiver cycle, DDSD intends to discontinue use of the SIS assessment data for tiered rates and rely on other assessments and data used for clinical justification of services to provide the basis for the tiered rates established for Customized Community Supports- group, Supported Living, and Community Integrated Employment- group.

• Access to certain ‘professional’ services was evaluated and resulted in the designation of ‘incentive’ counties and the corresponding establishment of higher rates for Behavior Support Consultation, Therapies, Preliminary Risk Screening and Consultation Related to Inappropriate Sexual Behavior, and Socialization and Sexuality Education. DDSD has established higher ‘incentive’ rates, based on participants’ county of residence, in order to build capacity for certain professional services where there is a shortage of providers in these areas. An analysis of claims data to measure participants’ access to these services as well as a review of the number of providers delivering services in each county was conducted to determine the geographical areas that saw provider shortages. Additional criteria to determine incentive counties include:

a. One or no providers in the county;

b. In counties with two or more providers, only one provider actually resides in the county;

c. The existing providers are at full capacity or are on Self-Imposed Moratorium;

d. There are individuals in service who have unmet needs due to lack of providers; and

e. Availability of funds.

Burns & Associates developed the rate models for incentive counties using the same approach for other services as described in Appendix I-2-a. The difference between the standard and incentive counties relates to a greater number of assumed miles traveled by the professionals delivering the service and a commensurately larger productivity adjustment for travel time. These assumptions recognize the more rural nature and lower population density of the incentive counties. Proposed rate models outlining specific cost assumptions were developed for each service. • The proposed rate models and supporting documentation were posted on a dedicated website. Providers and other stakeholders were notified of the posting via email and a webinar was conducted to explain the proposals. A dedicated email address was created to accept comments and suggestions for more than one month. DDSD reviewed every comment submitted and prepared a written document summarizing its response to each, including any resulting revision to the rate models or an explanation for why no change was made. This comment period occurred before the proposed rates were formally incorporated into the waiver application. The entire application, including the rates, was then subject to a formal comment period overseen by HSD.

• As required by Federal Court, individuals included in the class established pursuant to Walter Stephen Jackson, et al vs. Fort Stanton Hospital and Training School et. al, 757 F. Supp. 1243 (DNM 1990) (JCM) are using certain services, procedure codes and modifiers outlined in Appendix J in the approved waiver. The State is working with the Plaintiffs and the court to align the use of services, procedure codes and modifiers used by all waiver participants. The state expects this transition to occur in within the first year after approval of the new waiver with plaintiff agreement. A phased implementation of the final rates began in November, 2012.

• There is no formal schedule for a periodic review and adjustment of the rates, but several rates have been increased in the intervening years based on legislated appropriations and stakeholder feedback. Specifically, rates for Supported Living, Family Living, Customized In-Home Support, Customized Community Support-Group, and Supported Employment-Individual were increased in state fiscal year 2015 and rates for Supported Living, Customized In-Home Supports, and Customized Community Supports-Individual were increased in state fiscal year 2016. Additionally, DDSD periodically reviews the number of counties designated as incentive based upon an analysis of existing utilization patterns to determine which areas appear under served.

Rate and reimbursement methodologies for services not included in the rate-setting effort described above are as follows:

• Assistive Technology, Independent Living Transition Services, Personal Support Technology Installation, and Transportation Passes and Tickets are reimbursed based on the actual cost of goods purchased, plus an administrative fee of up to 10 percent (Assistive Technology and Non-Medical Transportation Passes and Tickets) or 15 percent (Independent Living Transition Services).

• Non-Medical Transportation is reimbursed at $0.41 per mile, the rate for state employees in effect when the waiver was approved.

• Rates for Case Management, Community Integrated Employment-Self-Employment, Environmental Modifications, Personal Support Technology-Monthly Maintenance, and Supplemental Dental Care were developed in an earlier rate study that relied upon wage proxies, estimates of staffing levels, and other estimates of costs that would be incurred in the course of service delivery. The central component of the study was a cost survey instrument adapted from Medicare cost reports that collected and recognized the costs that providers incur in order to deliver services.

• The rate for Socialization and Sexuality Education was developed based on research of the costs of conducting the seminar and typical attendance.

The waiver rates can be accessed through HSD’s website at http://www.hsd.state.nm.us/providers/fee-for-service.aspx. Individuals may also request a copy of the fee schedule from their case manager, DOH-DDSD, or HSD.

Additionally, in 2018 DOH-DDSD plans to conduct a comprehensive review of provider payment rates. The implementation and work of a rate study is scheduled to begin in state fiscal year (SFY) 2019.

In addition, the rate study and associated work in SFY 2019 will allow the state to address the following:

1. Identify a contractor that will ensure that the rate study and rate determination is conducted in accordance with methods and standards that have been approved by the state Medicaid agency.

2. All three of New Mexico’s HCBS waivers: Medically Fragile, Mi Via (NM.0448), and Developmental Disabilities (NM.0173) will be included in this comprehensive rate study. This ensures that HCBS waivers concurrently operating within the state have the comparable rate methodologies and standards applied in all jurisdictions and within similar services.

Factors that will be reviewed during the rate study will include: effect of recent FLSA changes; the CMS Final Rule: HCBS Settings Requirements; EVV; current wages; productivity assumptions; benefits factors; administrative overhead; program support costs; paid time off and training time; and staffing ratios. The rate study will assure that rates continually afford participants’ access to services and are consistent with efficiency, economy, and quality of care.

The rate study will be completed and new rates will be developed and submitted through the waiver amendment process within thirty months of the approval of this waiver renewal. New rates are contingent upon the availability of state dollars.

Effective January 1, 2019, the State will apply a two percent (2%) rate increase to all services except assistive technology purchasing agent, fiscal management of adult education opportunities, environmental modifications, independent living transition, non-medical transportation, personal support technology – installation, personal support technology – monthly maintenance, and socialization and sexuality education. The rate increase per service was calculated by using the specific service’s current rate per unit and adding a 2% increase onto the current base rate. Member utilization rates for each individual service were held constant at 2014 levels. A copy of the proposed rate table is available upon CMS request. The State included the proposed rate table as part of formal public comment for this amendment request.

Waiver Name:
Mi Via-ICF/MR
Effective Date:
10/1/2015
Expiration Date:
9/30/2020

Services

List of Services for New Mexico Waiver# 0448.R02.00

Cost Neutrality

Cost Neutrality for New Mexico Waiver# 0448.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
879 1165

Year 1 Waiver Services

List of Year 1 Waiver Services for New Mexico Waiver# 0448.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Customized Community Group Supports 15 minutes 67 1627.15 $4.09
Employment Supports 15 minutes 23 1292.11 $2.88

Year 5 Waiver Services

List of Year 5 Waiver Services for New Mexico Waiver# 0448.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Customized Community Group Supports 15 minutes 146 1627.15 $4.09
Employment Supports 15 minutes 50 1292.11 $2.88

Rate Determination Methods

Rate Determination Methods for New Mexico Waiver# 0448.R02.00

Mi Via participants have their individual budgetary allotments and a range of rates for services, based on Medicaid waiver rates, to utilize in developing their Service and Support Plans and budgets, determining payment rates and negotiating with providers. Participants are informed of the waiver payment range of rates, which are based on what Medicaid currently pays for traditional waiver services, during the Service and Support Planning process. Payment rates for participant-delegated community membership supports, living supports, health and wellness supports, Personal Plan Facilitation, and other supports available through Mi Via will be negotiated by participants in the same way any individual in the community would in making a similar purchase. In the self-directed model, participants are given some flexibility in deciding how much to pay for services and goods; however, both the Service and Support Plan and budget, including payment rates, are authorized by the State, as discussed in Appendix E. The State establishes set rates for the traditional waiver services, such as therapies; however, for Mi Via, the State utilizes a rate range wherein each participant can establish his/her own rate with a particular provider of the service. This rate range is within the parameters the State uses for the traditional waiver service.

Payment, along with other key components of Mi Via, is discussed with participants and stakeholders during the many Mi Via workgroups and task forces. HSD and DOH work collaboratively to determine rates and obtain stakeholder input.

Traditional waiver rates and all Medicaid rates are established by HSD/MAD. Information is obtained from the Medicaid Advisory Committee, which solicits public comments during meetings, advocacy organizations, and the New Mexico Legislature.

Rate ranges for waiver services are as follows:

Personal Plan Facilitation: $100-650 each unit

Homemaker/direct support: $7.50-$14.60 per hour

Home Health Aide: $16.32 per hour

Customized In-Home Living Supports: $25.00-$131.50 per day

Community Direct Support/Navigation: $1.88-15.48 per 15 minutes

Employment Supports (includes Job Coach): $2.15-$6.93 per 15 minutes

Job Developer: $100-700 each

Customized Community Supports: $1.36-$8.82 per 15 minutes

Physical Therapy: $13.51-$24.22 per 15 minutes

Occupational Therapy: $12.74-$23.71 per 15 minutes

Speech/Language Pathology: $16.06-$24.22

Behavior Support Consultation: $12.24-20.65 per 15 minutes

Private Duty Nursing Adults-: $6.79-$10.90 per 15 minutes

Nutrition Counseling-Adult: $42.83 per hour

Acupuncture: $12.50-$25.00 per 15 minutes

Biofeedback: $50.00-$100.00 per visit

Chiropractic: $50.00-$100.00 per visit

Cognitive Rehab Therapy: $12.50-$25.00 per 15 minutes

Hippotherapy: $50.00-$100.00 per visit

Massage Therapy: $12.50-$25.00 per 15 minutes

Naprapathy: $50.00 -$100.00

Native American Healers: negotiated

Ply Therapy: $12.50-$25.00 per 15 minutes

Respite: $3.38-$10.90 per 15 minutes

Emergency Response: $36.71-40.79 per month

Transportation Time: minimum wage- $14.60 per hour

Transportation Trip: negotiated

Transportation Mile: $0.34-$0.40 per mile

Related Goods: As approved by the TPA

Waiver Name:
NM Supports Waiver
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for New Mexico Waiver# NM.1726.R00.00

Cost Neutrality

Cost Neutrality for New Mexico Waiver# NM.1726.R00.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2000 5000

Year 1 Waiver Services

List of Year 1 Waiver Services for New Mexico Waiver# NM.1726.R00.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Customized Community Supports Individual 15 minutes 1565 213 $7.18
Customized Community Supports Group 15 minutes 368 169 $2.68
Employment Supports 15 minutes 91 147 $6.93

Year 5 Waiver Services

List of Year 5 Waiver Services for New Mexico Waiver# NM.1726.R00.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Customized Community Supports Individual 15 minutes 3911 213 $7.18
Customized Community Supports Group 15 minutes 921 169 $2.68
Employment Supports 15 minutes 227 147 $6.93

Rate Determination Methods

Rate Determination Methods for New Mexico Waiver# NM.1726.R00.00

Rate determination and oversight is a joint responsibility between the Department of Health’s Developmental Disabilities Supports Division (DDSD) and the Human Services Department (HSD). The State can increase rates based on Legislative appropriation, however, HSD must approve all rates and any changes to these rates. Most waiver services are reimbursed on a prospective, fee-for-service basis, with the exceptions noted below for items that are reimbursed based on cost. Rates do not vary by provider type.

To develop a waiver with both an agency based and participant directed service delivery model, the State used a combination of the existing rates available through the existing approved DD waiver, NM.0173 (agency based), and the Mi Via waiver, NM.0448 (participant directed). The state applied approved existing rates to the Supports Waiver services using rates for services whose definitions most closely matched the service scope and definitions used in the Supports Waiver. The available rates for the DD waiver and the Mi Via waiver are current approved, and funding is available through legislative appropriation. The Mi Via waiver utilizes a range of rates. When Mi Via rates were applied to Supports Waiver services, the top dollar amount in the range of rates was selected to support the use of both directly hired employees and agency supported employees through both Supports Waiver service delivery models.

NM.0448 Mi Via and NM.0173 Developmental Disabilities waiver rates models take into account numerous factors:

- Direct support professionals’ wages, benefits, and productivity (to account for non-billable responsibilities)

- Other direct care costs, such as transportation and program supplies

- Indirect costs such as program support and administration

In addition to cost assumptions, the rate models incorporate programmatic assumptions, such as staffing ratios. The individual assumptions within the rate models are not prescriptive to service providers; for example, providers are not required to pay the wages assumed in the rate models. Rather, providers have the flexibility within the total rate to design programs that meet members’ needs, consistent with service requirements and members’ individual service plans.

The Medicaid agency solicited public comment on the rate determination methods through its formal public comment process which included engagement with Tribal nations and pueblos as well as the general public. On January 10, 2020 HSD sent out notice to inform tribal leaders and tribal healthcare providers through letters and an HSD website posting regarding the proposed submission of the Supports Waiver application.

On February 12, 2020, a public notice was sent to all interested parties and newspaper announcements were released to the general public summarizing the proposed waiver application and fee schedule. Interested parties include but are not limited to: persons on the waiver central registry, advocacy groups, professional associations, and individual waiver providers. The notice provided the HSD weblink to the full waiver application and fee schedule. A contact name, number and email were provided on the public notice for individuals who had questions or needed more information. New paper notices for Public Comment were published in the Las Cruces Sun and Albuquerque Journal on February 12, 2020. The Albuquerque Journal is distributed statewide.

CUSTOMIZED COMMUNITY SUPPORTS SERVICE RATE

The monthly rate for the Community Supports Coordinator (CSC) is based on the scope of service most closely aligned with the current scope of the Mi Via consultant service. The scope of service includes monthly phone contact and quarterly home visits at a minimum, and assistance with participant-directed employer related functions. The rate is the current approved rate for the Mi Via consultant under the current approved service scope.

EMPLOYMENT SUPPORTS RATE

The rate for the Employment Supports is based on the scope of service most closely aligned with the current scope of the Mi Via waiver Employment Supports. The rate is the current top range of rates under the current approved Mi Via waiver.

SUPPORTS WAIVER SERVICE AND RATE

Community Supports Coordinator $231.13/month

Customized Community Supports-Individual $7.18/15 minutes

Customized Community Supports-Group $2.68/15 minutes

Employment Supports $6.93/15 minutes

Homemaker/Personal Care Services $14.60/hour Assistive Technology $5000 once every 5 years

Behavior Support Consultation $20.65/15 minutes

Environmental Modifications $5000/each once every 5 years

Respite Standard $3.38/15 minutes

Transportation $14.60/hour; $0.41/mile; passes

Vehicle Modifications $5000/each once every 5 years

RATE INFORMATION

The state makes rate information available to waiver participants through:

• Posting of the proposed fee schedule on the HSD and DOH websites.

• The participant reviews rates, units of service and total budget amounts with the Community Supports Coordinator during annual budget development, submission and approval.

New York Waiver# 0238.R04.00 

NYS OPWDD Comprehensive

Waiver Name:
NYS OPWDD Comprehensive
Effective Date:
10/1/2019
Expiration Date:
9/30/2024

Services

List of Services for New York Waiver# 0238.R04.00

Cost Neutrality

Cost Neutrality for New York Waiver# 0238.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
93594 102253

Year 1 Waiver Services

List of Year 1 Waiver Services for New York Waiver# 0238.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Group FFS day 46123 180 $163.00
Day Habilitation Group MC day 165 180 $163.00
Prevocational Services Community Based FFS hourly 6172 493 $26.00
Prevocational Services Community Based MC hour 8 493 $26.00
Prevocational Services Site Based FFS day 3093 128 $120.00
Prevocational Services Site Based MC day 36 128 $120.00
Supported Employment Hourly FFS hour 9954 135 $74.00
Supported Employment Self Directed MC hour 5 218 $44.00
Supported Employment Hourly MC hour 34 135 $74.00
Supported Employment Self Directed FFS hour 602 218 $44.00
Community Hab - Self- Direction - MC hour 7 753 $28.00
Community Hab - Self- Direction - FFS hour 21297 753 $28.00
Community Hab - Hourly - MC hour 29 345 $41.00
Community Hab - Hourly - FFS hour 19561 345 $41.00
Pathway to Employment - FFS hour 1768 97 $48.00
Pathway to Employment - MC hour 1 97 $48.00

Year 5 Waiver Services

List of Year 5 Waiver Services for New York Waiver# 0238.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Group FFS day 50761 173 $167.00
Day Habilitation Group MC day 2805 173 $167.00
Prevocational Services Community Based FFS hour 16266 493 $29.00
Prevocational Services Community Based MC hour 459 493 $29.00
Prevocational Services Site Based FFS day 1292 112 $149.00
Prevocational Services Site Based MC day 526 112 $149.00
Supported Employment Hourly FFS hour 10946 172 $76.24
Supported Employment Self Directed MC hour 20 271 $49.45
Supported Employment Hourly MC hour 539 172 $76.24
Supported Employment Self Directed FFS hour 675 271 $49.45
Community Hab - Self- Direction - MC hour 104 899 $32.00
Community Hab - Self- Direction - FFS hour 30603 899 $32.00
Community Hab - Hourly - MC hour 436 352 $44.00
Community Hab - Hourly - FFS hour 14933 352 $44.00
Pathway to Employment - FFS hour 1594 107 $48.00
Pathway to Employment - MC hour 16 107 $48.00

Rate Determination Methods

Rate Determination Methods for New York Waiver# 0238.R04.00

The following services within the Waiver Renewal are calculated utilizing methodologies based on provider reported costs and are periodically rebased: Residential Habilitation (Supervised IRA and Supportive IRA), Group Day Habilitation and Site-Based Prevocational.

Rates for residential services include an acuity factor which is developed utilizing components of DDP-2 scores, average bed size, Willowbrook class indicators and historical utilization data to predict direct care hours need to serve individuals. Additionally, Supervised IRA rates include an Occupancy Factor to account for days when Medicaid billing cannot occur because of the death or relocation of an individual.

Group Day Habilitation and Site-Based Prevocational services include a to/from transportation component which is rebased annually. These services also include capital costs that are helpful in developing and maintaining the provision of HCBS waiver services to beneficiaries determined in accordance with the cost principles described in the Medicare Provider Reimbursement Manual (Publication-15), with some exceptions.

The remaining services are fee-based. The fees are calculated utilizing various factors, including but not limited to, provider costs, historical utilization, DDP-2 scores, regional averages and review of nationally accepted methodologies and fees. Fee schedules are posted on the Department of Health’s webpage at: https://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/index.htm.

The DOH establishes all payment rates for waiver services. These payment rates are subject to the approval of the New York State Division of the Budget (DOB).

The Rate Methodology for payment of HCBS Waiver services are described in Addendum A to this document. The public can access information regarding rates paid for waiver service on the DOH website at: https://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/ and the OPWDD website where the waiver application is published at: https://opwdd.ny.gov/opwdd_services_supports/people_first_waiver/HCBS_waiver_services.

During the public comment period, hard copies of the Waiver language are available at all OPWDD Regional Offices for provider review and a Public Notice is also placed in the State Registry.

In addition, OPWDD meets with the Provider Associations on a monthly basis. During rate updates, OPWDD meets bi- weekly with a small Provider Rate Work Group to share rate runs and to discuss the effects of any changes to the methodology.

Waiver Name:
NC Innovations 
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for North Carolina Waiver# NC.0423.R03.01

Cost Neutrality

Cost Neutrality for North Carolina Waiver# NC.0423.R03.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
13138 13138

Year 1 Waiver Services

List of Year 1 Waiver Services for North Carolina Waiver# NC.0423.R03.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Networking 15 minutes 3369 1846 $5.45
Day Supports hour 5398 1255 $20.52
Supported Employment 15 minutes 1407 1550 $7.36

Year 5 Waiver Services

List of Year 5 Waiver Services for North Carolina Waiver# NC.0423.R03.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Networking 15 minutes 3369 1998 $5.90
Day Supports hour 5398 1358 $22.22
Supported Employment 15 minutes 1407 1678 $7.97

Rate Determination Methods

Rate Determination Methods for North Carolina Waiver# NC.0423.R03.01

The State employs an actuary to calculate actuarially sound payment rates per 42 CFR 438.6(c).

The PIHPs are responsible for setting all provider rates for waiver services. The PIHPs set rates based on demand for services, availability of qualified providers, clinical priority or best clinical practices and estimated provider service cost. The PIHPs use the State’s Medicaid rates for the same or similar services as a guide in setting rates.

All proposed changes to existing rates or for implementing new rates are reviewed internally by the PIHPs and externally by their respective PIHP provider advisory committee. The provider council is comprised of a cross section of the PIHP’s provider networks. Rate reviews focus on internal and external equity and consistency. Providers are notified of rate changes by announcement at the provider meetings and online posting on the PIHP’s website.

The PIHPs reimburse waiver service providers on a fee-for-service basis for most services and for most providers. To the extent that providers are capitated, then service level encounter data is provided so that the State can track services and set PIHP capitated rates.

For services provided through the individual and family directed option (employer of record model), the administrative portion of the service rate is set aside to cover charges for other administrative costs. The direct service portion of the rate is made available to the employer of record for wages and benefits.

Waiver Name:
NC TBI Waiver
Effective Date:
5/1/2018
Expiration Date:
4/30/2021

Services

List of Services for North Carolina Waiver# NC.1326.R00.00

Cost Neutrality

Cost Neutrality for North Carolina Waiver# NC.1326.R00.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
49 107

Year 1 Waiver Services

List of Year 1 Waiver Services for North Carolina Waiver# NC.1326.R00.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports 15 minutes 22 4105 $5.32
Supported Employment 15 minutes 7 1410 $7.60
Community Networking 15 minutes 10 1701 $5.37

Year 3 Waiver Services

List of Year 3 Waiver Services for North Carolina Waiver# NC.1326.R00.00

Year 3 Waiver Services Table
Year 3 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports 15 minutes 50 4105 $5.38
Supported Employment 15 minutes 15 1410 $7.68
Community Networking 15 minutes 22 1701 $5.43

Rate Determination Methods

Rate Determination Methods for North Carolina Waiver# NC.1326.R00.00

The State employs an actuary to calculate actuarially sound payment rates per 42 CFR 438.6(c).

The PIHPs are responsible for setting all provider rates for waiver services. The PIHPs set rates based on demand for services, availability of qualified providers, clinical priority or best clinical practices and estimated provider service cost. The PIHPs use the State’s Medicaid rates for the same or similar services as a guide in setting rates.

All proposed changes to existing rates or for implementing new rates are reviewed internally by the PIHPs and externally by their respective PIHP provider advisory committee. The provider council is comprised of a cross section of the PIHP’s provider networks. Rate reviews focus on internal and external equity and consistency. Providers are notified of rate changes by announcement at the provider meetings and online posting on the PIHP’s website.

The PIHPs reimburse waiver service providers on a fee-for-service basis for most services and for most providers. To the extent that providers are capitated, then service level encounter data is provided so that the State can track services and set PIHP capitated rates.

North Dakota Waiver# ND.0273.R05.03 

ND Medicaid Waiver for Home and Community Based Services

Waiver Name:
ND Medicaid Waiver for Home and Community Based Services
Effective Date:
4/1/2017
Expiration Date:
3/31/2022

Services

List of Services for North Dakota Waiver# ND.0273.R05.03

Cost Neutrality

Cost Neutrality for North Dakota Waiver# ND.0273.R05.03

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
496 580

Year 1 Waiver Services

List of Year 1 Waiver Services for North Dakota Waiver# ND.0273.R05.03

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 min. 4 470 $7.15
Community Support Service daily 0 0 $224.83

Year 5 Waiver Services

List of Year 5 Waiver Services for North Dakota Waiver# ND.0273.R05.03

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Supported Employment 15 min. 5 489 $8.04
Community Support Service daily 84 360 $236.79

Rate Determination Methods

Rate Determination Methods for North Dakota Waiver# ND.0273.R05.03

Rates are reviewed biannually when the Department’s budget is prepared. The sufficiency of a rate is determined based on the number of clients who are able to access services, including access in rural areas, the number of providers enrolled to provide care, & public comment. The SMA sets rates for services after the Legislature (LEG) appropriates funds for those services. Rates may be increased by LEG action. The LEG may or may not grant an inflationary increase during the LEG session which is held every two years. Testimony is encouraged during LEG Budget Hearings and Interim Human Serv. Committee hearings, qualified service providers (QSPs) give testimony regarding QSP rates.

The SMA gathers input on HCBS including rates via a survey process or public hearings that are held in every region of the State, including reservation communities. The public input is compiled & considered when determining budget & service delivery priorities. Waiver recipients are made aware of the QPS's rate when they choose their QSP. The rate for each service is also listed on the client's person centered plan. When LEG rate increases are approved, clients who have a recipient liability are informed in writing that the service costs will increase.

The SMA maintains a QSP list https://secure.apps.nd.gov/dhs/qsp/qspsearch.aspx that includes the rates by provider. This list is available to clients & the public via online database. Some rates are unique (i.e. Adult Foster Care (AFC) & Family Personal Care (FPC)) to the client because they are based on the client's assessed needs. Due to confidentiality these rates are not available to the public but are provided to the client and listed on their individual care plan (ICP). Rates for Medicaid waiver services are adequate to recruit and retain QSPs across the State to sufficiently meet client needs. We have over 1200 enrolled QSPs statewide and we do not have a waiting list for waiver services. We are continuing to evaluate how the Fair Labor Standards Act (FSLA) final rule applies to QSP & if changes to our program will be necessary if they are subject to the requirements of FLSA.

•The individual and agency fee for service (FFS) rates for respite care, chore, & supported employment were set during the 2007 LEG Session. A max rate was calculated using the SFY 06 individual & agency rates. Individual QSPs requested their rate up to a max rate allowed. Agency rates were based on actual cost reports and were inflated forward to reflect LEG rate increases. The rates have since been reviewed and increased based on LEG action.

•On 9/1/16 the homemaker (HMK) 15-min unit FFS agency & individual QSP rate was revised & was based on 90% of the current fee schedule. Originally individual QSPs requested their rate up to a max rate allowed & the agency FFS rate was based on actual costs and includes allowable administrative costs to the agency. Allowable admin costs include indirect cost of providing services: salaries, fringes, recruiting, phone, billing, office space, utilities, janitorial, bonding, & liability insurance.

•On 9/1/16 the rural differential (RD) HMK rates was also updated. The RD rate methodology remains the same as described below, but the HMK RD rate is based on the updated HMK FFS rate.

•The individual & agency provider FFS rates for Extended Personal Care was initially established in 2007 based on the cost of providing similar services i.e. respite care and personal care (PC). The original max rate was calculated using the SFY 06 individual & agency rates. Individual QSPs requested their rate up to a max rate allowed. Agency rates were based on actual cost reports and were inflated forward to reflect LEG rate increases. The rates have since been reviewed and increased based on LEG action.

•The original individual nurse ed. rate was based on the rates paid for a similar service i.e. nurse management. That rate was set in 2007 after considering Job Service data about the average wage paid in ND for RNs and LPNs inflated to cover admin and other costs. The LEG provided both agency & ind. nurse ed providers a .25 per 15 min unit plus 3% increase on 7/1/13 & 7/1/14.

•The agency FFS rate for nurse ed. is based on actual costs and includes allowable administrative costs to the agency. Allowable admin costs include the indirect cost of providing services: salaries, fringes, recruiting, phone, billing, office space, utilities, janitorial, bonding, & liability insurance.

•Rural Differential (RD) Rate on 1/1/14 the LEG appropriated funds to allow the following services to be paid at a higher rate when they are provided to recipients who live in rural areas: respite care, HMK, PC, Ex-PC (includes nurse ed), chore and transitional living services. Providers who are willing to travel at least 21 miles round trip to provide care to waiver recipients in rural areas may be paid at a higher rate. Providers who are not traveling to rural areas to provide these services will continue to use the previous rate. The SMA has established 3 rate tiers based on the number of miles a provider travels round trip to provide care. Tier 1 covers (21-50 miles), Tier 2 (51-70 miles) and Tier 3 (71+ miles). Estimates for the higher rates were based on the mid-point mileage amount of each tier, multiplied by 27.75 cents per mile (1/2 of the GSA mileage Rate as of 4/12).

•On 1/1/14 transitional living rates were calculated using the same agency 15 minute unit rate that was used to pay for similar services i.e. respite care, chore, and PC services.

•Supervision rates were set based on LEG action and were calculated based on 2013 average entry level wage paid for similar work i.e. child care in ND.

All other services are calculated in the following manner and were set during the 2013 LEG session:

•HDM-The per meal rate was originally based in 2007 on the current average cost of providing OAA nutrition services. The rates have since been reviewed and increased based on LEG action. •Agency providers that want to provide adult day care (ADC), adult residential service (ARS), or emergency response services are required to forward agency cost reports at the time of enrollment. Direct, indirect, and admin costs are provided to the State for rate determination. The agency cost reports are reviewed for reasonableness and a provider rate is set. Currently admin costs in excess of 15% of the direct care costs for providing these services are excluded when calculating the rate. ADC and ARS providers received an $8.00 per day plus 3% rate increase on 7/1/13. During the 2019 LEG session $200,000 was appropriated to rebase ARS rates effective 1/1/20. Providers submit cost reports which will be used to calculate the cost per service.

•AFC & FPC QSP rates are determined based on a formula and factor based system. This system considers the tasks required to care for specific clients. Each allowable task has an identified point factor. The total points are multiplied by a factor, which is unique to the specific service. The factor formula then calculates a daily rate. The assigned daily rate takes into consideration the limit for AFC and FPC. If the rate is at the limit or less, the provider is notified of the assigned rate. If the rate is greater than the limit, the rate is reduced and the provider is notified of the rate. The LEG provided an $8.00 per day plus 3% increase to the previous limits for these services in 2013.

•Rates for self-employed indep. contractors who enroll to provide CM services under the waiver were calculated in 2012 by using the US Bureau of Labor & Statistics (BLS) avg wage paid for social workers (SW) in ND plus the average cost of benefits. That rate was then multiplied by the avg amount of time it takes to complete an annual assessment and the avg time it takes to complete a quarterly contact.

•Agency CM providers rates were initially established by a committee that was charged with establishing the rates based on the average salary being paid to SW at that time and other information provided by the CM entities. Rates were reviewed in the 1990s and increased based on the cost of providing services at the time. Rates have since been inflated based on LEG action. The agency rate is used for all waiver services and was inflated to account for the estimated average additional time it takes to participate in PCP meetings with a team and/or conduct additional home visits.

Annual review of CM records indicates that waiver cases are more complex and/or require frequent changes to the PCP. The unit rate is a monthly rate. The estimated number of units is 4 units per consumer per year. If CM client contact that impacts eligibility, care planning etc. or they complete an assessment with the client on a given day during the month they would be paid 1 unit of CM at the monthly rate. The max amount they could receive would be the monthly rate regardless of how many billable tasks they performed that month. Clients are made aware of the CM costs on their ICP. Each CM agency receives the same rate for providing services. The rates have since been reviewed and increased based on LEG action.

•Environmental modification (Env Mod) and specialized equipment (Sp Eq) costs are based on the actual cost of the modification or the cost of the equipment. Cost proposals for Env Mod & Sp Eq are reviewed to assure that preliminary costs do not exceed the individual budget amount.

•Non-medical transportation rates include a flat round trip rate for in-town trips and a per mileage rate for out of town trips. The current mileage rate is based on the state mileage rate.

•The rate for transition coordination under community transition services is calculated by using the median hourly wage paid to a SW in ND for similar work based on the BLS ($28) and multiplying it by 30% for fringes and by 15% for administrative costs.

•The amount for one-time transition costs under community transition services is based on the historical cap of similar services provided under the Money Follows the Person (MFP) grant inflated by 3% for WY 3-5.

•The rate for residential habilitation (Res Hab) & community support services is based on the similar services provided under the ND Traditional IID/DD HCBS Waiver. The DD Division contracted with a vendor who reviewed the DD providers' general ledgers to determine appropriate cost centers (components) for the expenses. The components are direct care staff, employment related costs, program supports, & general & admin costs. The rate is non-negotiable. SMA uses a FFS system where the budget for a service is based on the max number of hrs authorized for the client. Res Hab is paid on a daily rate based on the number of hrs of daily service authorized for each client and the rates vary by client.

The level on ongoing daily support will be determined by the assessed need from the HCBS assessment tool & person- centered planning. QSPs may only be reimbursed for the time spent providing habilitation to the client. The rates are uniform across all QSPs.

•The rate for companionship services is based on the similar service of HMK so is calculated using the same 15 minute unit rate. The rate is based on 90% of the current fee schedule, which was determined by considering the following information: minimum wage inflated by 30% to cover self-employment costs & US BLS.

A 3% inflationary increase to all provider rates was applied for 9 months of each waiver year based on historical rate increases granted to waiver providers. Inflation was added for 9 months each year because rate adjustments are historical made in Jul of each year. This amount is consistent with the current CPI for Medical Care Services which is 3.6% ending Jan 2017.

QSPs are notified they must charge private pay clients at a rate equal to or greater than the rate set with the State. In all cases the QSP is notified of the initial rate and is notified when the rate changes.

North Dakota Waiver# ND.0037.R08.01 

ND Traditional ID/DD HCBS

Waiver Name:
ND Traditional ID/DD HCBS
Effective Date:
4/1/2019
Expiration Date:
3/31/2024

Services

List of Services for North Dakota Waiver# ND.0037.R08.01

Cost Neutrality

Cost Neutrality for North Dakota Waiver# ND.0037.R08.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5830 6830

Year 1 Waiver Services

List of Year 1 Waiver Services for North Dakota Waiver# ND.0037.R08.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 1214 7360 $6.14
Independent Habilitation 15 minutes 309 1440 $9.28
Individual Employment Support 15 minutes 378 1280 $11.46
Prevocational Services 15 minutes 546 7360 $6.14
Small Group Employment Support 15 minutes 359 7360 $6.14

Year 5 Waiver Services

List of Year 5 Waiver Services for North Dakota Waiver# ND.0037.R08.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 1305 7360 $6.72
Independent Habilitation 15 minutes 350 1440 $10.14
Individual Employment Support 15 minutes 457 1280 $12.54
Prevocational Services 15 minutes 637 7360 $6.72
Small Group Employment Support 15 minutes 450 7360 $6.72

Rate Determination Methods

Rate Determination Methods for North Dakota Waiver# ND.0037.R08.01

Prior to beginning development of proposed waiver, the department held public hearings in all eight regional human service centers to solicit input. The Legislative process allows for public comment during appropriation committee hearings. Inflationary adjustments are determined by legislative appropriation and are subject to that public process.

The Department uses a fee for service system (for Residential Habilitation, Independent Habilitation, Day Habilitation, Individual Employment Support, Small Group Employment Support, and Prevocational Services) wherein the budget for a service is based on the maximum number of hours authorized for the client. The rate for each service is non-negotiable. These rates are determined based on legislative appropriations, and only updated when the legislature approves the amount of change. The initial rates went into effect April 1, 2018. To develop these rates the department contracted with a vendor who reviewed the provider general ledgers to determine the appropriate cost centers (components) for the expenses. The components are direct care staff, employment related costs, program supports, and general and administrative costs. After these were identified, the history of spending was analyzed using cost reports as well as information taken directly from the provides accounting systems. As the vendor did the analysis, they would report out to the steering committee which provided guidance. The steering committee, which was established in 2011, continues to meet on a regular basis to monitor the rate methodology and determine if any changes are necessary. At these meetings, the Department encourages all stakeholders to voice their concerns.

For Residential Habilitation, Independent Habilitation, Day Habilitation, Prevocational Services, Individual Employment Support and Small Group Employment Support, a standardized assessment tool is used to assess participants. Sections of the assessment score are factored into an algorithm to determine the average number of direct care staff hours in a 24-hour period needed by the individual per day of service. For each service, the client budget is calculated by multiplying the hourly rate from the rate matrix times the direct care staff hours identified through the algorithm utilizing the client’s assessment. The hourly rates for these services include the following components: direct care staff wages, employment related expenses, program support, relief staff, and administrative costs.

The Residential Habilitation hourly rate also contains a vacancy factor intended to cover costs when a client is no longer in the setting with no intent to return. The vacancy factor was established by reviewing the distribution of vacancy utilization on MMIS claims from 1/2016- 4/2019.

In Residential Habilitation a personal assistance retainer payment is allowed for reimbursement during a participant’s temporary absence from the setting. The personal assistance retainer allows for continued payment while a participant is hospitalized or otherwise away from the setting in order to ensure stability and continuity of staffing up to thirty calendar days per year per participant.

Payment rates for Residential Habilitation, Day Habilitation, Prevocational Services, and Small Group Employment Support, may include a component for ongoing nursing support, higher credentialed staff, and increased programmatic oversight. There are 3 additional medical acuity tiers for the rate. The development of these tiers included a program support component to represent the hours of nursing relative to the hours of direct support professionals at each acuity tier, then adjusted this ratio to account for higher relative wages for CNAs and RNs based on 2018 Bureau of Labor Statistics Data.

Payment rates for Parenting Supports, Provider Managed In-Home Supports, Family Care Option, and Extended Home Health Care include the following components: administrative costs, program supervision and direct intervention time (direct support staff salary and fringes). The support hours needed are recommended by interdisciplinary teams and reviewed and approved by the Regional DD Program Administrator and the DD Division. Family Care Option is paid as a daily rate. Parenting Supports, Provider Managed In-Home Supports, and Extended Home Health Care are paid at an hourly rate.

Rates by Service Type

• Day Habilitation, Prevocational Services, and Small Group Employment Supports are paid for 15 minute units.

• Individual Employment Support is paid 15 minute units. The direct care staff wage accounts for client related activities outside of direct intervention time.

• Residential Habilitation is paid on a daily rate that based on the number of hours of daily service authorized for each participant. Providers may only be reimbursed for the time spent providing habilitation to the participant.

New residential facility care providers may receive a base staffing rate until fully occupied, or for three (3) months, whichever comes first.

• Independent Habilitation is paid 15 minute units based on the number or hours authorized for each client.

Infant Development has four established fee for service pay points which include evaluation\ assessment, home visit, consultations, and IFSP development. The dollar amount for these pay points were established by stakeholder and state comparison process in July 2010. Adjustments are made based on legislatively approved inflationary increases.

Homemaker: the 15 minute unit fee for service agency and individual provider rate will be based on 90% of the current fee schedule. The agency fee for service rate was initially based on actual costs and includes allowable administrative costs to the agency. Allowable administrative costs include the indirect cost of providing services such as salaries, fringes, recruiting, telephone, billing, office space, utilities, janitorial, bonding, and liability insurance. The individual provider rate was initially established after considering the following information: minimum wage inflated by 30% to cover self-employment costs, the mean rate that was being paid to individuals who were currently providing waiver services and U.S. Bureau of Labor and Statistics information about the average salary paid in North Dakota for similar work.

Adult Foster Care (AFC): provider rates are determined based on a formula and factor based system (which is shown on a worksheet). This system considers the tasks required to care for specific clients. Each allowable task has an identified point factor. The total points are multiplied by a factor, which is unique to AFC. The factor formula then calculates a daily rate. Adult Foster Care rates are determined according to a rate worksheet completed by the DDPM which assesses actual intervention needs of the individual. The resulting score yields a monthly reimbursement. Relief care may be provided according to intensity of support needs. The assigned daily rate takes into consideration the limit for AFC. If the rate is at the limit or less, the provider is notified of the assigned rate. If the rate is greater than the limit, the rate is reduced, and the provider is notified of the rate. The legislature provided an $8.00 per day plus 3% increase to the previous limits for these services in 2013.

Environmental Modifications, Equipment and Supplies, Behavioral Consultation, and Community Transition Services: The rates are determined by the individual within an individualized budget developed with the DDPM and reviewed/approved by the Regional DDPA and the DD Division.

Self-Directed Services In-Home Supports: The DDPM develops the client’s individualized budget based on the amount and frequency as identified during the person-centered planning process, informal resources available to the client, the client’s risk of unwanted out-of-home placement, additional client preferences, the maximum allowable hours for each self-directed service, and the service rate set in by the state legislative body. Clients are responsible for determining staff wages. They are free to choose a wage rate above the wage limits established by the State, but may not reallocate funds assigned to each service.

Ohio Waiver# OH.0231.R05.02 

Individual Options

Waiver Name:
Individual Options
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Ohio Waiver# OH.0231.R05.02

Cost Neutrality

Cost Neutrality for Ohio Waiver# OH.0231.R05.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
26100 30500

Year 1 Waiver Services

List of Year 1 Waiver Services for Ohio Waiver# OH.0231.R05.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation - Adult Day Support Day day 13746 150 $62.14
Habilitation - Adult Day Support Hour hour 12746 110 $10.36
Career Planning - Benefits Education and Analysis item 35 1 $321.25
Career Planning Career Exploration hour 70 100 $54.20
Career Planning Worksite Accessibility hour 0 6 $54.20
Career Planning Employment/Self-Employment Plan Item 5 1 $813.15
Career Planning - Job Development hour 100 100 $54.20
Career Planning Self-Employment Launch hour 5 6 $54.20
Career Planning Career Discovery item 60 1 $1129.62
Career Planning Situational Observation and Assessment Item 6 1 $813.15
Group Employment Support Day day 1280 28 $43.70
Group Employment Support Hour hour 430 680 $5.38
Habilitation- Vocational Habilitation-Hour hour 7925 75 $10.36
Habilitation- Vocational Habilitation day 8925 95 $62.14
Individual Employment Support hour 1400 40 $43.90

Year 5 Waiver Services

List of Year 5 Waiver Services for Ohio Waiver# OH.0231.R05.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation - Adult Day Support Day Day 15173 150 $62.14
Habilitation - Adult Day Support Hour hour 14173 110 $10.36
Career Planning - Benefits Education and Analysis Item 60 1 $321.25
Career Planning Career Exploration hour 110 100 $54.20
Career Planning Worksite Accessibility hour 20 6 $54.20
Career Planning Employment/Self-Employment Plan Item 25 1 $813.15
Career Planning - Job Development hour 140 100 $54.20
Career Planning Self-Employment Launch hour 25 6 $54.20
Career Planning Career Discovery item 100 1 $1129.62
Career Planning Situational Observation and Assessment item 26 1 $813.15
Group Employment Support Day day 1441 28 $43.70
Group Employment Support Hour hour 484 680 $5.38
Habilitation- Vocational Habilitation-Hour hour 10920 75 $10.36
Habilitation- Vocational Habilitation Day 11920 95 $62.14
Individual Employment Support Hour 1576 40 $43.90

Rate Determination Methods

Rate Determination Methods for Ohio Waiver# OH.0231.R05.02

Methods that are Employed to Establish Provider Payment Rates

Legislative actions, primarily resulting from biennial budget initiatives have been the primary driver for establishing service rates. The Department of Developmental Disabilities (DODD) frequently engages individuals, providers, advocates, and other stakeholders in discussions regarding rate setting, in routine forums, most notably the monthly Waiver Workgroup. Analysis of appropriate rates for services occurs throughout the life of the waiver, through these forums, and are frequently updated prior to a renewal application of a waiver.

DODD maintains fee schedules, which are codified in Ohio Administrative Code (OAC) and are accessible in Chapters 5123:2-09/5123-09 at http://dodd.ohio.gov/RulesLaws/Pages/RulesInEffect.aspx.

Fee schedules incorporate geographic and acuity factors, depending on the service. OAC 51239-40 documents the use of these factors in relationship to the Self-Empowered Life Funding (SELF) waiver services.

When necessary to comply with Fair Labor Standards Act (FLSA), the reimbursement to independent providers will be adjusted for overtime compensation. Overtime payments are calculated based on the wage component of the service rate.

Entities that are Responsible for Rate Determinations

DODD is responsible for the development of statewide rates for waiver services, which they oversee, through an Interagency Agreement with the Ohio Department of Medicaid (ODM). The rate development process includes input from stakeholders. Once developed by DODD, ODM is responsible for the final review and approval of all rates.

Opportunity for Public Comments on Rate Setting

Once approved by ODM, all reimbursement rates are incorporated into OAC, which includes a period for public comment as well as a public hearing process that allows for public testimony before Ohio's Joint Commission on Agency Rule Review (JCARR), a body compromised of representatives from the Ohio Senate and the Ohio House of Representatives. Public comments are solicited during the public hearing phase for any new/amended/to be rescinded administrative rules in Ohio. Information about payment rates is posted on DODD's website. Additionally, proposals concerning payment rate restructuring are made public via the Federal Rate change process whereby the State posts the notice of a payment rate restructuring to the Ohio Registrar's website.

Payment rates are made available to the individual.

Analysis of appropriate rates for services occurs throughout the life of the waiver, through these forums, and are frequently updated prior to a renewal application of a waiver.

DODD maintains fee schedules, which are codified in Ohio Administrative Code (OAC) and are accessible in Chapters 5123:2-09/5123-09 at dodd.ohio.gov.

Fee schedules incorporate geographic and acuity factors, depending on the service. OAC 51239-40 documents the use of these factors in relationship to the Self-Empowered Life Funding (SELF) waiver services.

When necessary to comply with Fair Labor Standards Act (FLSA), the reimbursement to independent providers will be adjusted for overtime compensation. Overtime payments are calculated based on the wage component of the service rate.

Groupings of Services Using the Same Rate Setting Methodology The State broadly categorizes services into three different groups:

The Independent Rate Model- The services that use an independent model (or are based on other services that used the independent model) are as follows:

• Adult Day Support (ADS);

• Assistive Technology Consultation/Supports;

• Community and Residential Respite;

• Group Employment;

• Participant-Directed HPC (PD-HPC);

• Remote Supports;

• Support Brokerage; and

• Vocational Habilitation (VH). Equipment Rate Model- The services that use an Equipment Rate Model are as follows:

• Assistive Technology Equipment;

• Functional Behavioral Assessment

• Participant-Directed Goods and Services; and

• Participant/Family Stability Assistance;

Service-Specific models- The following services are paid using their own, individually customized, rate models:

• Career Planning;

• Clinical/Therapeutic Intervention;

• Individual Employment Supports;

• Nursing Delegation; and

• Transportation, Non-Medical Transportation (NMT) (per mile).

Rate Setting for Waiver Services Independent Rate Model

The services that use the independent model (or are based on other services that used an independent model) are as follows: Adult Day Support (ADS), Assistive Technology Consultation/Supports, Community and Residential Respite, Group Employment, , Participant-Directed HPC (PD-HPC), Remote Supports, Support Brokerage, and Vocational Habilitation (VH). The independent rate model was originally developed by third party consultants for the HPC service and has since served as the basis for the above services.

The base wage rate used in the independent rate model was set using the average of the BLS job categories of Home Health Aides (31-1011) and Nursing Aides, Orderlies and Attendants (31-1012). Inflation was adjusted by .98% in 2013 and an additional 6% in 2016. In July 2019, the Ohio General Assembly passed a 20% increase to the Homemaker/Personal Care (HPC) rate, and a 40% increase to the Onsite/On-call HPC rate, set to take effect in 2020 and 2021 (the routine HPC increase was implemented in two stages).

ERE was projected at 30% of the base wage for agencies and 32% for independent providers. Productivity adjustments of 1.02 and 1.10 for agencies and independents, respectively, were used. Overhead was estimated at 18% for agencies and 7% for independents. With the exception of the Support Brokerage service, this results in a statewide ceiling for each service. Rates for PD-HPC can then be negotiated by the participant and Support Brokerage but cannot exceed the rate ceiling. For the Support Brokerage service, the rate is a fixed statewide rate because the Support Brokerage is the only person allowed to negotiate rates on the participant’s behalf.

For all independent rates, there is no adjustment for administrative overhead or non-billable work time. Administrative overhead is assumed to be incurred by the Financial Management Service (FMS), which will be paid separately (contract) for their services. Independent providers are assumed to be 100% productive, thus all time spent with the participant is assumed to be billable work time.

As with the independent provider model, the agency provider rate model begins with Bureau of Labor Statistics (BLS) information specific to Ohio's job market and incorporates factors for employee-related expenses, administrative overhead, and non-billable work time. The model’s assumptions for employee-related expenses, non-billable work time, and administrative overhead are similar to previously approved rate models. For all agency providers, the rate is a fixed statewide rate with no cost of doing business adjustment or negotiation.

The rates may be adjusted using "add-ons" for services rendered to individuals who meet certain medical, behavioral, and/or complex care criteria, for routine PD-HPC services rendered by direct support professionals (DSPs). Medical and behavioral add-on’s are applicable to the Adult Day Service for dates of service on and after April 1, 2017. A community integration add-on was made available when Adult Day Support and Vocational Habilitation is delivered in integrated settings in groups of four or fewer individuals. Staff providing the service must demonstrate successful completion of a DODD approved program instruction in community integration to be eligible for the add-on. The agency and independent rates are adjusted by the cost of doing business (CODB) factors.

Participant Direction

PD-HPC rates are based on the independent rate model discussed above. The Appendix to OAC 5123-9-32 details information concerning common law employee and agency with choice rates. For further information regarding PD-HPC, reference Appendix E.

Independent Model Services: Non-HPC

The independent rate model was originally developed for Non-Medical Transportation (NMT) per trip and per mile rates, and the model continues to be used for per trip rates. Per trip Non-Medical Transportation rates are calculated using data from cost reports. From the cost report data, the total reported transportation costs for adults are divided by the total number of reported trips to derive a cost per trip by county. The calculated transportation rates are then adjusted regional cost of doing business factors to derive the final rates. The original per mile non-medical transportation rate combines the hourly rate of the provider/vehicle driver with the mileage rate to derive a single payment rate.

The NMT per mile rate was adjusted beginning in January 2020 as a result of stakeholder discussions and legislative appropriations. The per mile rate is no longer include staff time as a component of the rate. The rate equals the Federal transportation reimbursement rate as of 2019. A vehicle modification rate was also added as a result of this amendment. The vehicle modification rate is equal to $1.00 per mile. This is not in addition to the regular $.58 per mile rate.

The independent rate model was modified for the Remote Support waiver service. The model includes BLS information specific to Ohio’s job market and incorporated reimbursement for employee related expenses, administrative overhead, productivity assumptions and a responder/on call component.

The independent rate model was modified for adult day support, vocational habilitation, and supported employment- enclave services. Data from 1/1/2005-6/30/2005 county board cost reports were used to calculate a series of additional wage cost components These rates are adjusted for cost of doing business and for the acuity requirements noted in C-4. The rates may be adjusted using "add-ons" for services rendered to individuals who meet certain medical and/or behavioral criteria, or for ADS and VH services when provided in integrated settings in groups of four or fewer individuals by staff of who have completed a DODD approved community integration program; this is the community integration add-on.

Equipment Rate Model

The following services are paid on an "equipment rate model": Assistive Technology Equipment, Functional Behavioral Assessment, Participant-Directed Goods and Services (PDGS), and Participant/Family Stability Assistance. These services are based on the manufacturer's suggested retail price or usual and customary charge defined as: The current retail price of an equipment item that is recommended by the product's manufacturer. If a provider of equipment is also the manufacturer, the provider may establish a suggested retail price provided that the price is equal to or less than the suggested retail price for the same or a comparable item recommended by one or more other manufacturers.

Statewide maximum rates are in place for Assistive Technology Equipment. Reimbursement for these services is the lower of the provider's usual charge or the established statewide maximum.

Service-Specific Rate Models

The Individual Employment Supports and Career Planning service rates were developed by using a blend of two components (initial and retention supports) of a historical service under the SELF waiver. This cost is then adjusted for inflation and eight CODB categories.

**Please refer to Main B Optional for additional rate determination methods information.**

Waiver Name:
Level One
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Ohio Waiver# OH.0380.R03.08

Cost Neutrality

Cost Neutrality for Ohio Waiver# OH.0380.R03.08

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
16600 19200

Year 1 Waiver Services

List of Year 1 Waiver Services for Ohio Waiver# OH.0380.R03.08

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Adult Day Support Day 6113 158 $31.40
Habilitation Adult Day Support hour 2038 950 $7.85
Habilitation Vocational Habilitation Day 1942 158 $31.40
Habilitation Vocational Habilitation Hour 647 950 $7.85
Career Planning Situational Observation and Assessment Item 284 1 $813.15
Career Planning Career Exploration hour 284 6 $54.20
Career Planning - Benefits Education and Analysis Item 284 1 $285.00
Career Planning Career Discovery Item 284 1 $1129.62
Career Planning Employment/Self-Employment Plan Item 284 1 $813.15
Career Planning - Job Development Hour 284 6 $54.20
Career Planning Self-Employment Launch hour 284 6 $54.20
Career Planning Worksite Accessibility Hour 284 6 $54.20
Career Planning Assistive Technology Assessment Item 284 1 $352.30
Group Employment Support hour 2092 563 $5.15
Group Employment Support Day 0 0 $43.70
Individual Employment Support Hour 1892 19 $43.90
Supported Employment - Community (Terminated Eff. 3/31/2017 hour 1892 5 $36.60
Supported Employment - Enclave (Terminated Eff. 3/31/2017) hour 2092 188 $5.15

Year 5 Waiver Services

List of Year 5 Waiver Services for Ohio Waiver# OH.0380.R03.08

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Adult Day Support Day 6113 158 $31.40
Habilitation Adult Day Support hour 2038 950 $7.85
Habilitation Vocational Habilitation Day 1942 158 $31.40
Habilitation Vocational Habilitation hour 647 950 $7.85
Career Planning Situational Observation and Assessment Item 328 1 $813.15
Career Planning Career Exploration hour 328 6 $54.20
Career Planning - Benefits Education and Analysis Item 328 1 $285.00
Career Planning Career Discovery Item 328 1 $1129.62
Career Planning Employment/Self-Employment Plan Item 328 1 $813.15
Career Planning - Job Development hour 328 6 $54.20
Career Planning Self-Employment Launch hour 328 6 $54.20
Career Planning Worksite Accessibility hour 328 6 $54.20
Career Planning Assistive Technology Assessment Item 0 0 $352.30
Group Employment Support hour 605 563 $5.15
Group Employment Support Day 1814 23 $43.70
Individual Employment Support hour 2189 24 $43.90
Supported Employment - Community (Terminated Eff. 3/31/2017 hour 0 0 $36.04
Supported Employment - Enclave (Terminated Eff. 3/31/2017) hour 0 0 $40.70

Rate Determination Methods

Rate Determination Methods for Ohio Waiver# OH.0380.R03.08

Methods that are Employed to Establish Provider Payment Rates

Legislative actions, primarily resulting from biennial budget initiatives have been the primary driver for establishing service rates. The Department of Developmental Disabilities (DODD) frequently engages individuals, providers, advocates, and other stakeholders in discussions regarding rate setting, in routine forums, most notably the monthly Waiver Workgroup. Analysis of appropriate rates for services occurs throughout the life of the waiver, through these forums, and are frequently updated prior to a renewal application of a waiver. DODD maintains fee schedules, which are codified in Ohio Administrative Code (OAC), and are accessible in Chapters 5123:2-09/5123-09 at http://dodd.ohio.gov/RulesLaws/Pages/RulesInEffect.aspx.

Fee schedules incorporate geographic and acuity factors, depending on the service. OAC 5123:2-9-06 and 5123:2-9-19 document the use of these factors in relationship to the Level One (L1) waiver services.

When necessary to comply with Fair Labor Standards Act (FLSA), the reimbursement to non-agency providers will be adjusted for overtime compensation. Overtime payments are calculated based on the wage component of the service rate.

Entities that are Responsible for Rate Determinations

DODD is responsible for the development of statewide rates for waiver services, which they oversee, through an Interagency Agreement with the Ohio Department of Medicaid (ODM). The rate development process includes input from stakeholders. Once developed by DODD, ODM is responsible for the final review and approval of all rates.

Opportunity for Public Comments on Rate Setting

Once approved by ODM, all reimbursement rates are incorporated into OAC, which includes a period for public comment as well as a public hearing process that allows for public testimony before Ohio's Joint Commission on Agency Rule Review (JCARR), a body compromised of representatives from the Ohio Senate and the Ohio House of Representatives. Public comments are solicited during the public hearing phase for any new/amended/to be rescinded administrative rules in Ohio. Information about payment rates is posted on DODD's website. Additionally, proposals concerning payment rate restructuring are made public via the Federal Rate change process whereby the State posts the notice of a payment rate restructuring to the Ohio Registrar's website.

Payment rates are made available to the individual during the Individual Service Planning (ISP) and waiver service planning processes. The Cost Projection Tool (CPT), developed and maintained by DODD, is used to determine the total expected amount of payment for each individual's waiver span as well as the total service hours that are expected to be rendered. The projection of service costs and payment standards are in accordance with Chapters 5160-41, 5123-9 and 5123:2-9 of the OAC.

Groupings of Services Using the Same Rate Setting Methodology The State broadly categorizes services into three different groups:

The Independent Rate Model- The services that use an independent model (or are based on other services that used the independent model) are as follows:

• Adult Day Support (ADS);

• Assistive Technology Consultation/Supports;

• Community, Informal, and Residential Respite;

• Group Employment;

• Non-Medical Transportation (per mile);

• Homemaker/Personal Care (HPC);

• Money Management;

• Participant-Directed HPC (PD-HPC);

• Remote Supports; and

• Vocational Habilitation (VH).

Equipment Rate Model- The services that use an Equipment Rate Model are as follows:

• Assistive Technology Equipment;

• Environmental Accessibility Adaptations; and

• Specialized Medical Equipment and Supplies

Service-Specific models- The following services are paid using their own, individually customized, rate models:

• Career Planning; • Individual Employment Supports;

• Home Delivered Meals;

• Nursing Delegation; and

• Transportation

Rate Setting for Waiver Services Independent Rate Model

The services that use the independent model (or are based on other services that used an independent model) are as follows: Adult Day Support (ADS), Vocational Habilitation (VH), Group Employment, Non-Medical Transportation (per mile), Homemaker/Personal Care (HPC), Participant-Directed HPC (PD-HPC), HPC Daily Billing Unit, Shared Living, Money Management, Remote Supports, Assistive Technology Consultation/Supports, and Community and Residential Respite. The independent rate model was originally developed by third party consultants for the HPC service and has since served as the basis for the above services.

Reimbursement rates for HPC and the additional direct services are created by utilizing the independent rate setting model, developed by a third-party consultant. The model uses Bureau of Labor Statistics (BLS) information specific to Ohio's job market, reimbursement for employee related expenses (ERE), administrative overhead and non-billable work time to calculate a statewide rate for each service. This statewide rate is then adjusted for eight CODBs.

The base wage rate used in the independent rate model was set using the average of the BLS job categories of Home Health Aides (31-1011) and Nursing Aides, Orderlies and Attendants (31-1012). Inflation was adjusted by .98% in 2013 and an additional 6% in 2016. ERE was projected at 30% of the base wage for agencies and 32% for independent providers. Productivity adjustments of 1.02 and 1.10 for agencies and independents, respectively, were used. Overhead was estimated at 18% for agencies and 7% for independents.

The statewide rates for agency providers and non-agency providers reflect differences in administrative overhead, supervisory-related expenses, and non-billable work time. The rates are adjusted upward based on the number of individuals sharing services, up to four individuals per setting.

The rates may be adjusted using "add-ons" for services rendered to individuals who meet certain medical, behavioral, and/or complex care criteria, for routine HPC services rendered by direct support professionals (DSPs). An add on for DSPs who have at least 2 years experience and 60 hours accredited competency-based training for HPC services is termed a "competency-based" add-on. The add-on of $0.39/unit was developed with stakeholder input in response to the existing workforce shortage. The intent was to promote retention of direct support professionals by making available an additional $1.00/hour. Upon increasing the wage component of the homemaker/personal care rate to reflect the additional $0.25/unit, the employee-related expenses, productivity assumptions, and administrative assumptions that are part of the rate methodology were increased accordingly. A one-year term limited add-on for HPC when the individuals formerly resided in intermediate care facilities for individuals with intellectual disabilities (ICFs-IID termed a “community integration” add on.

In July 2019, the Ohio General Assembly passed a total 20% increase, and a 40% increase to direct service providers of routine Homemaker/Personal Care (HPC) and Onsite/On call HPC, respectively. The rates for these affected services are set to take effect on January 1, 2020 and January 1, 2021 (for routine HPC only).

Independent Model Services: Non-HPC

Rates are paid in fifteen-minute units for services to individuals who do not share services with others (e.g., live alone or live with others who do not receive HPC services from the same provider).

Independent Model Services: Non-HPC

The independent rate model was developed for Non-Medical Transportation (NMT), which may be billed either per trip or per mile. Trip rates are calculated using 1/1/2005-6/30/2005 county board cost report data. From the cost report data, the total reported transportation costs for adults are divided by the total number of reported trips to derive a cost per trip by county. This cost is then adjusted for inflation and eight cost of doing business categories. The original mile rates combine the hourly rate of the vehicle driver with the mileage rate based on the 2 minutes of service at HPC cost for each mile driven.

The NMT per mile rate will be adjusted beginning in January 2020 as a result of stakeholder discussions and legislative appropriations. The per mile rate will no longer include staff time as a component of the rate. The rate will equal the Federal transportation reimbursement rate as of 2019. A vehicle modification rate will also be added as a result of this amendment. The vehicle modification rate is equal to $1.00 per mile. This is not in addition to the regular $.58 per mile rate.

The independent rate model was modified for the Remote Support waiver service. The model includes BLS information specific to Ohio’s job market and incorporated reimbursement for employee related expenses, administrative overhead, productivity assumptions and a responder/on call component.

The independent rate model was modified for adult day support, vocational habilitation, and supported employment- enclave services. Data from 1/1/2005-6/30/2005 county board cost reports were used to calculate a series of additional wage cost components These rates are adjusted for cost of doing business and for the acuity requirements noted in C-4. The rates may be adjusted using "add-ons" for services rendered to individuals who meet certain medical and/or behavioral criteria, or for ADS and VH services when provided in integrated settings in groups of four or fewer individuals by staff of who have completed a DODD approved community integration program; this is the community integration add-on.

Equipment Rate Model

The following services are paid on an "equipment rate model": Assistive Technology Equipment, Environmental Accessibility and Adaptations, Specialized Medical Equipment and Supplies, and Community Transition Services (CTS). Except for CTS, these services are based on the manufacturer's suggested retail price defined as: The current retail price of an equipment item that is recommended by the product's manufacturer. If a provider of equipment is also the manufacturer, the provider may establish a suggested retail price provided that the price is equal to or less than the suggested retail price for the same or a comparable item recommended by one or more other manufacturers. The CTS rate is comparable to the rate previously offered under Ohio Medicaid's Money Follows the Person Program (HOME Choice) for the same service.

Statewide maximum rates are in place for Assistive Technology Equipment, Environmental Accessibility and Adaptations, Specialized Medical Equipment and Supplies, and CTS. Reimbursement for these services is the lower of the provider's usual charge or the established statewide maximum.

Service-Specific Rate Models

The Individual Employment Supports and Career Planning service rates were developed by using a blend of two components (initial and retention supports) of a historical service under the SELF waiver. Ohio assumed that 70% of all employment services are for retention and 30% for placement. This cost is then adjusted for inflation and eight CODB categories.

The rate methodology used to determine Home Delivered Meals is unknown at this time. However, the United States Department of Agriculture (USDA) estimated that costs for home prepared meals cost approximately $49 per week in 1994. Ohio’s reimbursement rate of $7 per meal is consistent with the USDA estimate.

*Please see Main B Option for additional information*

Ohio Waiver# OH.0877.R02.00 

Self Empowered Life Funding (SELF)

Waiver Name:
Self Empowered Life Funding (SELF)
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for Ohio Waiver# OH.0877.R02.00

Cost Neutrality

Cost Neutrality for Ohio Waiver# OH.0877.R02.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2200 3200

Year 1 Waiver Services

List of Year 1 Waiver Services for Ohio Waiver# OH.0877.R02.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Planning Worksite Accessibility hour 5 6 $54.20
Career Planning Career Discovery Item 7 1 $1161.64
Career Planning Situation Observation and Assessment Item 5 1 $813.15
Career Planning Career Exploration hour 3 59.67 $40.56
Career Planning Benefits Education and Analysis Item 8 1 $285.00
Career Planning Employment/Self Employment Plan Item 1 1 $813.15
Career Planning Job Development hour 11 39.27 $54.20
Career Planning Self Employment Launch hour 2 70.5 $54.20
Group Employment Support Day 75 74 $33.40
Group Employment Support hour 75 1070 $5.60
Habilitation-Adult Day Support Hour 430 460 $7.72
Habilitation-Adult Day Support Day 440 100 $50.85
Habilitation- Vocational Habilitation Day 320 100 $41.48
Habilitation- Vocational Habilitation hour 300 350 $6.88
Individual Employment Support hour 250 100 $41.32

Year 5 Waiver Services

List of Year 5 Waiver Services for Ohio Waiver# OH.0877.R02.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Planning Worksite Accessibility hour 25 6 $54.20
Career Planning Career Discovery Item 47 1 $1161.00
Career Planning Situation Observation and Assessment Item 25 1 $813.15
Career Planning Career Exploration hour 43 59.67 $40.56
Career Planning Benefits Education and Analysis Item 28 1 $285.00
Career Planning Employment/Self Employment Plan Item 21 1 $813.15
Career Planning Job Development hour 51 39.27 $54.20
Career Planning Self Employment Launch hour 22 70.5 $54.20
Group Employment Support Day 175 75 $33.40
Group Employment Support hour 275 1070 $5.60
Habilitation-Adult Day Support Hour 640 100 $50.85
Habilitation-Adult Day Support Day 680 460 $7.72
Habilitation- Vocational Habilitation Day 460 350 $6.88
Habilitation- Vocational Habilitation hour 480 100 $41.48
Individual Employment Support hour 390 100 $41.32

Rate Determination Methods

Rate Determination Methods for Ohio Waiver# OH.0877.R02.00

Methods that are Employed to Establish Provider Payment Rates

Legislative actions, primarily resulting from biennial budget initiatives have been the primary driver for establishing service rates. The Department of Developmental Disabilities (DODD) frequently engages individuals, providers, advocates, and other stakeholders in discussions regarding rate setting, in routine forums, most notably the monthly Waiver Workgroup. Analysis of appropriate rates for services occurs throughout the life of the waiver, through these forums, and are frequently updated prior to a renewal application of a waiver.

DODD maintains fee schedules, which are codified in Ohio Administrative Code (OAC), and are accessible in Chapters 5123:2-09/5123-09 at http://dodd.ohio.gov/RulesLaws/Pages/RulesInEffect.aspx.

Fee schedules incorporate geographic and acuity factors, depending on the service. OAC 51239-40 documents the use of these factors in relationship to the Self-Empowered Life Funding (SELF) waiver services.

When necessary to comply with Fair Labor Standards Act (FLSA), the reimbursement to independent providers will be adjusted for overtime compensation. Overtime payments are calculated based on the wage component of the service rate.

Entities that are Responsible for Rate Determinations

DODD is responsible for the development of statewide rates for waiver services, which they oversee, through an Interagency Agreement with the Ohio Department of Medicaid (ODM). The rate development process includes input from stakeholders. Once developed by DODD, ODM is responsible for the final review and approval of all rates.

Opportunity for Public Comments on Rate Setting

Once approved by ODM, all reimbursement rates are incorporated into OAC, which includes a period for public comment as well as a public hearing process that allows for public testimony before Ohio's Joint Commission on Agency Rule Review (JCARR), a body compromised of representatives from the Ohio Senate and the Ohio House of Representatives. Public comments are solicited during the public hearing phase for any new/amended/to be rescinded administrative rules in Ohio. Information about payment rates is posted on DODD's website. Additionally, proposals concerning payment rate restructuring are made public via the Federal Rate change process whereby the State posts the notice of a payment rate restructuring to the Ohio Registrar's website.

Payment rates are made available to the individual during the Individual Service Planning (ISP) and waiver service planning processes.

Groupings of Services Using the Same Rate Setting Methodology The State broadly categorizes services into three different groups:

The Independent Rate Model- The services that use an independent model (or are based on other services that used the independent model) are as follows:

• Adult Day Support (ADS);

• Assistive Technology Consultation/Supports;

• Community and Residential Respite;

• Group Employment;

• Non-Medical Transportation (per mile);

• Participant-Directed HPC (PD-HPC);

• Remote Supports;

• Support Brokerage; and

• Vocational Habilitation (VH).

Equipment Rate Model- The services that use an Equipment Rate Model are as follows:

• Assistive Technology Equipment;

• Functional Behavioral Assessment

• Participant-Directed Goods and Services; and

• Participant/Family Stability Assistance;

Service-Specific models- The following services are paid using their own, individually customized, rate models:

• Career Planning;

• Clinical/Therapeutic Intervention;

• Individual Employment Supports; • Nursing Delegation; and

• Transportation

Rate Setting for Waiver Services Independent Rate Model

The services that use the independent model (or are based on other services that used an independent model) are as follows: Adult Day Support (ADS), Assistive Technology Consultation/Supports, Community and Residential Respite, Group Employment, Non-Medical Transportation (per mile), Participant-Directed HPC (PD-HPC), Remote Supports, Support Brokerage, and Vocational Habilitation (VH). The independent rate model was originally developed by third party consultants for the HPC service and has since served as the basis for the above services.

The base wage rate used in the independent rate model was set using the average of the BLS job categories of Home Health Aides (31-1011) and Nursing Aides, Orderlies and Attendants (31-1012). Inflation was adjusted by .98% in 2013 and an additional 6% in 2016. ERE was projected at 30% of the base wage for agencies and 32% for independent providers. Productivity adjustments of 1.02 and 1.10 for agencies and independents, respectively, were used. Overhead was estimated at 18% for agencies and 7% for independents. With the exception of the Support Brokerage service, this results in a statewide ceiling for each service. Rates for PD-HPC can then be negotiated by the participant and Support Brokerage but cannot exceed the rate ceiling. For the Support Brokerage service, the rate is a fixed statewide rate because the Support Brokerage is the only person allowed to negotiate rates on the participant’s behalf.

For all independent rates, there is no adjustment for administrative overhead or non-billable work time. Administrative overhead is assumed to be incurred by the Financial Management Service (FMS), which will be paid separately (contract) for their services. Independent providers are assumed to be 100% productive, thus all time spent with the participant is assumed to be billable work time.

As with the independent provider model, the agency provider rate model begins with Bureau of Labor Statistics (BLS) information specific to Ohio's job market and incorporates factors for employee-related expenses, administrative overhead, and non-billable work time. The model’s assumptions for employee-related expenses, non-billable work time, and administrative overhead are similar to previously approved rate models. For all agency providers, the rate is a fixed statewide rate with no cost of doing business adjustment or negotiation.

The rates may be adjusted using "add-ons" for services rendered to individuals who meet certain medical, behavioral, and/or complex care criteria, for routine PD-HPC services rendered by direct support professionals (DSPs). Medical and behavioral add-on’s are applicable to the Adult Day Service for dates of service on and after April 1, 2017. A community integration add-on was made available when Adult Day Support and Vocational Habilitation was provisioned in integrated settings in groups of four or fewer individuals. Staff providing the service must demonstrate successful completion of a DODD approved program instruction in community integration to be eligible for the add-on. Ohio assumed that 70% of all employment services are for retention and 30% for placement. The agency and independent rates are adjusted by the cost of doing business (CODB) factors. This service will be replaced with Individual Employment Supports and Career Planning services and will use a similar rate structure.

Participant Direction

PD-HPC rates are based on the independent rate model discussed above. The Appendix to OAC 5123-9-32 details information concerning common law employee and agency with choice rates. For both common law and agency with choice on-site/on-call PD-HPC, these rates are synchronous with minimum wage in Ohio. These rates adjust based on changes to Ohio’s minimum wage, with an addition of 13% to cover employer-related expenses. For further information regarding PD-HPC, reference Appendix E.

In July 2019, the Ohio General Assembly passed a total 20% increase, and a 40% increase to direct service providers of routine Homemaker/Personal Care (HPC) and Onsite/On call HPC, respectively. The rates for these affected services are set to take effect on January 1, 2020 and January 1, 2021 (for routine HPC only).

Independent Model Services: Non-HPC

The independent rate model was developed for Non-Medical Transportation (NMT), which may be billed either per trip or per mile. Per trip Non-Medical Transportation rates are calculated using data from cost reports. From the cost report data, the total reported transportation costs for adults are divided by the total number of reported trips to derive a cost per trip by county. The calculated transportation rates are then adjusted regional cost of doing business factors to derive the final rates. The original per mile non-medical transportation rate combines the hourly rate of the provider/vehicle driver with the mileage rate to derive a single payment rate.

The NMT per mile rate will be adjusted beginning in January 2020 as a result of stakeholder discussions and legislative appropriations. The per mile rate will no longer include staff time as a component of the rate. The rate will equal the Federal transportation reimbursement rate as of 2019. A vehicle modification rate will also be added as a result of this amendment. The vehicle modification rate is equal to $1.00 per mile. This is not in addition to the regular $.58 per mile rate.

The independent rate model was modified for the Remote Support waiver service. The model includes BLS information specific to Ohio’s job market and incorporated reimbursement for employee related expenses, administrative overhead, productivity assumptions and a responder/on call component.

The independent rate model was modified for adult day support, vocational habilitation, and supported employment- enclave services. Data from 1/1/2005-6/30/2005 county board cost reports were used to calculate a series of additional wage cost components These rates are adjusted for cost of doing business and for the acuity requirements noted in C-4. The rates may be adjusted using "add-ons" for services rendered to individuals who meet certain medical and/or behavioral criteria, or for ADS and VH services when provided in integrated settings in groups of four or fewer individuals by staff of who have completed a DODD approved community integration program; this is the community integration add-on.

Equipment Rate Model

The following services are paid on an "equipment rate model": Assistive Technology Equipment, Functional Behavioral Assessment, Participant-Directed Goods and Services (PDGS), and Participant/Family Stability Assistance. These services are based on the manufacturer's suggested retail price or usual and customary charge defined as: The current retail price of an equipment item that is recommended by the product's manufacturer. If a provider of equipment is also the manufacturer, the provider may establish a suggested retail price provided that the price is equal to or less than the suggested retail price for the same or a comparable item recommended by one or more other manufacturers.

Statewide maximum rates are in place for Assistive Technology Equipment. Reimbursement for these services is the lower of the provider's usual charge or the established statewide maximum.

Service-Specific Rate Models

The Individual Employment Supports and Career Planning service rates were developed by using a blend of two components (initial and retention supports) of a historical service under the SELF waiver. Ohio assumed that 70% of all employment services are for retention and 30% for placement. This cost is then adjusted for inflation and eight CODB categories.

**Please see Main B Option for additional information.**

Waiver Name:
Community Waiver
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Oklahoma Waiver# OK.0179.R06.06

Cost Neutrality

Cost Neutrality for Oklahoma Waiver# OK.0179.R06.06

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
3150 3310

Year 1 Waiver Services

List of Year 1 Waiver Services for Oklahoma Waiver# OK.0179.R06.06

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Training Specialist Services 1 hour 2045 1500 $15.12
Prevocational Services 1 hour 1524 942 $8.62
Supported Employment Individual 1 hour 414 348 $15.76
Supported Employment Group 1 hour 999 1065 $13.03

Year 5 Waiver Services

List of Year 5 Waiver Services for Oklahoma Waiver# OK.0179.R06.06

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Training Specialist Services 1 hour 2278 1547 $16.84
Prevocational Services 1 hour 1643 732 $9.59
Supported Employment Individual 1 hour 437 299 $17.47
Supported Employment Group 1 hour 1290 1003 $14.14

Rate Determination Methods

Rate Determination Methods for Oklahoma Waiver# OK.0179.R06.06

Rates are determined according to Oklahoma Statute Title 74, Section 85 The Oklahoma Central Purchasing Act, Chapter 4. The OHCA State Plan Amendment Rate Committee (SPARC) is responsible for reviewing and setting all service rates for Medicaid services. Rates are given final consideration and approval by the OHCA Board.

Rates for waiver services are set by one of the methodologies below.

1) Method One - Utilizing the Medicaid Rate: When a waiver service is the same as a Medicaid service for which a fee schedule has been established, the current Medicaid rate is utilized. Services utilizing the Medicaid Rate are: »Audiology »Dental »Nutrition »Prescription Drugs The State affirms that all waiver services provided under the State Plan are provided under the same rate as the State Plan rate for all providers.

2)Method Two - Fixed and Uniform Rate: Title 74 of the Oklahoma Statutes provides a methodology for setting fixed and uniform rates. a. Determination of need for a fixed and uniform rate

i. New: A new service is developed, or

ii. Existing Service: Feedback from providers, clients, or the general public indicates that the existing rate is not sufficient to ensure access to an existing service.

b. Preparation of a Rates and Standards Brief:

i. Preparation: Staff prepares a position paper that at a minimum includes a description of the service, the payment history including rates and utilization, the methodology utilized to arrive at the proposed rate, and a description of the funding source. ii. Public Hearing: A public hearing notice is prepared and a hearing is scheduled.

iii. Oklahoma Office of Central Services: Copies of the public hearing notice, the Rates and Standards Brief and any other pertinent data is delivered to the Oklahoma Office of Central Services at least 30 days before the date of the public hearing. The Director of the Department of Central Services shall communicate any observation, reservation, criticism or recommendation to the agency, either in person at the time of the hearing or in writing delivered to the State agency before or at the time of the hearing. c. Public Hearing Notice: Notice of public hearing will be provided in the following:

i. Posted in the office of the Secretary of State

ii. Posted by the Oklahoma Health Care Authority at its physical location and on the web site calendar

iii. Published by the Oklahoma Health Care Authority in various newspaper publications across Oklahoma

d. Public Hearing:

i. Committee: The public hearing is conducted by the Rates and Standards Committee of the Oklahoma Health Care Authority. The committee is comprised of staff from the OHCA and DHS.

ii. Public comment: All attendees of the public hearing are offered an opportunity to voice their opposition or approval of the proposed rates. All comments become part of the permanent minutes of the hearing.

e. Final Approval: The rate is then scheduled for consideration and approval by the Board of Directors of the OHCA prior to implementation. Services utilizing the Fixed Rate are:

» Adult Day

» Agency Companion

» Daily Living Supports

» Extended Duty Nursing

» Family Counseling

» Group Home

» Habilitation Training Specialist

» Homemaker

» Intensive Personal Supports

» Nursing

» Occupational Therapy

» Physical Therapy

» Prevocational*

» Psychological

» Respite Care

» Specialized Foster Care

» Specialized Medical Supplies and Assistive Technology**

» Speech Therapy

» Supported Employment***

» Transportation

All fixed rates established by operating agency received a 4% increase effective October 1, 2019, as reflected in Appendix J. If service utilization is distributed equally throughout the year, only 75% of services would receive the increase. Services provided July through September would be at the original rate. Services provided October through June would reflect the rate increase of 4%. Services not receiving the increase are those services that are based on Medicare or State Medicaid Rates or are manually priced.

3) Method Three - Individual Rate: Certain services, because of their variables, do not lend themselves to a fixed and uniform rate. Payment for these services is made on an individual basis following a uniform process approved by the Medicaid Agency. Services using this methodology are:

» Family Training - Reimbursement made based on rate approved by DHS/DDS after evaluation of provider proposal and rate

comparison process, not to exceed limits established at OAC 317:30-5-412.

» Environmental Accessibility Adaptations and Architectural Modification - Methodology for these rates varies for different providers according to actual provider specialty. Providers may include Architects, Electricians, Engineers, Mechanical Contractors, Plumbers, Re-modelers and Builders. Further, each required environmental modification is different. Fox example, ramps costs (due to the initial conditions of the home and yard) differ according to such variables as the length of the ramp, types of rails, and strength of the ramp needed if, for instance the member has an electric wheelchair.

The State requires three bids based on specifications in the scope of work. There are no set rates for these services as the State utilizes a bidding process to determine the vendor based on the ability to meet the member needs taking into consideration cost, completion time and contract with the State.

» Community Transition Services - Reimbursement approved by DHS/DDS based on receipt for item or service, not to exceed limitations per OAC 317:30-5-423.

* Consistent with the approach to reimbursement for prevocational services approved by CMS in 1995, Oklahoma will continue to reimburse for prevocational services based per hour of participation (control number 0234.90.01). For individuals requiring enhanced supports, a differential rate is available.

** Oklahoma Health Care Authority has an established pricing methodology for Specialized Medical Supplies and Assistive Technology that do not have fixed rates. Rates are determined using SoonerCare reimbursement methodology or individual rate. Assistive Technology services are authorized by selecting the best bid from among a minimum of three when the cost exceeds $5000.00. If the item is not available under the SoonerCare State Plan, but the item is essential to the member's health and/or safety, the item may be authorized through the waiver.

*** Consistent with the approach to reimbursement for supported employment services approved by CMS in 1995, Oklahoma will continue to reimburse for job coaching and stabilization based on hours worked (control number 0234.90.01). Individual placement in job coaching services require the on-site provision of supports by a job coach for more than 20% of the individual’s compensable hours. Stabilization services require the on-site provision of supports by a job coach for 20% or less of the individual’s compensative hours. A differential rate is available for individuals requiring enhanced supports.

Nursing and Extended Duty Nursing:

The rate-setting methodology is identified above in the fixed-rate method outlined in method two.

The rate setting methodologies for nursing and extended duty nursing services were reviewed in 2006. Two separate and unrelated circumstances prompt this request for a rate change. First, the utilization of the per visit code for service plan development participation and assessment/evaluation has become increasingly problematic. This is because the time period of these encounters are extremely variable, yet, the code allows for only a fixed rate reimbursement.

Consequently, this fixed rate often and increasingly fails to cover nursing costs incurred. The second event was the 55% increase, effective October 1, 2005, in the Medicaid State Plan Home Health benefit skilled nurse rate to which the waiver skilled nurse rates had previously been linked in policy. The rate methodology used to set the revised Medicaid State Plan Home Health benefit skilled nurse rate was based upon Medicare Home Health benefit rate tables and protocols. However, the skilled nursing services provided under the waiver and the Medicare program are not the same and agency providers of skilled nursing services under DDS are not required to be Medicare certified providers and usually are not. In addition, changes in Medicaid State Plan Personal Care (SPPC) policy shift responsibility for skilled nursing assessment and service planning from state DHS nurses to provider agency nurses.

Effective January 2016, under the direction of CMS, the code G0154 was split into two codes to differentiate levels of nursing services provided during a hospice stay and/or home health episode of care. The G0299 code represents direct skilled nursing services of an RN and G0300 represents direct skilled nursing services of an LPN. At that time the State identified that the rate for the codes were sufficient and there was no need to consider a rate change at that time. In addition, OHCA agreed to maintain parity between waiver services programs in their core in-home services. SB1600 appropriated funds for a 7% provider rate increase effective July 1, 2018.

Therapy Services:

The rate setting methodology for therapy services were reviewed in September 2012. At that time DDS therapy service rates had not been increased since 1997. Per the rate brief, the average Consumer Price Index (CPI) had increased at an annual rate of 2.2% since 2006 and the price of gasoline, which is a major cost center for these services, has increased at an annual rate of 4.8% since 2006. SB1979 authorized $1.5 million in appropriated funds for “an increase in reimbursement rates for the DDS programs in FY13". The proposed rate increases honor this legislative intent.

Therapy rates for occupational and physical were increased from $13.75 to $20.00, for a total of a $6.25 increase which equates to 45.5%. Therapy rates for speech were increased to $18.79 in 2005. In addition, OHCA agreed to maintain parity between the waiver service programs in their core in home services. The rates were determined by utilization of services, the last time a rate increase was done for those services, and a comparison of rates in other states. Due to a 4% rate increase mandated by the Oklahoma Legislature in 2019, Occupational Therapy and Physical Therapy services increased to $20.80 per 15 minute unit increment and the Speech Therapy service rate increased to $19.54 per 15 minute unit increment. Oklahoma Legislature will mandate any future change in therapy service rates.

Respite Services:

The rate setting methodology for respite services was reviewed in May 2018. At that time, daily respite services had mirrored the setting rate for agency companion services, specialized foster care, and group home services. The rate was not sufficient to cover the member's room and board costs, so we calculated a rate that was 90% of the SSI payment for a single individual. Respite Daily in-home and Respite hourly rates do not include room and board. Effective October 1, 2019, an across the board 4% rate increase was applied to all rates established by the operating agency. The remaining 1% of the increase was applied in year 5.

Payment rates are available to members on the OHCA web site. Notice of Authorization statements, which include service rates, are automatically mailed to members via an electronic authorization system when authorizations are issued or updated. In addition, a master list of all waiver services, with correlating HCPC code and rate, is available for viewing on the OKDHS web site.

Additional information may be found in section Main B.1

Waiver Name:
Homeward Bound
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Oklahoma Waiver# OK.0399.R03.06

Cost Neutrality

Cost Neutrality for Oklahoma Waiver# OK.0399.R03.06

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
667 640

Year 1 Waiver Services

List of Year 1 Waiver Services for Oklahoma Waiver# OK.0399.R03.06

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Training Specialist Services 1 hour 620 4148.75 $15.12
Prevocational Services 1 hour 283 527 $10.46
Supported Employment Individual 1 hour 75 491 $16.80
Supported Employment Group 1 hour 191 1102 $13.02

Year 5 Waiver Services

List of Year 5 Waiver Services for Oklahoma Waiver# OK.0399.R03.06

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Training Specialist Services 1 hour 572 4327 $16.84
Prevocational Services 1 hour 257 423 $11.51
Supported Employment Individual 1 hour 70 360 $18.38
Supported Employment Group 1 hour 190 912 $14.10

Rate Determination Methods

Rate Determination Methods for Oklahoma Waiver# OK.0399.R03.06

Rates are determined according to Oklahoma Statute Title 74, Section 85 The Oklahoma Central Purchasing Act, Chapter 4. The OHCA State Plan Amendment Rate Committee (SPARC) is responsible for reviewing and setting all service rates for Medicaid services. Rates are given final consideration and approval by the OHCA Board.

Rates for waiver services are set by one of the methodologies below.

1) Method One - Utilizing the Medicaid Rate: When a waiver service is the same as a Medicaid service for which a fee schedule has been established, the current Medicaid rate is utilized. Services utilizing the Medicaid Rate are:

» Audiology

» Dental

» Nutrition

» Prescription Drugs

The State affirms that all waiver services provided under the State Plan are provided under the same rate as the State Plan rate for all providers.

2) Method Two - Fixed and Uniform Rate: Title 74 of the Oklahoma Statutes provides a methodology for setting fixed and uniform rates.

a. Determination of need for a fixed and uniform rate

i. New: A new service is developed, or

ii. Existing Service: Feedback from providers, clients, or the general public indicates that the existing rate is not sufficient to ensure access to an existing service.

b. Preparation of a Rates and Standards Brief:

i. Preparation: Staff prepares a position paper that at a minimum includes a description of the service, the payment history

including rates and utilization, the methodology utilized to arrive at the proposed rate, and a description of the funding source.

ii. Public Hearing: A public hearing notice is prepared and a hearing is scheduled.

iii. Oklahoma Office of Central Services: Copies of the public hearing notice, the Rates and Standards Brief and any other pertinent data is delivered to the Oklahoma Office of Central Services at least 30 days before the date of the public hearing. The Director of the Department of Central Services shall communicate any observation, reservation, criticism or recommendation to the agency, either in person at the time of the hearing or in writing delivered to the State agency before or at the time of the hearing.

c. Public Hearing Notice: Notice of public hearing will be provided in the following:

i. Posted in the office of the Secretary of State

ii. Posted by the Oklahoma Health Care Authority at its physical location and on the web site calendar

iii. Published by the Oklahoma Health Care Authority in various newspaper publications across Oklahoma

d. Public Hearing:

i. Committee: The public hearing is conducted by the Rates and Standards Committee of the Oklahoma Health Care Authority. The committee is comprised of staff from the OHCA and DHS. prior to implementation.

Services utilizing the Fixed Rate are:

» Adult Day

» Agency Companion

» Daily Living Supports

» Extended Duty Nursing

» Family Counseling

» Group Home

» Habilitation Training Specialist

» Homemaker

» Intensive Personal Supports

» Nursing

» Occupational Therapy

» Physical Therapy

» Physician Services (provided by a Psychiatrist)

» Prevocational*

» Psychological

» Respite Care

» Specialized Foster Care

» Specialized Medical Supplies and Assistive Technology**

» Speech Therapy

» Supported Employment***

» Transportation

All fixed rates established by operating agency received the 4% increase. Appendix J reflects the cost estimate with the rate going in to effect October 1, 2019. If service utilization is distributed equally throughout the year only 75% of services would receive the increase. Services provided July through September would be at the original rates October through June would reflect the rate increase of 4%. Services not receiving the increase are those services that are based on Medicare or State Medicaid Rates or are manually priced.

3) Method Three - Individual Rate: Certain services, because of their variables, do not lend themselves to a fixed and uniform rate. Payment for these services is made on an individual basis following a uniform process approved by the Medicaid Agency. Services using this methodology are:

» Family Training - Reimbursement made based on rate approved by DHS/DDS after evaluation of provider proposal and rate

comparison process, not to exceed limits established at OAC 317:30-5-412.

» Environmental Accessibility Adaptations and Architectural Modification - Methodology for these rates varies for different providers according to actual provider specialty. Providers may include Architects, Electricians, Engineers, Mechanical Contractors, Plumbers, Re-modelers and Builders. Further, each required environmental modification is different. Fox example, ramps costs (due to the initial conditions of the home and yard) differ according to such variables as the length of the ramp, types of rails, and strength of the ramp needed if, for instance the member has an electric wheelchair.

The State requires three bids based on specifications in the scope of work. There are no set rates for these services as the State utilizes a bidding process to determine the vendor based on the ability to meet the member needs taking into consideration cost, completion time and contract with the State.

» Community Transition Services - Reimbursement approved by DHS/DDS based on receipt for item or service, not to exceed limitations per OAC 317:30-5-423.

* Consistent with the approach to reimbursement for prevocational services approved by CMS in 1995, Oklahoma will continue to reimburse for prevocational services based per hour of participation (control number 0234.90.01). For individuals requiring enhanced supports, a differential rate is available.

ii. Public comment: All attendees of the public hearing are offered an opportunity to voice their opposition or approval of the proposed rates. All comments become part of the permanent minutes of the hearing.

e. Final Approval: The rate is then scheduled for consideration and approval by the Board of Directors of the OHCA ** Oklahoma Health Care Authority has an established pricing methodology for Specialized Medical Supplies and Assistive Technology that do not have fixed rates. Rates are determined using the SoonerCare reimbursement methodology or individual rate. Assistive Technology services are authorized by selecting the best bid from among a minimum of three when the cost exceeds $5000.00. If the item is not available under the SoonerCare State Plan, but the item is essential to the member's health and/or safety, the item may be authorized through the waiver.

*** Consistent with the approach to reimbursement for supported employment services approved by CMS in 1995, Oklahoma will continue to reimburse for job coaching and stabilization based on hours worked (control number 0234.90.01). Individual placement in job coaching services require the on-site provision of supports by a job coach for more than 20% of the individual’s compensable hours. Stabilization services require the on-site provision of supports by a job coach for 20% or less of the individual’s compensative hours. A differential rate is available for individuals requiring enhanced supports.

Nursing and Extended Duty Nursing:

The rate-setting methodology is identified above in the fixed-rate method outlined in method two.

The rate setting methodologies for nursing and extended duty nursing services were reviewed in 2006. Two separate and unrelated circumstances prompt this request for a rate change. First, the utilization of the per visit code for service plan development participation and assessment/evaluation has become increasingly problematic. This is because the time period of these encounters are extremely variable, yet, the code allows for only a fixed rate reimbursement.

Consequently, this fixed rate often and increasingly fails to cover nursing costs incurred. The second event was the 55% increase, effective October 1, 2005, in the Medicaid State Plan Home Health benefit skilled nurse rate to which the waiver skilled nurse rates had previously been linked in policy. The rate methodology used to set the revised Medicaid State Plan Home Health benefit skilled nurse rate was based upon Medicare Home Health benefit rate tables and protocols. However, the skilled nursing services provided under the waiver and the Medicare program are not the same and agency providers of skilled nursing services under DDS are not required to be Medicare certified providers and usually are not. In addition, changes in Medicaid State Plan Personal Care (SPPC) policy shift responsibility for skilled nursing assessment and service planning from state DHS nurses to provider agency nurses.

Effective January 2016 under the direction of CMS the code G0154 was split into two codes to differentiate levels of nursing services provided during a hospice stay and/or home health episode of care. The G0299 code represents direct skilled nursing services of an RN and G0300 represents direct skilled nursing services of an LPN. At that time the State identified that the rate for the codes were sufficient and there was no need to consider a rate change at that time. In addition, OHCA agreed to maintain parity between waiver services programs in their core in-home services. SB1600 appropriated funds for a 7% provider rate increase effective July 1, 2018.

Therapy Services:

The rate setting methodology for therapy services were reviewed in September 2012. At that time DDS therapy service rates had not been increased since 1997. Per the rate brief, the average Consumer Price Index (CPU) had increased at an annual rate of 2.2% since 2006 and the price of gasoline, which is a major cost center for these services, has increased at an annual rate of 4.8% since 2006. SB1979 authorized $1.5 million in appropriated funds for “an increase in reimbursement rates for the DDS programs in FY13. The proposed rate increases honor this legislative intent.

Therapy rates for occupational and physical were increased from $13.75 to $20.00, for a total of a $6.25 increase which equates to 45.5%. Therapy rates for speech were increased to $18.79 in 2005. In addition, OHCA agreed to maintain parity between the waiver service programs in their core in home services. The rates were determined by utilization of services, the last time a rate increase was done for those services, and a comparison of rates in other states. Due to a 4% rate increase mandated by the Oklahoma Legislature in 2019, Occupational Therapy and Physical Therapy services increased to $20.80 per 15 minute unit increment and the Speech Therapy service rate increased to $19.54 per 15 minute unit increment. Oklahoma Legislature will mandate any future change in therapy service rates.

Respite Services:

The rate setting methodology for respite services was reviewed in May 2018. At that time, daily respite services had mirrored the setting rate for agency companion services, specialized foster care, and group home services. The rate was not sufficient to cover the member's room and board costs, so we calculated a rate that was 90% of the SSI payment for a single individual. Respite Daily in home and Respite hourly rates do not include room and board.

Payment rates are available to members on the OHCA web site. Notice of Authorization statements, which include service rates, are automatically mailed to members via an electronic authorization system when authorizations are issued or updated. In addition, a master list of all waiver services, with correlating HCPC code and rate, is available for viewing on the OKDHS web site.

Additional information may be found in section Main B.

Oklahoma Waiver# OK.0343.R04.06 

In-Home Supports Waiver for Adults

Waiver Name:
In-Home Supports Waiver for Adults
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for Oklahoma Waiver# OK.0343.R04.06

Cost Neutrality

Cost Neutrality for Oklahoma Waiver# OK.0343.R04.06

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1620 2100

Year 1 Waiver Services

List of Year 1 Waiver Services for Oklahoma Waiver# OK.0343.R04.06

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Training Specialist Services - Self Directed 1 hour 80 955 $13.48
Habilitation Training Specialist Services 1 hour 1252 1000 $15.16
Prevocational Services 1 hour 335 254 $15.13
Supported Employment Individual 1 hour 144 350 $16.60
Supported Employment Group 1 hour 144 350 $12.48

Year 5 Waiver Services

List of Year 5 Waiver Services for Oklahoma Waiver# OK.0343.R04.06

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Habilitation Training Specialist Services - Self Directed 1 hour 108 645 $16.84
Habilitation Training Specialist Services 1 hour 1645 894 $16.84
Prevocational Services 1 hour 409 587 $8.18
Supported Employment Individual 1 hour 100 21 $14.70
Supported Employment Group 1 hour 338 769 $13.38

Rate Determination Methods

Rate Determination Methods for Oklahoma Waiver# OK.0343.R04.06

Rates are determined according to Oklahoma Statute Title 74, Section 85 The Oklahoma Central Purchasing Act, Chapter 4. The OHCA State Plan Amendment Rate Committee (SPARC) is responsible for reviewing and setting all service rates for Medicaid services. Rates are given final consideration and approval by the OHCA Board.

Rates for waiver services are set by one of the methodologies below.

1) Method One - Utilizing the Medicaid Rate: When a waiver service is the same as a Medicaid service for which a fee schedule has been established, the current Medicaid rate is utilized. Services utilizing the Medicaid Rate are:

» Audiology

» Dental

» Nutrition

» Prescription Drugs

The State affirms that all waiver services provided under the State Plan are provided under the same rate as the State Plan rate for all providers.

2) Method Two - Fixed and Uniform Rate: Title 74 of the Oklahoma Statutes provides a methodology for setting fixed and uniform rates.

a. Determination of need for a fixed and uniform rate

i. New: A new service is developed, or

ii. Existing Service: Feedback from providers, clients, or the general public indicates that the existing rate is not sufficient to ensure access to an existing service.

b. Preparation of a Rates and Standards Brief:

i. Preparation: Staff prepares a position paper that at a minimum includes a description of the service, the payment history

including rates and utilization, the methodology utilized to arrive at the proposed rate, and a description of the funding source.

ii. Public Hearing: A public hearing notice is prepared and a hearing is scheduled.

iii. Oklahoma Office of Central Services: Copies of the public hearing notice, the Rates and Standards Brief and any other pertinent data is delivered to the Oklahoma Office of Central Services at least 30 days before the date of the public hearing. The Director of the Department of Central Services shall communicate any observation, reservation, criticism or recommendation to the agency, either in person at the time of the hearing or in writing delivered to the State agency before or at the time of the hearing.

c. Public Hearing Notice: Notice of public hearing will be provided in the following:

i. Posted in the office of the Secretary of State

ii. Posted by the Oklahoma Health Care Authority at its physical location and on the web site calendar

iii. Published by the Oklahoma Health Care Authority in various newspaper publications across Oklahoma

d. Public Hearing:

i. Committee: The public hearing is conducted by the Rates and Standards Committee of the Oklahoma Health Care Authority. The committee is comprised of staff from the OHCA and DHS.

ii. Public comment: All attendees of the public hearing are offered an opportunity to voice their opposition or approval of the proposed rates. All comments become part of the permanent minutes of the hearing.

e. Final Approval: The rate is then scheduled for consideration and approval by the Board of Directors of the OHCA prior to implementation.

Services utilizing the Fixed Rate are:

» Adult Day

» Family Counseling

» Habilitation Training Specialist

» Homemaker

» Intensive Personal Supports

» Nursing

» Occupational Therapy

» Physical Therapy

» Prevocational*

» Psychological

» Respite Care

» Specialized Medical Supplies and Assistive Technology**

» Speech Therapy

» Supported Employment***

» Transportation

All fixed rates established by operating agency received the 4% increase. Appendix J reflects the cost estimate with the rate going in to effect October 1, 2019. If service utilization is distributed equally throughout the year only 75% of services would receive the increase. Services provided July through September would be at the original rate. Services provided October through June would reflect the rate increase of 4%. Services not receiving the increase are those services that are based on Medicare or State Medicaid Rates or are manually priced.

1) Method Three - Individual Rate: Certain services, because of their variables, do not lend themselves to a fixed and uniform rate. Payment for these services is made on an individual basis following a uniform process approved by the Medicaid Agency. Services using this methodology are:

» Family Training - Reimbursement made based on rate approved by DHS/DDS after evaluation of provider proposal and rate

comparison process, not to exceed limits established at OAC 317:30-5-412.

» Environmental Accessibility Adaptations and Architectural Modification - Methodology for these rates varies for different providers according to actual provider specialty. Providers may include Architects, Electricians, Engineers, Mechanical Contractors, Plumbers, Re-modelers and Builders. Further, each required environmental modification is different. Fox example, ramps costs (due to the initial conditions of the home and yard) differ according to such variables as the length of the ramp, types of rails, and strength of the ramp needed if, for instance the member has an electric wheelchair.

The State requires three bids based on specifications in the scope of work. There are no set rates for these services as the State utilizes a bidding process to determine the vendor based on the ability to meet the member needs taking into consideration cost, completion time and contract with the State.

Environmental Accessibility Adaptations and Architectural Modification Services are limited by the annual overall plan of care limit. The annual limit may be increased when Environmental Accessibility Adaptations or Arch Mod services were ordered under a previous year's plan but not delivered or completed until the current plan of care year. In that case, the current plan of care may exceed the annual limit by the cost of the previously authorized Environmental Accessibility or Arch Mod services. The annual limit may also be authorized to allow for major expenses in excess of $2,500 of Environmental Accessibility Adaptations or Arch Mod services, but not to exceed $10,000 in any 5-year period.

» Self Directed Goods and Services - The rate for Self Directed Goods and Services is based on a cost estimate from a vendor in the community.

* Consistent with the approach to reimbursement for prevocational services approved by CMS in 1995, Oklahoma will continue to reimburse for prevocational services based per hour of participation (control number 0234.90.01). For individuals requiring enhanced supports, a differential rate is available.

** Oklahoma Health Care Authority has an established pricing methodology for Specialized Medical Supplies and Assistive Technology that do not have fixed rates. Rates are determined using the SoonerCare reimbursement methodology or individual rate. Assistive Technology services are authorized by selecting the best bid from among a minimum of three when the cost exceeds $5000.00. If the item is not available under the SoonerCare State Plan, but the item is essential to the member's health and/or safety, the item may be authorized through the waiver.

*** Consistent with the approach to reimbursement for supported employment services approved by CMS in 1995, Oklahoma will continue to reimburse for job coaching and stabilization based on hours worked (control number 0234.90.01). Individual placement in job coaching services require the on-site provision of supports by a job coach for more than 20% of the individual’s compensable hours. Stabilization services require the on-site provision of supports by a job coach for 20% or less of the individual’s compensative hours. A differential rate is available for individuals requiring enhanced supports.

Therapy Services:

The rate setting methodology for therapy services were reviewed in September 2012. At that time DDS therapy service rates had not been increased since 1997. Per the rate brief, the average Consumer Price Index (CPU) had increased at an annual rate of 2.2% since 2006 and the price of gasoline, which is a major cost center for these services, has increased at an annual rate of 4.8% since 2006. SB1979 authorized $1.5 million in appropriated funds for “an increase in reimbursement rates for the DDS programs in FY13. The proposed rate increases honor this legislative intent.

Therapy rates for occupational and physical were increased from $13.75 to $20.00, for a total of a $6.25 increase which equates to 45.5%. Therapy rates for speech were increased to $18.79 in 2005. In addition, OHCA agreed to maintain parity between the waiver service programs in their core in home services. The rates were determined by utilization of services, the last time a rate increase was done for those services, and a comparison of rates in other states. Due to a 4% rate increase mandated by the Oklahoma Legislature in 2019, Occupational Therapy and Physical Therapy services increased to $20.80 per 15 minute unit increment and the Speech Therapy service rate increased to $19.54 per 15 minute unit increment. Oklahoma Legislature will mandate any future change in therapy service rates.

Payment rates are available to members on the OHCA web site. Notice of Authorization statements, which include service rates, are automatically mailed to members via an electronic authorization system when authorizations are issued or updated. In addition, a master list of all waiver services, with correlating HCPC code and rate, is available for viewing on the OKDHS web site.

Every three years, the Oklahoma Health Care Authority completes an Access Monitoring Review Plan. The OHCA is committed to continuous quality improvement with respect to services and beneficiaries, while maintain an extensive provider base. Since the Agency’s first AMRP, OHCA continues to focus on access to care for its members by establishing new services and rate increases for providers. In general, unless noted by policy change, most year-to-year fluctuations in provider counts are from temporary decreases due to contract renewal periods, especially in regards to out-of-state providers, or it’s due to changes in the methodology of how provider types and specialties are counted.

All rates are taken to a public Tribal Consultation, a public rate hearing, a public notice, and taken to a public OHCA Board meeting. Feedback is taken from providers on rates and rate methods. Additionally, the OHCA’s Member and Provider Services Unit take calls from members and providers when there are access issues. If there is a continual problem with rates, rate methods can be changed accordingly based on the feedback. Also, care managers speak directly with members and can locate resources if they are having difficulty gaining access to services.

Further, the AMRP demonstrates the Agency’s compliance with 1902(a)(30)(A) of the SSA, which assures state payments are consistent with efficiency, economy, and quality of care sufficient to enlist enough providers so that services under the State Plan are available to beneficiaries at least to the extent that those services are available to the general public.

Waiver Name:
OR Adults HCBS
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Oregon Waiver# OR.0375.R04.01

Cost Neutrality

Cost Neutrality for Oregon Waiver# OR.0375.R04.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
18721 21420

Year 1 Waiver Services

List of Year 1 Waiver Services for Oregon Waiver# OR.0375.R04.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Path Services hours 2000 460 $18.14
Supported Employment Individual - Job Coaching Initial hours 750 176 $31.41
Supported Employment Individual - Job Coaching Ongoing hours 1350 370 $26.86
Supported Employment Individual - Job Coaching Maintenance hours 700 411 $23.13
Supported Employment Individual - Job Development Placement outcome 630 1 $2093.00
Supported Employment Individual - Job Development Retention outcome 523 1 $1309.00
Discovery/Career Exp Outcome 580 1 $1920.00
Supported Employment Small Group Hours 995 405 $19.67

Year 5 Waiver Services

List of Year 5 Waiver Services for Oregon Waiver# OR.0375.R04.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Path Services hours 1450 375 $19.09
Supported Employment Individual - Job Coaching Initial hours 938 194 $31.41
Supported Employment Individual - Job Coaching Ongoing hours 1688 407 $26.86
Supported Employment Individual - Job Coaching Maintenance hours 926 453 $23.13
Supported Employment Individual - Job Development Placement outcome 0 1 $2093.02
Supported Employment Individual - Job Development Retention outcome 50 1 $1309.85
Discovery/Career Exp Outcome 500 1 $1920.00
Supported Employment Small Group Hours 995 405 $19.67

Rate Determination Methods

Rate Determination Methods for Oregon Waiver# OR.0375.R04.01

Rates guidelines for all waiver services are established and published by the Department. Costs of services are estimated based upon DHS-published allowable rates and other limitations imposed by Oregon Administrative Rule. Rates must comply with Oregon's minimum wage standards.

Wages for Personal Support Workers are established in the Collective Bargaining Agreement (CBA). Adjustments to wages are legislatively approved and negotiated through the CBA process. CBAs are negotiated biennially. The Department applies cost of living adjustments as required by legislative mandates or other CBA. The rates do not include employee benefits, room and board administrative costs, or other indirect costs.

All rate information for employment services can be found in Main B-Optional

Direct nursing waiver services payments are based on an approved state plan rate methodology for private duty nursing. The fee schedule was set in 1993 based upon the wages received for private duty nursing services in the community in 1993. Since that time there have been periodic adjustments to these rates, based upon cost of living increases via the legislative budget process. There has been 4 periodic CPI or COLAs adjustments since 1993. The percentage of CPI or COLA is based upon the agency budget request.

Family Training – Conferences and Workshops: the actual cost of enrollment fees and educational materials.

Environmental Safety Modifications, Specialized Medical Equipment, and Vehicle Modifications are the actual, most cost-effective price for the product offered through appropriate vendors.

Waiver Case Management: Oregon will pay for qualifying waiver case management (WCM) activities on an encounter methodology. Oregon will limit payment to one waiver case management contact per individual per day. If two distinct, qualifying waiver case management contacts are provided to a single individual in a single day, Oregon will only pay for one waiver case management contact for that individual. Conducting functional needs assessment is excluded from this limitation. The agency’s state-wide rates were set as of 07/01/2009 and are effective for services on or after that date.

The fee schedule and any annual/periodic adjustments to the fee schedule are published on the department’s website at http://www.oregon.gov/DHS/spd/provtools/. The waiver case management rate is derived using the following formula: Total cost to DHS, ODDS to provide waiver case management divided by projected biennial case management contacts. The total cost to DHS of providing waiver case management includes:

• Waiver case management staff salary and other personnel expenses;

• Supervisory salary and other personnel expenses in support of WCM services; and

• Indirect expenses (General government service charges, worker’s comp, property insurance, etc.).

The sum of these expenses is then multiplied by a percentage determined by the Legislature. ODDS will monitor waiver case management utilization to ensure services are being administered economically and efficiently. Adjustments to the waiver case management rate may be made periodically during the biennium if waiver case management contacts are materially different from beginning-of-biennium projections. New waiver case management contact rates will be established at the beginning of each state biennium period using this same methodology.

The rate guidelines are published to the web. The public may comment to the case management entity about rates or may contact the Department directly. Rates for services to be provided, as well as an estimate of the annual cost for each waiver service, are included on the Individual Support Plan, which serves to notify the participant of the cost of waiver services.

Oregon Waiver# OR.40194.R04.01 

Behavioral (ICF/IDD) Model

Waiver Name:
Behavioral (ICF/IDD) Model
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Oregon Waiver# OR.40194.R04.01

Cost Neutrality

Cost Neutrality for Oregon Waiver# OR.40194.R04.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
154 165

Year 1 Waiver Services

List of Year 1 Waiver Services for Oregon Waiver# OR.40194.R04.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Path Services hour 2 200 $26.01
Supported Employment Individual - Job Development Placement outcome 1 1 $2965.80
Supported Employment Individual - Job Development Retention outcome 1 1 $1977.20
Supported Employment Individual - Job Coaching Initial hour 1 150 $61.83
Supported Employment Individual - Job Coaching Ongoing hour 1 250 $55.14
Supported Employment Individual - Job Coaching Maintenance hour 0 0 $54.96
Discovery/Career Exp outcome 1 1 $2222.55
Supported Employment Small Group hour 1 300 $24.77

Year 5 Waiver Services

List of Year 5 Waiver Services for Oregon Waiver# OR.40194.R04.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Path Services hour 2 200 $26.01
Supported Employment Individual - Job Development Placement outcome 1 1 $2965.80
Supported Employment Individual - Job Development Retention outcome 1 1 $1977.20
Supported Employment Individual - Job Coaching Initial hour 1 150 $61.83
Supported Employment Individual - Job Coaching Ongoing hour 1 250 $55.14
Supported Employment Individual - Job Coaching Maintenance hour 0 0 $54.96
Discovery/Career Exp outcome 1 1 $2222.55
Supported Employment Small Group Hours 1 300 $24.77

Rate Determination Methods

Rate Determination Methods for Oregon Waiver# OR.40194.R04.01

Rates guidelines for all waiver services are established and published by the Department. Costs of services are estimated based upon DHS published allowable rates and other limitations imposed by Oregon Administrative Rule.

Consistent with the roles and responsibilities identified in the DHS/OHA Interagency Agreement, DHS (the operating agency) commences the public notice and comment period adhering with the requirements of 42 CFR 447.205 and the approved Medicaid State Plan. Designated staff from the OHA (the Medicaid Agency) reviews and approves the public notice materials prior to DHS releasing the notice and monitors throughout the process to assure that all requirements and timeframes are met. Once the public notice and comment period has expired, OHA staff reviews the comments and DHS’ responses to comments and provides input, if necessary.

Waiver Case Management for contracted case management entities:

Oregon will pay for qualifying waiver case management (WCM) activities on a per-contact-per-day methodology. Oregon will limit payment to one waiver case management contact per individual per day. If two distinct, qualifying waiver case management contacts are provided to a single individual in a single day, Oregon will only pay for one waiver case management contact for that individual. Conducting functional needs assessment is excluded from this limitation.

The agency’s state-wide rates were set as of 07/01/2009 and are effective for services on or after that date. All rates are published on the agency’s website. The fee schedule and any annual/periodic adjustments to the fee schedule are published on the department’s website at http://www.oregon.gov/DHS/spd/provtools/.

The waiver case management rate is derived using the following formula:

Total cost to DHS, ODDS to provide waiver case management divided by projected biennial case management contacts. The total cost to DHS of providing waiver case management includes:

• Waiver case management staff salary and other personnel expenses;

• Supervisory salary and other personnel expenses in support of WCM services; and

• Indirect expenses (General government service charges, worker’s comp, property insurance, etc.). The sum of these expenses is then multiplied by a percentage determined by the Legislature.

ODDS will monitor waiver case management utilization to ensure services are being administered economically and efficiently. Adjustments to the waiver case management rate may be made periodically during the biennium if waiver case management contacts are materially different from beginning-of-biennium projections.

New waiver case management contact rates will be established at the beginning of each state biennium period using this same methodology.

Waiver case management for employees of DHS, Office of Developmental Disabilities Services (ODDS)-

The rate setting methodology incorporates wages and benefits as well as other payroll expenditures (OPE), allowable administration percentages, and other costs associated with operating a business. It also incorporates information on revenue and expenses about the service so that DHS can assure that the total funding does not exceed the cost of providing the case management service.

All rate information for employment services can be found in Main B-Optional section.

Payments for environmental safety modifications, vehicle modifications, specialized medical supplies, family training and individual directed goods and services are determined by the actual cost of the item or service.

Oregon Waiver# OR.40193.R04.01 

OR Medically Fragile (Hospital) Model

Waiver Name:
OR Medically Fragile (Hospital) Model
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Oregon Waiver# OR.40193.R04.01

Cost Neutrality

Cost Neutrality for Oregon Waiver# OR.40193.R04.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
104 116

Year 1 Waiver Services

List of Year 1 Waiver Services for Oregon Waiver# OR.40193.R04.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Path Services hours 2 200 $26.01
Supported Employment Individual - Job Development Placement outcome 1 1 $2965.80
Supported Employment Individual - Job Development Retention outcome 1 1 $1977.20
Supported Employment Individual - Job Coaching Initial hour 1 150 $61.83
Supported Employment Individual - Job Coaching Ongoing hour 1 150 $54.96
Supported Employment Individual - Job Coaching Maintenance hour 0 0 $54.96
Discovery/Career Exp outcome 1 1 $2222.55
Supported Employment Small Group hours 1 300 $24.77

Year 5 Waiver Services

List of Year 5 Waiver Services for Oregon Waiver# OR.40193.R04.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Path Services hours 2 200 $26.01
Supported Employment Individual - Job Development Placement outcome 1 1 $2965.80
Supported Employment Individual - Job Development Retention outcome 1 1 $1977.20
Supported Employment Individual - Job Coaching Initial hour 1 150 $61.83
Supported Employment Individual - Job Coaching Ongoing hour 1 150 $54.96
Supported Employment Individual - Job Coaching Maintenance hour 0 0 $54.96
Discovery/Career Exp outcome 1 1 $2222.55
Supported Employment Small Group hour 1 300 $24.77

Rate Determination Methods

Rate Determination Methods for Oregon Waiver# OR.40193.R04.01

Rates guidelines for all waiver services are established and published by the Department. Costs of services are estimated based upon DHS published allowable rates and other limitations imposed by Oregon Administrative Rule.

Consistent with the roles and responsibilities identified in the DHS/OHA Interagency Agreement, DHS (the operating agency) commences the public notice and comment period adhering with the requirements of 42 CFR 447.205 and the approved Medicaid State Plan. Designated staff from the OHA (the Medicaid Agency) reviews and approves the public notice materials prior to DHS releasing the notice and monitors throughout the process to assure that all requirements and timeframes are met. Once the public notice and comment period has expired, OHA staff reviews the comments and DHS’ responses to comments and provides input, if necessary.

Waiver Case Management for contracted case management entities:

Oregon will pay for qualifying waiver case management (WCM) activities on a per-contact-per-day methodology. Oregon will limit payment to one waiver case management contact per individual per day. If two distinct, qualifying waiver case management contacts are provided to a single individual in a single day, Oregon will only pay for one waiver case management contact for that individual. Conducting functional needs assessment is excluded from this limitation.

The agency’s state-wide rates were set as of 07/01/2009 and are effective for services on or after that date. All rates are published on the agency’s website. The fee schedule and any annual/periodic adjustments to the fee schedule are published on the department’s website at http://www.oregon.gov/DHS/spd/provtools/.

The waiver case management rate is derived using the following formula:

Total cost to DHS, ODDS to provide waiver case management divided by projected biennial case management contacts.

The total cost to DHS of providing waiver case management includes:

• Waiver case management staff salary and other personnel expenses;

• Supervisory salary and other personnel expenses in support of WCM services; and

• Indirect expenses (General government service charges, worker’s comp, property insurance, etc.). The sum of these expenses is then multiplied by a percentage determined by the Legislature.

ODDS will monitor waiver case management utilization to ensure services are being administered economically and efficiently. Adjustments to the waiver case management rate may be made periodically during the biennium if waiver case management contacts are materially different from beginning-of-biennium projections.

New waiver case management contact rates will be established at the beginning of each state biennium period using this same methodology.

Waiver case management for employees of DHS, Office of Developmental Disabilities Services (ODDS)-

The rate setting methodology incorporates wages and benefits as well as other payroll expenditures (OPE), allowable administration percentages, and other costs associated with operating a business. It also incorporates information on revenue and expenses about the service so that DHS can assure that the total funding does not exceed the cost of providing the case management service.

All rate information for employment services can be found in Main B-Optional section. Family Training – Conferences and Workshops:

Conference - the actual cost of enrollment fees and educational materials.

Individual Directed Goods and Services, Environmental Safety Modifications, Specialized Medical Equipment, and Vehicle Modifications are the actual, most cost-effective price for the product offered through appropriate vendors. In order to determine the most cost-effective price a competitive bidding process may be used for Environmental Safety Modifications and Vehicle Modifications.

Pennsylvania Waiver# PA.1486.R00.06 

PA Community Living Waiver

Waiver Name:
PA Community Living Waiver
Effective Date:
1/1/2018
Expiration Date:
12/31/2022

Services

List of Services for Pennsylvania Waiver# PA.1486.R00.06

Cost Neutrality

Cost Neutrality for Pennsylvania Waiver# PA.1486.R00.06

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1050 3750

Year 1 Waiver Services

List of Year 1 Waiver Services for Pennsylvania Waiver# PA.1486.R00.06

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Support Base 15 minutes 100 3750 $4.86
Community Participation Support Level 1 15 minutes 50 3600 $4.81
Community Participation Support Level 2 15 minutes 100 3600 $6.34
Community Participation Support Level 3 15 minutes 50 3450 $11.79
Community Participation Support Level 4 15 minutes 5 3300 $20.53
Community Participation Support Older Adult Living 15 minutes 20 6000 $2.68
Community Participation Support On-Call and Remote Support 15 minutes 0 0 $0.01
Supported Employment Career Assessment 15 minutes 190 250 $17.75
Supported Employment Job Finding and Development 15 minutes 80 250 $17.75
Supported Employment Job Coaching - Base (1:2 to 1:4) 15 minutes 25 250 $10.45
Supported Employment Job Coaching and Support Level 1 (1:1) 15 minutes 40 250 $17.75
Advanced Supported Employment Outcome Based Unit 3 1 $5865.71
Benefits Counseling 15 minutes 5 20 $11.40
Small Group Employment Base 15 minutes 70 1000 $2.29
Small Group Employment Level 1 15 minutes 80 1500 $3.52
Small Group Employment Level 2 15 minutes 70 1000 $6.83
Small Group Employment Level 3 15 minutes 60 1000 $12.48

Year 5 Waiver Services

List of Year 5 Waiver Services for Pennsylvania Waiver# PA.1486.R00.06

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Support Base 15 minutes 500 3500 $4.86
Community Participation Support Level 1 15 minutes 200 2500 $4.81
Community Participation Support Level 2 15 minutes 3000 2650 $6.34
Community Participation Support Level 3 15 minutes 300 2250 $11.79
Community Participation Support Level 4 15 minutes 25 1500 $20.53
Community Participation Support Older Adult Living 15 minutes 25 1250 $2.68
Community Participation Support On-Call and Remote Support 15 minutes 100 500 $1.33
Supported Employment Career Assessment 15 minutes 50 100 $17.75
Supported Employment Job Finding and Development 15 minutes 200 300 $17.75
Supported Employment Job Coaching - Base (1:2 to 1:4) 15 minutes 50 100 $10.45
Supported Employment Job Coaching and Support Level 1 (1:1) 15 minutes 400 750 $17.75
Advanced Supported Employment Outcome Based Unit 50 1 $5865.71
Benefits Counseling 15 minutes 25 25 $11.40
Small Group Employment Base 15 minutes 50 500 $2.29
Small Group Employment Level 1 15 minutes 80 2500 $3.52
Small Group Employment Level 2 15 minutes 400 2500 $6.83
Small Group Employment Level 3 15 minutes 80 500 $12.48

Rate Determination Methods

Rate Determination Methods for Pennsylvania Waiver# PA.1486.R00.06

There are several approaches to set rates under the PPS, depending on the type of service: fee schedule rates, cost-based rates, payment for vendor goods & services, and participant-directed service rates. For the purposes of this waiver, vendor goods & services refers to payment for the completion of a task or delivery of an item.

1. Medical Assistance (MA) Fee Schedule: Services are identified by ODP for placement on the fee schedule prior to July 1 of each year.

MA Fee Schedule rates are developed using a market-based approach. This process includes a review of the service definitions & a determination of allowable cost components which reflect costs that are reasonable, necessary & related to the delivery of the service, as defined in Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (OMB Circular Uniform Guidance, 12/26/14). The Department establishes the fee schedule rates to fund services at a level sufficient to ensure access, encourage provider participation & promote provider choice, while at the same time ensuring cost effectiveness and fiscal accountability. The fee schedule rates represent the maximum rates that the Department will pay for each service. In developing MA fee schedule rates, the following occurs:

*ODP evaluates and uses various independent data sources such as a Pennsylvania-specific compensation study & data from prior approved cost reports, as applicable, and considers the expected expenses for the delivery of the services for the major allowable cost categories listed below:

- Support needs of the participants

- Staff wages

- Staff-related expenses

- Productivity

- Occupancy

- Program expenses and administration-related expenses

- A review of approved service definitions and determinations made about cost components that reflect costs necessary and related to the delivery of each service

- A review of the cost of implementing Federal, State and local statutes, regulations and ordinances.

*One MA fee schedule rate is developed for each service. ODP uses independent data sources to analyze the wages across the state. Effective 1/1/18, PA is using a single statewide rate for each fee schedule service.

*The Department will refresh the data to establish fee schedule rates at least every 3 years.

*ODP established a variance process for participants who need enhanced levels of staffing (staff to participant ratio of 2:1 or staffing by a person who has a certification or bachelor's degree). When a participant has a need for enhanced levels of staffing, the SC will complete a variance form describing why a participant needs this level of service. The completed variance form will be submitted to the AE for review & approval.

*Rates for the following services and components of a service are on the MA fee schedule: Behavioral Support; Therapy (Physical; Occupational; Speech/Language and Visual/Mobility); Shift Nursing; Companion; Supports Broker; In-Home and Community Support; Supported Employment; Respite (excluding respite camp); Life Sharing, Supported Living, Small Group Employment; Homemaker/Chore; Advanced Supported Employment; Community Participation Support; Music, Art and Equine Assisted Therapy; Benefits Counseling; Communication Specialist; Consultative Nutritional Services; Housing Transition & Tenancy services; Family/Caregiver Training & Support (excluding training registration & fees); and Supports Coordination. The rate for the on-call and remote support component of Community Participation Support follows the fee schedule rate setting methodology described in this section. The assumptions used to develop the on-call and remote support fee schedule rate included a 1:15 participant to staff ratio and a 0% absentee factor.

*Each year additional services are considered for the fee schedule. The waiver will be amended prospectively when additional services are added to the fee schedule contingent upon approval from CMS.

*Changes & addition of services to the fee schedule are communicated through a notice published in the Pennsylvania Bulletin prior to the effective date of any change or addition. Fee schedule rates are implemented prospectively.

*ODP will complete studies of the costs associated with the provision of services & the assumptions used to make the rate determinations in timeframes compliant with applicable state regulations & no later than the renewal of the waiver (7/1/22).

2. Cost-Based: The cost-based rates are developed in accordance with Department standards in 55 Pa. Code Chapter 6100, as follows:

*Cost & utilization data is collected using a standardized cost report as prepared and submitted by providers of service. Cost reports undergo a desk review in which the reported data is analyzed by ODP or its designee for completeness & accuracy based on cost report instructions & standardized review procedures.

*Cost report data is adjusted to reflect changes in the service definitions, if necessary, to account for differences in service definitions between the historical reporting period & the period in which the rates will be in effect. * Providers who do not submit a cost report, do not submit a cost report that is approved by ODP, or fail to submit an audit are assigned rates by ODP. New providers or current providers who offer new services (defined as providers that enroll & qualify to provide a new service after the cost report process is complete for that period & have no cost history) will also be assigned a rate by ODP. ODP assigns rates in the following manner:

-A provider is assigned the provider's cost-based rates for an existing service at a new service location if the provider has an approved cost-based rate at another service location. A provider shall be assigned the state-set rates for new services if:

(1) The cost report did not contain the new service because the service was not delivered during the reporting period.

(2) A provider is a new provider who was not delivering services during the reporting period of the cost report.

*For providers whose cost reports are approved, the cost report data is reviewed undergo a review conducted by ODP or their designee. The review includes identifying outliers using a standardized set of criteria for all services with sufficient data points. For outliers, ODP conducts analysis to determine whether adjustments are needed to address variation among providers' unit costs.

*Since the cost report data is from a historical time period, a Cost of Living Adjustment(COLA) is applied as appropriated by the General Assembly.

*Prior to the effective date of the rates, the methodology for calculating rates, including a description of the outlier review & rate assignment processes are communicated to the provider in the rate notice & in a public notice published in the Pennsylvania Bulletin. Cost report rates are implemented prospectively.

*The provider rate notice includes information on the process to contact ODP on questions & concerns related to the rate notice. Providers have the right to appeal as outlined in 55 Pa. Code Chapter 41. The appeal language is included in the rate notice.

*Providers meeting the criteria for audit submission outlined in I-2 are required to submit their Audited Financial Statements to ODP for review. ODP may require resubmission of the cost report if there are material differences between the independent audit & the approved cost report filed by the provider. ODP may also conduct additional audits of providers' costs reports. ODP may recalculate rates for providers who have material differences between their approved & resubmitted cost reports.

*ODP has a process in place to allow for additional staffing costs above what is included in the approved cost report rate if there is a new participant entering the program that has above average staffing needs.

Transportation providers are both private & local government agency providers. Effective 1/1/18, transportation (per trip) will be the only service that utilizes the cost-based methodology.

3. Payment for vendor goods & services:

*ODP reimburses vendor goods & services based on the cost charged to the general public for the good or services. Services reimbursed under vendor goods & services are: Home and Vehicle Accessibility Adaptations, Assistive Technology, Specialized Supplies, Education Support, Public Transportation, Family/Caregiver Training and Support- registration and fees, Participant Directed Goods and Services & Respite Camp.

*Vendor goods & services must be the most cost-effective to meet the participant's need(s) using a system of competitive bidding or written estimates or the market price of comparable goods or services available in the provider's region. To ensure cost-effectiveness & compliance with the service definition, the SC and service plan team review the bids prior to putting the vendor good or service onto the service plan. The AE also reviews the bids prior to authorizing and approving the service plan. Finally, ODP’s QA&I process monitors vendor goods & services to ensure that bids are competitive & cost-efficient.

*Transportation Mileage is reimbursed at the established rate for Department employees for business travel.

4. Participant-directed service (PDS) rates: Rates for PDS are established through the development of standard wage ranges (which apply to both Vendor Fiscal/Employer Agent [VF/EA]and Agency with Choice [AWC] models) and a fee schedule (AWC model). Effective 7/1/19 Transportation Trip is available through both VF/EA and AWC models and will be reimbursed through a fee schedule rate.

*ODP establishes the VF/EA wage ranges by evaluating various data sources, such as a PA-specific compensation study.

*ODP establishes wage ranges & fee schedule for AWC rates. ODP also establishes fee schedule rates for Transportation Trip zones. The fee schedule rate development for AWC and Transportation Trip zones follows the same process as that outlined previously in this section for non-participant directed fee schedule services.

*The Department will refresh the data to establish PDS rates at least every 3 years.

*Effective 1/1/18, rates for the following services or components of a service are developed consistent with the participant-directed methodologies described above: Homemaker/Chore, Supports Broker, Companion, Supported Employment, In-Home and Community Support and Unlicensed Respite. If the participant chooses to self-direct some or all of these needed services, he or she will utilize the current VF/EA or AWC wage range communication issued by ODP. If the participant chooses not to self-direct any of these services, the MA Fee Schedule rate will be utilized.

The VF/EA and AWC wage ranges are issued by ODP prior to July 1 each year in a standard ODP communication. In addition, the AWC MA fee schedule rates are communicated prior to implementation through a notice published in the Pennsylvania Bulletin. Wage ranges & fee schedule rates, when applicable, are implemented prospectively.

Additional information can be found in Main Module - Optional.

Waiver Name:
PA Adult Autism Waiver
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Pennsylvania Waiver# PA.0593.R02.05

Cost Neutrality

Cost Neutrality for Pennsylvania Waiver# PA.0593.R02.05

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
702 754

Year 1 Waiver Services

List of Year 1 Waiver Services for Pennsylvania Waiver# PA.0593.R02.05

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 11 2242 $5.33
Supported Employment Intensive Job Coaching 15 minutes 114 830 $10.95
Supported Employment Extended Employment Supports 15 minutes 34 75 $10.95
Career Planning Vocational Assessment 15 minutes 22 40 $13.05
Career Planning Job Finding 15 minutes 35 95 $13.05
Small Group Employment 15 minutes 1 5958 $3.17

Year 5 Waiver Services

List of Year 5 Waiver Services for Pennsylvania Waiver# PA.0593.R02.05

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation 15 minutes 15 3215 $5.33
Supported Employment Intensive Job Coaching 15 minutes 80 900 $10.95
Supported Employment Extended Employment Supports 15 minutes 80 175 $10.95
Career Planning Vocational Assessment 15 minutes 55 110 $13.05
Career Planning Job Finding 15 minutes 80 200 $13.05
Small Group Employment 15 minutes 3 3500 $3.17

Rate Determination Methods

Rate Determination Methods for Pennsylvania Waiver# PA.0593.R02.05

Services in the Adult Autism Waiver are paid based on a Medical Assistance fee schedule or on invoice costs for vendor services.

Medical Assistance (MA) Fee Schedule:

MA fee schedule rates are developed using a market-based approach. This process includes a review of the service definitions and a determination of allowable cost components which reflect costs that are reasonable, necessary and related to the delivery of the service, as defined in Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (OMB Circular Uniform Guidance, December 26, 2014). ODP establishes the fee schedule rates to fund services at a level sufficient to ensure access, encourage provider participation and promote provider choice, while at the same time ensuring cost effectiveness and fiscal accountability. The fee schedule rates represent the maximum rates that ODP will pay for each service.

ODP develops rates for each of the MA fee schedule services using the following process. ODP:

• Reviews wage data provided by the Bureau of Labor Statistics to develop service-specific wage rates based on the staffing requirements and roles and responsibilities of the worker. This component is the most significant portion of the total payment rate.

• Considers the expected expenses for the delivery of the services under the waiver for the following major allowable cost categories:

- The support needs of the participants

- Staff wages

- Staff-related expenses

- Productivity

- Occupancy

- Program expenses and administration-related expenses

- A review of approved service definitions in the waiver and determinations made about cost components that reflect costs necessary and related to the delivery of each service

- A review of the cost of implementing Federal, State and local statutes, regulations and ordinances.

Providers are reimbursed on a statewide fee for service basis for Specialized Skill Development, Day Habilitation, Family Support, Career Planning, Nutritional Consultation, Residential Habilitation, Respite, Supported Employment, Supports Coordination, Temporary Supplemental Services, Therapies, Small Group Employment and Transportation- Trip.

Changes to the fee schedule are communicated through a public notice published in the Pennsylvania Bulletin prior to the effective date of any change or addition. Fee schedule rates are implemented prospectively.

ODP will complete studies of the costs associated with the provision of waiver services and the assumptions used to make the rate determinations in timeframes compliant with applicable state regulations and no later than the renewal of the waiver (7/1/21).

Vendor Goods and Services: For Assistive Technology, Community Transition Services, Transportation (Public), Home Modifications, and Vehicle Modifications, providers are reimbursed at the invoice cost for the service or equipment provided. DHS reimburses those services based on the cost charged to the general public for the service or equipment.

Total costs may not exceed the limits in Appendix C-3 for each service unless an exception to the limit is requested of and approved by ODP.

Pennsylvania Waiver# PA.0386.R04.00 

PA Community HealthChoices 

Waiver Name:
PA Community HealthChoices 
Effective Date:
1/1/2020
Expiration Date:
12/31/2024

Services

List of Services for Pennsylvania Waiver# PA.0386.R04.00

Cost Neutrality

Cost Neutrality for Pennsylvania Waiver# PA.0386.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
107404 140985

Year 1 Waiver Services

List of Year 1 Waiver Services for Pennsylvania Waiver# PA.0386.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Skills Development 15 minutes 136 2938 $6.73
Job Coaching 15 minutes 66 1145 $10.68
Structured Day Habilitation Services hour 704 999 $32.60
Benefits Counseling 15 minutes 2 30 $10.86
Career Assessment 15 minutes 3 167 $13.05
Job Finding 15 minutes 13 133 $12.66

Year 5 Waiver Services

List of Year 5 Waiver Services for Pennsylvania Waiver# PA.0386.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Skills Development 15 minutes 178 2997 $7.00
Job Coaching 15 minutes 87 1168 $11.11
Structured Day Habilitation Services hour 924 1019 $33.92
Benefits Counseling 15 minutes 10 30 $10.86
Career Assessment 15 minutes 4 170 $13.58
Job Finding 15 minutes 17 136 $13.18

Rate Determination Methods

Rate Determination Methods for Pennsylvania Waiver# PA.0386.R04.00

Under CHC, the method of determining the capitation rate is subject to the 1915(b) requirements and criteria. The Commonwealth has contracted with an actuarial firm to develop the actuarially sound capitation payment rates on an annual basis.

There was a 1% annual unit cost trend was included as an estimate of potential future fee schedule unit cost growth during the prospective time period including inflationary growth in services paid at cost such as Assistive Technology, Specialized Medical Equipment & Supplies, etc. The 1% factor was informed by BLS employment cost index trends and actual historical fee schedule rate increases that OLTL has made.

Waiver Name:
PA Consolidated Waiver
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for Pennsylvania Waiver# PA.0147.R06.04

Cost Neutrality

Cost Neutrality for Pennsylvania Waiver# PA.0147.R06.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
18752 18981

Year 1 Waiver Services

List of Year 1 Waiver Services for Pennsylvania Waiver# PA.0147.R06.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Support Base 15 minutes 2715 3031.2 $4.86
Community Participation Support Level 1 15 minutes 679 3584.8 $4.81
Community Participation Support Level 2 15 minutes 11527 2563.2 $6.34
Community Participation Support Level 3 15 minutes 4130 2200 $11.79
Community Participation Support Level 4 15 minutes 235 1555.2 $20.53
Community Participation Support Older Adult Living 15 minutes 361 3444.7 $2.68
Community Participation Support On-Call and Remote Support 15 minutes 0 0 $0.01
Supported Employment Career Assessment 15 minutes 186 425.6 $17.75
Supported Employment Job Finding and Development 15 minutes 401 459.9 $17.75
Supported Employment Job Coaching - Base (1:2 to 1:4) 15 minutes 7 1332.8 $10.45
Supported Employment Job Coaching and Support Level 1 (1:1) 15 minutes 903 669.2 $17.75
Advanced Supported Employment Outcome Based Unit 8 1 $5865.71
Benefits Counseling 15 minutes 13 16.8 $11.40
Small Group Employment Base 15 minutes 88 2107.5 $2.29
Small Group Employment Level 1 15 minutes 302 1628.25 $3.52
Small Group Employment Level 2 15 minutes 228 1727.25 $6.83
Small Group Employment Level 3 15 minutes 142 1392.75 $12.48

Year 5 Waiver Services

List of Year 5 Waiver Services for Pennsylvania Waiver# PA.0147.R06.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Support Base 15 minutes 2800 1900 $4.86
Community Participation Support Level 1 15 minutes 1000 1750 $4.81
Community Participation Support Level 2 15 minutes 14500 1500 $6.34
Community Participation Support Level 3 15 minutes 5500 1450 $11.79
Community Participation Support Level 4 15 minutes 300 1250 $20.53
Community Participation Support Older Adult Living 15 minutes 300 3000 $2.68
Community Participation Support On-Call and Remote Support 15 minutes 100 500 $1.33
Supported Employment Career Assessment 15 minutes 527 323 $17.75
Supported Employment Job Finding and Development 15 minutes 158 142 $17.75
Supported Employment Job Coaching - Base (1:2 to 1:4) 15 minutes 17 1172 $10.45
Supported Employment Job Coaching and Support Level 1 (1:1) 15 minutes 1053 768 $17.75
Advanced Supported Employment Outcome Based Unit 9 1 $5865.71
Benefits Counseling 15 minutes 22 19 $11.40
Small Group Employment Base 15 minutes 74 2069 $2.29
Small Group Employment Level 1 15 minutes 239 1989 $3.52
Small Group Employment Level 2 15 minutes 279 1939 $6.83
Small Group Employment Level 3 15 minutes 169 1498 $12.48

Rate Determination Methods

Rate Determination Methods for Pennsylvania Waiver# PA.0147.R06.04

There are several approaches to set rates under the PPS, depending on the type of service: fee schedule rates, cost-based rates, payment for vendor goods and services, and participant-directed service rates. For the purposes of this waiver, vendor goods and services refers to payment for the completion of a task or delivery of an item.

1. Medical Assistance (MA) Fee Schedule: Services are identified by ODP for placement on the fee schedule prior to July 1 of each year.

MA Fee Schedule rates are developed using a market-based approach. This process includes a review of the service definitions & a determination of allowable cost components which reflect costs that are reasonable, necessary & related to the delivery of the service, as defined in Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (OMB Circular Uniform Guidance, 12/26/14). The Department establishes the fee schedule rates to fund services at a level sufficient to ensure access, encourage provider participation & promote provider choice, while at the same time ensuring cost effectiveness and fiscal accountability. The fee schedule rates represent the maximum rates that the Department will pay for each service. In developing MA fee schedule rates, the following occurs:

*ODP evaluates and uses various independent data sources such as a Pennsylvania-specific compensation study & data from prior approved cost reports, as applicable, and considers the expected expenses for the delivery of the services for the major allowable cost categories listed below:

- Support needs of the participants

- Staff wages

- Staff-related expenses

- Productivity

- Occupancy

- Program expenses and administration-related expenses

- A review of approved service definitions and determinations made about cost components that reflect costs necessary and related to the delivery of each service

- A review of the cost of implementing Federal, State and local statutes, regulations and ordinances.

*One MA fee schedule rate is developed for each service.

*ODP established a variance process for services as stipulated in the service definition in Appendix C when the needs of the participant require higher staffing levels or higher trained staff. Variances can also be requested for medically or behaviorally complex individuals who receive Residential Habilitation whose needs exceed the standard fee schedule rate.

*Rates for the following services and components of a service are on the MA fee schedule: Behavioral Support; Physical Therapy; Occupational Therapy; Speech/Language Therapy; Visual/Mobility Therapy; Shift Nursing; Companion; Supports Broker; Residential enhanced staffing (Supplemental Habilitation and Additional Individualized Staffing which are discrete services not included in rates for Life Sharing, Supported Living and Residential Habilitation); In-Home and Community Support; Supported Employment; Respite(excluding respite camp); Small Group Employment; Homemaker/Chore; Advanced Supported Employment; Community Participation Support; Music, Art & Equine Assisted Therapy; Benefits Counseling; Communication Specialist; Consultative Nutritional Services; Housing Transition & Tenancy services; Family/Caregiver Training & Support (excluding training registration and fees); Supported Living & Supports Coordination. Effective 1/1/18, rates for the following services transitioned to the MA fee schedule: Unlicensed & Licensed Residential Habilitation and Unlicensed & Licensed Life Sharing. The rate for the on-call and remote support component of Community Participation Support follows the fee schedule rate setting methodology described in this section. The assumptions used to develop the on-call and remote support fee schedule rate included a 1:15 participant to staff ratio and a 0% absentee factor.

*Each year additional services are considered for the fee schedule. The waiver will be amended prospectively when additional services are added to the fee schedule contingent upon approval from CMS.

*Changes and addition of services to the fee schedule are communicated through a public notice published in the Pennsylvania Bulletin prior to the effective date of any change or addition. Fee schedule rates are implemented prospectively.

*ODP will complete studies of the costs associated with the provision of waiver services and the assumptions used to make the rate determinations in timeframes compliant with applicable state regulations and no later than the renewal of the waiver (7/1/22).

2. Cost-Based: Cost-based rates are developed in accordance with Department standards in 55 Pa. Code Chapter 6100 as follows:

*Cost and utilization data is collected using a standardized cost report as prepared and submitted by providers of service. Cost reports undergo a desk review in which the reported data is analyzed by ODP or its designee for completeness & accuracy based on cost report instructions & standardized review procedures.

*Cost report data is adjusted to reflect changes in the service definitions, if necessary, to account for differences in service definitions between the historical reporting period and the period in which the rates will be in effect.

* Providers who do not submit a cost report, do not successfully submit a cost report that is approved by ODP, or fail to submit an audit are assigned rates by ODP. New providers or current providers who offer new services (defined as providers that enroll and qualify to provide a new service after the cost report process is complete for that period and have no cost history) will also be assigned a rate by ODP. ODP assigns rates in the following manner:

-A provider is assigned the provider's cost-based rates for an existing service at a new service location if the provider has an approved cost-based rate at another service location. A provider shall be assigned the state-set rates for new services if:

(1) The cost report did not contain the new service because the service was not delivered during the reporting period.

(2) A provider is a new provider who was not delivering services during the reporting period of the cost report.

*For providers whose cost reports are approved, the cost report data is reviewed undergo a review conducted by ODP or their designee. The review includes identifying outliers using a standardized set of criteria for all services with sufficient data points. For outliers, ODP conducts analysis to determine whether adjustments are needed to address variation among providers' unit costs.

*Since the cost report data is from a historical time period, a Cost of Living Adjustment(COLA) is applied as appropriated by the General Assembly.

*Prior to the effective date of the rates, the methodology for calculating rates, including a description of the outlier review and rate assignment processes are communicated to the provider in the provider rate notice and in a public notice published in the Pennsylvania Bulletin. Cost report rates are implemented prospectively.

*The provider rate notice includes information on the process to contact ODP on questions and concerns related to the provider rate notice. Providers have the right to appeal as outlined in 55 Pa. Code Chapter 41. The appeal language is included in the individual provider rate notice.

*Providers meeting the criteria for audit submission outlined in I-2 are required to submit their Audited Financial Statements to ODP for review. ODP may require resubmission of the cost report if there are material differences between the independent audit and the approved cost report filed by the provider. ODP may also conduct additional audits of providers' costs reports. ODP may recalculate rates for providers who have material differences between their approved and resubmitted cost reports.

*ODP has a process in place to allow for additional staffing costs above what is included in the approved cost report rate if there is a new participant entering the program that has above average staffing needs.

Transportation providers are both private & local government agency providers. Effective 1/1/18, transportation (per trip) will be the only service remaining that utilizes the cost-based methodology.

3. Payment for vendor goods and services:

*ODP reimburses vendor goods and services based on the cost charged to the general public for the good or service. Services reimbursed under this approach are: Home and Vehicle Accessibility Adaptations, Assistive Technology, Specialized Supplies, Education Support, Public Transportation, Family/Caregiver Training and Support – registration and fees, and Respite Camp.

*Vendor goods and services must be the most cost-effective to meet the participant's needs using a system of competitive bidding or written estimates or the market price of comparable goods or services available in the provider's region.

* Transportation Mileage is reimbursed at the established rate for employees of the Department for business travel.

4. Participant-directed service rates: Rates for participant-directed services are established through the development of standard wage ranges(which apply to both Vendor Fiscal/Employer Agent [VF/EA] & Agency with Choice [AWC] models) and a fee schedule(AWC model). Effective July 1, 2019 Transportation Trip is available thought both VF/EA and

AWC models and will be reimbursed through a fee schedule rate.

*ODP establishes the VF/EA wage ranges by evaluating various data sources, such as a PA-specific compensation study.

*ODP establishes wage ranges and fee schedule for AWC rates. ODP also establishes fee schedule rates for Transportation Trip zones. The fee schedule rate development for AWC and Transportation Trip zones follows the same process as that outlined previously in this section for non-participant directed fee schedule services.

*Effective 7/1/17, rates for the following services or components of a service are developed consistent with the participant-directed methodologies described above: Homemaker/Chore, Supports Broker, Companion, Supported Employment, In-Home and Community Support & Unlicensed Respite. If the participant chooses to self-direct some or all of these services, he or she will utilize the current VF/EA or AWC wage range communication issue by ODP. If the participant chooses not to self-direct any of these services, the MA Fee Schedule rate will be utilized.

The VF/EA and AWC wage ranges are issued by ODP prior to July 1 each year in a standard ODP communication. In addition, the AWC MA fee schedule rates are communicated prior to July 1 each year through a public notice published in the PA Bulletin. Wage ranges and fee schedule rates are implemented prospectively.

Claims are processed through PROMISe which is administered by the Office of Medical Assistance Programs (OMAP) and the Department's Bureau of Information Systems (BIS). Claims and payments are monitored by ODP and Administrative Entities (AEs) through the use of PROMISe and HCSIS generated reports.

In the future, ODP may use a variety of mechanisms to obtain public comment on rate determination methodologies, including stakeholder workgroup discussions, draft documents distributed for public comment, communications & public meetings.

The rate development assumption logs for residential and non-residential services can be accessed under the Draft Fee Schedule Documents header at http://dhs.pa.gov/provider/developmentalprograms/2017waiverrenewals/Appendices/index.htm.

Pennsylvania Waiver# PA.0354.R04.04 

PA Person/Family Directed Support

Waiver Name:
PA Person/Family Directed Support
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for Pennsylvania Waiver# PA.0354.R04.04

Cost Neutrality

Cost Neutrality for Pennsylvania Waiver# PA.0354.R04.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
15490 15490

Year 1 Waiver Services

List of Year 1 Waiver Services for Pennsylvania Waiver# PA.0354.R04.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Support Base 15 minutes 2939 2634.8 $4.86
Community Participation Support Level 1 15 minutes 790 2667 $4.81
Community Participation Support Level 2 15 minutes 5788 1877.4 $6.34
Community Participation Support Level 3 15 minutes 272 865.2 $11.79
Community Participation Support Level 4 15 minutes 5 140.7 $20.53
Community Participation Support Older Adult Living 15 minutes 64 2977.1 $2.68
Community Participation Support On-Call and Remote Support 15 minutes 0 0 $0.01
Supported Employment Career Assessment 15 minutes 147 262.5 $17.75
Supported Employment Job Finding and Development 15 minutes 454 255.5 $17.75
Supported Employment Job Coaching - Base (1:2 to 1:4) 15 minutes 7 470.4 $10.45
Supported Employment Job Coaching and Support Level 1 (1:1) 15 minutes 1534 337.4 $17.75
Advanced Supported Employment Outcome Based Unit 4 1 $5865.71
Benefits Counseling 15 minutes 10 38 $11.40
Small Group Employment Base 15 minutes 103 1823.25 $2.29
Small Group Employment Level 1 15 minutes 300 1776.75 $3.52
Small Group Employment Level 2 15 minutes 285 1110 $6.83
Small Group Employment Level 3 15 minutes 61 490.5 $12.48

Year 5 Waiver Services

List of Year 5 Waiver Services for Pennsylvania Waiver# PA.0354.R04.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Support Base 15 minutes 3100 2700 $4.86
Community Participation Support Level 1 15 minutes 1200 1500 $4.81
Community Participation Support Level 2 15 minutes 7250 1500 $6.34
Community Participation Support Level 3 15 minutes 300 900 $11.79
Community Participation Support Level 4 15 minutes 25 225 $20.53
Community Participation Support Older Adult Living 15 minutes 50 3000 $2.68
Community Participation Support On-Call and Remote Support 15 minutes 100 500 $1.33
Supported Employment Career Assessment 15 minutes 150 150 $17.75
Supported Employment Job Finding and Development 15 minutes 600 200 $17.75
Supported Employment Job Coaching - Base (1:2 to 1:4) 15 minutes 25 500 $10.45
Supported Employment Job Coaching and Support Level 1 (1:1) 15 minutes 1800 400 $17.75
Advanced Supported Employment Outcome Based Unit 25 1 $5865.71
Benefits Counseling 15 minutes 50 25 $11.40
Small Group Employment Base 15 minutes 100 2000 $2.29
Small Group Employment Level 1 15 minutes 250 2000 $3.52
Small Group Employment Level 2 15 minutes 250 1200 $6.83
Small Group Employment Level 3 15 minutes 75 700 $12.48

Rate Determination Methods

Rate Determination Methods for Pennsylvania Waiver# PA.0354.R04.04

There are several approaches to set rates under the PPS, depending on the type of service: fee schedule rates, cost-based rates, payment for vendor goods and services, and participant-directed service rates. For the purposes of this waiver, vendor goods and services refers to payment for the completion of a task or delivery of an item.

1. Medical Assistance (MA) Fee Schedule: Services are identified by ODP for placement on the fee schedule prior to July 1 of each year.

MA Fee Schedule rates are developed using a market-based approach. This process includes a review of the service definitions & a determination of allowable cost components which reflect costs that are reasonable, necessary & related to the delivery of the service, as defined in Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (OMB Circular Uniform Guidance, 12/26/14). The Department establishes the fee schedule rates to fund services at a level sufficient to ensure access, encourage provider participation & promote provider choice, while at the same time ensuring cost effectiveness and fiscal accountability. The fee schedule rates represent the maximum rates that the Department will pay for each service. In developing MA fee schedule rates, the following occurs:

*ODP evaluates & uses various independent data sources such as a Pennsylvania-specific compensation study & data from prior approved cost reports, as applicable, & considers the expected expenses for the delivery of the services for the major allowable cost categories listed below:

- Support needs of the participants

- Staff wages

- Staff-related expenses

- Productivity

- Occupancy

- Program expenses & administration-related expenses

- A review of approved service definitions & determinations made about cost components that reflect costs necessary & related to the delivery of each service

- A review of the cost of implementing Federal, State and local statutes, regulations and ordinances.

*One MA fee schedule rate is developed for each service and is adjusted by geographical area factors to reflect consideration for differences in wages observed across Pennsylvania. ODP uses independent data sources to analysis the wages.

*ODP established a variance process for services as stipulated in the service definition in Appendix C when a participant's needs require higher staffing levels or higher trained staff.

*Rates for the following services and components of a service are on the MA fee schedule: Behavioral Support; Physical Therapy; Occupational Therapy; Speech/Language Therapy; Visual/Mobility Therapy; Shift Nursing; Companion; Supports Broker; In-Home and Community Support; Supported Employment; Respite (excluding respite camp); Small Group Employment; Homemaker/Chore; Advanced Supported Employment; Community Participation Support; Music, Art and Equine Assisted Therapy; Benefits Counseling; Communication Specialist; Consultative Nutritional Services; Housing Transition and Tenancy services; Family/Caregiver Training and Support (excluding training registration and fees); and Supports Coordination. The rate for the on-call and remote support component of Community Participation Support follows the fee schedule rate setting methodology described in this section. The assumptions used to develop the on-call and remote support fee schedule rate included a 1:15 participant to staff ratio and a 0% absentee factor.

*Each year additional services are considered for the fee schedule. The waiver will be amended prospectively when additional services are added to the fee schedule contingent upon approval from CMS.

*Changes & addition of services to the fee schedule are communicated through a public notice published in the Pennsylvania Bulletin prior to the effective date of any change or addition. Fee schedule rates are implemented prospectively.

*ODP will complete studies of the costs associated with the provision of services and the assumptions used to make the rate determinations in timeframes compliant with applicable state regulations and no later than the renewal of the waiver (7/1/22).

2. Cost-Based: The cost-based rates are developed in accordance with Department standards in 55 Pa. Code Chapter 6100 as follows:

*Cost and utilization data is collected using a standardized cost report as prepared and submitted by providers of service. Cost reports undergo a desk review in which the reported data is analyzed by ODP or its designee for completeness & accuracy based on cost report instructions & standardized review procedures.

*Cost report data is adjusted to reflect changes in the service definitions, if necessary, to account for differences in service definitions between the historical reporting period and the period in which the rates will be in effect.

* Providers who do not submit a cost report, do not successfully submit a cost report that is approved by ODP, or fail to submit an audit are assigned rates by ODP. New providers or current providers who offer new services (defined as providers that enroll and qualify to provide a new service after the cost report process is complete for that period and have no cost history) will also be assigned a rate by ODP. ODP assigns rates in the following manner:

-A provider is assigned the provider's cost-based rates for an existing service at a new service location if the provider has an approved cost-based rate at another service location. A provider shall be assigned the state-set rates for new services if:

(1) The cost report of the provider did not contain the new service because the service was not delivered during the reporting period.

(2) A provider is a new provider who was not delivering services during the reporting period of the cost report.

*For providers whose cost reports are approved, the cost report data undergoes a review conducted by ODP or their designee. The review includes identifying outliers using a standardized set of criteria for all services with sufficient data points. For outliers, ODP conducts analysis to determine whether adjustments are needed to address variation among providers' unit costs.

*Since the cost report data is from a historical time period, a Cost of Living Adjustment(COLA) is applied as appropriated by the General Assembly.

* Prior to the effective date of the rates, the methodology for calculating rates, including a description of the outlier review and rate assignment processes are communicated to the provider in the provider rate notice and in a public notice published in the Pennsylvania Bulletin. Cost report rates are implemented prospectively.

*The individual provider rate notice includes information on the process to contact ODP on questions and concerns related to the provider rate notice. Providers have the right to appeal as outlined in 55 Pa. Code Chapter 41. The appeal language is included in the provider rate notice.

*Providers meeting the criteria for audit submission outlined in I-2 are required to submit their Audited Financial Statements to ODP for review. ODP may require resubmission of the cost report if there are material differences between the independent audit and the approved cost report filed by the provider. ODP may also conduct additional audits of providers' costs reports. ODP may recalculate rates for providers who have material differences between their approved & resubmitted cost reports.

*ODP has a process in place to allow for additional staffing costs above what is included in the approved cost report rate if there is a new participant entering the program that has above average staffing needs.

Transportation providers are both private & local government agency providers. Effective 1/1/18, transportation (per trip) will be the only service remaining that utilizes the cost-based methodology.

3. Payment for vendor goods and services:

*ODP reimburses vendor goods and services based on the cost charged to the general public for the good or services. Services reimbursed under vendor goods and services are: Home and Vehicle Accessibility Adaptations, Assistive Technology, Specialized Supplies, Education Support, Public Transportation, Family/Caregiver Training and Support - registration and fees, Participant Directed Goods and Services and Respite Camp.

*Vendor goods and services must be the most cost-effective to meet the participant's need(s) using a system of competitive bidding or written estimates or the market price of comparable goods or services available in the provider's region. To ensure cost-effectiveness and compliance with the service definition, the SC and service plan team review the bids prior to putting the vendor good or service onto the service plan. The AE also reviews the bids prior to authorizing and approving the service plan. Finally, ODP's QA&I process monitors vendor goods and services to ensure that bids are competitive and cost-efficient.

*Transportation Mile is reimbursed at the established rate for employees of the Department for business travel.

4. Participant-directed service (PDS) rates: Rates for PDS are established through the development of standard wage ranges (which apply to both Vendor Fiscal/Employer Agent [VF/EA] and Agency with Choice [AWC] models) and a fee schedule (AWC model). Effective 7/1/19 Transportation Trip is available thought both VF/EA and AWC models and will be reimbursed through a fee schedule rate.

*ODP establishes the VF/EA wage ranges by evaluating various data sources, such as a Pennsylvania-specific compensation study.

*ODP establishes wage ranges and fee schedule for AWC rates. ODP also establishes fee schedule rates for Transportation Trip zones. The fee schedule rate development for AWC and Transportation Trip zones follows the same process as that outlined previously in this section for non-participant directed fee schedule services.

*Effective 7/1/17 rates for the following services or components of a service are developed consistent with the participant-directed methodologies described above: Homemaker/Chore, Supports Broker, Companion, Supported Employment, In-Home and Community Support and Unlicensed Respite. If the participant chooses to self-direct some or

all of these needed services, he or she will utilize the current Vendor Fiscal/Employer Agent or Agency With Choice wage range communication issue by ODP. If the participant chooses not to self-direct any of these services, the MA Fee Schedule rate will be utilized.

The VF/EA and AWC wage ranges are issued by ODP prior to July 1 each year in a standard ODP communication. In addition, the AWC Medical Assistance fee schedule rates are communicated prior to July 1 each year through a public notice published in the Pennsylvania Bulletin. Wage ranges and fee schedule rates, when applicable, are implemented prospectively.

Claims are processed through PROMISe which is administered by the Office of Medical Assistance Programs (OMAP) and the Department's Bureau of Information Systems (BIS). Claims and payments are monitored by ODP and Administrative Entities (AEs) through the use of PROMISe and HCSIS generated reports.

In the future, ODP may use a variety of mechanisms to obtain public comment on rate determination methodologies, including, but not limited to stakeholder workgroup discussions, draft documents distributed for public comment, communications and public meetings.

Waiver Name:
PA OBRA
Effective Date:
7/1/2016
Expiration Date:
6/30/2021

Services

List of Services for Pennsylvania Waiver# PA.0235.R05.09

Cost Neutrality

Cost Neutrality for Pennsylvania Waiver# PA.0235.R05.09

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1517 420

Year 1 Waiver Services

List of Year 1 Waiver Services for Pennsylvania Waiver# PA.0235.R05.09

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Skills Development 15 minutes 84 2621.3 $21.00
Job Coaching 15 minutes 41 68 $60.00
Structured Day Habilitation Services hour 88 1002.6 $34.56
Structured Day Habilitation Services 1:1 hour 30 520.1 $19.62
Structured Day Habilitation Services 2:1 hour 1 727.4 $39.23
Benefits Counseling 15 minutes 25 11 $60.00
Career Assessment 15 minutes 25 11 $64.00
Job Finding 15 minutes 25 11 $60.00
Prevocational Services 15 minutes 80 947.5 $6.39
Supported Employment hour 34 99.5 $40.86

Year 5 Waiver Services

List of Year 5 Waiver Services for Pennsylvania Waiver# PA.0235.R05.09

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Employment Skills Development 15 minutes 12 871.9 $14.96
Job Coaching 15 minutes 2 2973.1 $10.87
Structured Day Habilitation Services hour 25 1118.6 $34.56
Benefits Counseling 15 minutes 8 661.6 $19.62
Career Assessment 15 minutes 0 0 $0.01
Job Finding 15 minutes 1 25 $60.00
Prevocational Services 15 minutes 0 0 $0.01
Supported Employment hour 0 0 $0.01

Rate Determination Methods

Rate Determination Methods for Pennsylvania Waiver# PA.0235.R05.09

OLTL’s Medical Assistance fee schedule rates are developed using a market-based approach, using the most current available market data, as opposed to reliance solely on provider-specific cost data. In the few cases where provider data is available, it is reviewed to help identify certain cost components and to inform the fee development process, but no fees are set solely on reported provider costs.

After allowable cost components are identified and market data are reviewed, the process used to calculate the MA fee schedule rates starts with the assumed direct care worker salary expenses. Consideration for all employee-related expenses and productivity adjustments are loaded on top of the wage to calculate a full hourly cost for the direct care worker. Once this amount is established, other program indirect costs are factored in, followed lastly by the loading on of administration expense considerations. The resulting hourly amount is then converted to the appropriate unit definition for the given procedure code (e.g., 15 min, day). Please refer to the unit definitions by procedure code in the rate table found at the link below. These unit definitions are consistent with the units of service displayed in Appendix J.

After a rate is developed, OLTL develops geographical fees to reflect service delivery costs in regions across the Commonwealth. Region 1 represents Pittsburgh and surrounding counties, Region 4 represents Philadelphia and surrounding counties, Region 3 represents Harrisburg and surrounding counties and Region 2 represents all other counties. Fee schedule rates vary depending on the geographic region in which the service is provided. The link to OLTL’s current rate schedule can be found on the following web page under OLTL Home and Community-Based Services Regulations and Rates, MA Fee Schedule Rates: http://www.dhs.pa.gov/provider/longtermcareprov/

Please refer to the following link for a description of the regions and a summary of the rate-setting methodology: http://www.pabulletin.com/secure/data/vol42/42-23/1058.html.

Fee schedule rates are established by OLTL to fund services at a level sufficient to ensure participant access to services and to encourage sufficient provider participation so that participants have provider choice, while at the same time ensuring cost effectiveness and fiscal accountability.

Rates and the rate methodology are reviewed at least every 5 years to ensure quality of services and a sufficient provider base. A more frequent review and amendment of rates can occur as a result of stakeholder input or passage of federal and state legislation.

The fee schedule rates are not adjusted for acuity determination considerations, as differences in acuity are reflected through the use of different staffing ratios or intensity levels for some services. In years when a fee schedule re-base has not been performed, OLTL reviews the fee schedule and applies a cost of living (i.e., inflation factor) adjustment, if needed. No other adjustments were considered to develop the final fee schedule rates.

Rates for the following services are on the waiver fee schedule: Adult Daily Living Services (Basic and Enhanced), Behavior Therapy, Benefits Counseling, Career Assessment, Cognitive Rehabilitation Therapy, Community Integration, Counseling Services, Employment Skills Development, Home Health Services (Nursing, Occupational Therapy, Physical Therapy and Speech and Language Therapy), Job Coaching, Job Finding, Nutritional Consultation, Personal Assistance Services (agency and participant-directed), Personal Assistance Services – participant-directed overtime, Prevocational Services, Residential Habilitation, Residential Habilitation Enhanced staffing, Respite (agency and participant-directed), Respite – participant-directed overtime, Service Coordination, Structured Day Habilitation, and Structured Day Habilitation Enhanced Staffing.

Participant-directed overtime rates were established through the development of standard rate ranges as described above for personal assistance and respite services. The resulting waiver fee schedule rate was multiplied by 1.5 to obtain the overtime rate. The overtime rate is only paid to participant-employed direct care workers who do not live in the same residence as the participant and for hours worked over 40 hours per week.

Home Adaptations, Assistive Technology, Specialized Medical Equipment and Supplies, Vehicle Modifications, Non- Medical Transportation, Community Transition Services, and Personal Emergency Response Services are all vendor services; vendors may charge what is “usual and customary” for the general public. OLTL does not determine the provider’s Usual Customary Charge (UCC). If OLTL had cause to investigate, OLTL would request the provider’s documentation to support their UCC (such as their fee schedule), and any other records to show that the provider actually applied the UCC charged to the commonwealth to individuals in the general public. In January 2020, the existing fee schedule rates for Personal Assistance Services (PAS) are increased by 2%. The intent of the increase is to provide for a wage increase for direct care workers providing agency-directed personal assistance services. This increase is pursuant to Section 1729-J of the Act of April 9, 1929 (P.L. 343, No. 176), also known as the Fiscal Code, added June 28, 2019 (P.L. 173, Act No. 20) (vii.2) which states the following: The appropriation for Home and Community-Based Services includes sufficient funds for a 2% increase, effective January 1, 2020, to the existing OLTL Home and Community Based Waiver Services Fee Schedule Rate for Procedure Code W1793 - PAS (Agency) Services. The intent of the increase is to provide for a wage increase for direct care workers providing agency-directed personal assistance services. Additionally, as indicated in the Department’s Public Notice on August 24, 2019, the Department is also increasing the PAS (Consumer) and PAS (Consumer Overtime) rates, procedure codes W1792, and W1792 TU, to maintain equity in all the PAS rates in the OBRA waiver.

The State acknowledges that the populations in need of care are projected to grow rapidly and the need for a robust, skilled, and dedicated direct care workforce is more important than ever. The turnover rate for direct care workers is estimated at 44-65% each year and the number one contributing factor for this turnover rate is low wages. Therefore, the State modeled a wage increase, and 2% was assessed to be successful in providing an increase in wages to direct care staff in order to ensure continued access while also remaining within the parameters of the budget appropriations.

In addition, the existing fee schedule rates for Residential Habilitation are increased by 3% to account for vacancy. The provider cannot bill for days the participant is not in the residence to receive services; yet the provider must still maintain the residence and provide some level of staffing. The provider is being paid a higher rate for days the participant receives services to account for these circumstances.

The 3% increase for Residential Habilitation was derived by the desire to have consistency in the reimbursement of like services across Department program offices.

OLTL provides stakeholders and the general public input on rates in a variety of ways. Feedback is solicited through various forums, including convening a provider workgroup, conducting on-site provider interviews, issuing an all- provider survey, and providing updates at the Long-Term Care Subcommittee of the Medical Assistance Advisory Committee (MAAC). In addition, once rates are determined, OLTL publishes a rate notice in the PA Bulletin with a 30- comment period. Comments received are considered in subsequent revisions to the MA Program Fee Schedule.

When the participant chooses to self-direct some or all of their services, the F/EA is responsible for informing the participant of the established rate for that service.

While monitoring providers on-site, the Quality Management Efficiency Teams request all mileage sheets and/or receipts from buses, taxis or other modes of transportation related to non-medical transportation. The Financial Representative then compares them to the amount billed and paid. Staff then reviews the participant files for the individualized assessment which was performed determining the participants need, and contact notes in HCSIS or SAMS to verify that the service approved was provided.

Non-Medical Transportation services cannot be authorized for a participant that is receiving Residential Habilitation services. The Bureau of Participant Operations ensures that both Residential Habilitation and Non-Medical Transportation are not mutually present on service plans at time of review. BPO also performs random reviews of those ISPs that go through the auto approval process. In addition, during the biennial provider monitoring process, QMETs review a statically significant sample of ISPs and correlated billing documents.

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

South Carolina Waiver# SC.0676.R02.02 

SC Community Supports (CS) Waiver

Waiver Name:
SC Community Supports (CS) Waiver
Effective Date:
7/1/2017
Expiration Date:
6/30/2022

Services

List of Services for South Carolina Waiver# SC.0676.R02.02

Cost Neutrality

Cost Neutrality for South Carolina Waiver# SC.0676.R02.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5800 8500

Year 1 Waiver Services

List of Year 1 Waiver Services for South Carolina Waiver# SC.0676.R02.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Preparation Services unit 1740 222 $27.27
Community Services - Individual unit 290 84 $27.27
Community Services - Group unit 696 222 $27.27
Day Activity unit 1334 222 $27.27
Employment Services - Individual hour 522 222 $87.80
Employment Services - Group unit 1160 42 $27.27

Year 5 Waiver Services

List of Year 5 Waiver Services for South Carolina Waiver# SC.0676.R02.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Preparation Services Unit 2550 238 $32.77
Community Services - Individual unit 425 91 $32.77
Community Services - Group unit 1020 238 $32.77
Day Activity unit 1955 238 $32.77
Employment Services - Individual hour 765 238 $98.81
Employment Services - Group unit 1700 45 $32.77

Rate Determination Methods

Rate Determination Methods for South Carolina Waiver# SC.0676.R02.02

The SCDHHS, Department of Reimbursement Methodology and Policy, in collaboration with the SCDHHS Division of Community Options, and the SCDDSN, is responsible for the development of waiver service payment rates. The SCDHHS allows the public to offer comments on waiver rates changes and rate setting methodology either through Medical Care Advisory Committee meetings, public hearings, or through meetings with association representatives. The SCDHHS receives contractually required annual cost report submissions from SCDDSN for the Community Supports waiver services provided by the Disabilities and Special Needs Boards (38) across the state. As of October 1, 2012, the date of implementation of our prospective payment system, these reports are used to substantiate Certified Public Expenditures only.

The costs of the Boards are initially accumulated and compiled into four regional consolidated reports. The costs are separated by medical service/waiver. The SCDDSN also contracts with SCDHHS for the services of ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)), TCM (Targeted Case Management), Early Intervention, Rehabilitative Behavioral Health services, as well as two other HCBS waivers. As a comprehensive health care provider, the SCDDSN uses the CMS form 2552 to distribute or step down the cost of general service and supporting cost centers to the benefitting services and waivers. Upon completion of the 2552 format, the SCDDSN then prepares a Community Supports waiver specific cost report which further delineates cost among the specific services provided within the waiver. Utilization statistics (units of service) for the specific waiver services are accumulated by SCDDSN for the total population of users of the services and reported in the cost report.

Upon receipt of the annual reports, staff of the Department of Reimbursement Methodology and Policy review the reports for accuracy, reasonableness, and compliance with Medicare cost definitions. Samples of cost and service data from individual Boards (chosen from each regional report) are reviewed for compliance and then traced into the applicable supporting worksheets within the waiver cost report. Upon the completion and determination of allowable costs, the average cost per unit for each waiver service is calculated by dividing the total allowable cost per service by the total units of service for that service (i.e. for the total population of service recipients). The SCDHHS uses Medicare cost principles as reflected in the CMS Provider Reimbursement Manual (HIM-15) as our guidance for establishing allowable cost definitions for non-institutional cost reports required by SCDHHS.

For the waiver services provided by DDSN’s Boards under contract, the 2010 cost report was used to establish prospective rates as of October 1, 2012. The average SFY 2010 cost per unit for each contracted service becomes the basis for rates effective with October 1, 2012 dates of service. To approximate allowable Medicaid costs, the 2010 rates were trended by a rate of 3.76%. The trend factor was determined by using the Medicare Economic Index (MEI) for Calendar Year 2010 (1.2%) and multiplying the index by the number of years between the midpoint of the cost reporting year (January 2010) and the midpoint of the rate year (February 14, 2013). Note: Cost reporting year = 07/01/09- 06/30/10 and Rate year = 10/01/12-06/30/13.

To provide some background on the current status of cost reports for this waiver (and the two other waiver administered by the contractor SCDDSN), SCDHHS has been working with SCDDSN, with technical assistance and oversight from CMS, in finalizing the proper treatment of SCDDSN Central Office administrative costs from the SFY 2012 cost report submission among state plan and waiver services. The SCDHHS completed its review of the SFY 2012 SCDDSN central office administrative cost allocation methodology to ensure compliance with the cost allocation methodology previously agreed to between CMS and SCDHHS and submitted the results of our review to CMS for comment and official approval.

This process is the initial step of the compliance measures required by a CMS review that included the instruction to remove non-service related SCDDSN Central Office administrative costs from reimbursable service costs for periods January 1, 2011 and forward. Once the initial step of identifying and properly reclassifying the SFY 2012 SCDDSN Central Office administrative costs has been completed, the following processes must be completed to ensure compliance with the CMS review:

1) Waiver service costs previously submitted on the SFY 2011 cost report must be revised to reflect the reduction of SCDDSN Central Office administrative costs for the period January 1, 2011 through June 30, 2011.

2) Waiver cost reports for the SFYs 2013 forward can be filed by SCDDSN using the same cost finding and classification methodology as related to the SCDDSN Central Office administrative costs as was used in the determination of allowable waiver costs for SFY 2012.

3) Prospective waiver rates for the periods October 1, 2012 and currently in effect (based on SFY 2010 cost reports) must be adjusted for a factor which approximates the value of SCDDSN Central Office administrative costs which were included in the original prospective rate determination.

4) Effect all rate revisions in MMIS and outstanding cost settlements (and rate revision settlements) to SCDDSN for the affected cost reporting years and rate periods.

5) An analysis of the current prospective rates, as revised for the deletion of the Central Office Administrative costs, to access the need for a rebasing of rates to align rates to projected current costs.

The processes and procedures noted above are extensive and encompass effectively all of the Medicaid services rendered by SCDDSN. As part of this effort, the SCDHHS ensured that indirect costs associated with room and board have been properly determined and removed from allowable Medicaid reimbursable waiver costs. These efforts have required the participation of SCDHHS, SCDDSN and CMS staff.

The SCDDSN SFY 2012 cost report review was completed and submitted to CMS for approval and concurrence that the SCDDSN Central Office administrative cost was allocated in accordance with the previously-approved CMS cost allocation methodology. Only one change was requested by CMS related to the allocation statistics used to allocate information technology costs (CMS requires the use of accumulated costs for this cost center in lieu of time usage between administrative and service functions). SCDHHS has made the appropriate adjustments and has ensured the proper treatment of SCDDSN CO costs when it determines allowable Medicaid reimbursable costs for its SFY 2012 CPE analysis.

The SCDHHS is employing the services of Myers and Stauffer to complete the outstanding SCDDSN cost reports. Myers and Stauffer and SCDDSN are completing the SFY 2016 cost reports for submission in the early spring of 2019. The SCDHHS will use the SFY 2016 cost reports to rebase rates for both state plan and waiver services after ensuring that only allowable Medicaid reimbursable costs are included. Standard desk review procedures as previously described will be applied to the SFY 2016 cost reports to assure adherence with SC Medicaid reimbursement policies relating to accuracy, reasonableness, and compliance with Medicare cost definitions. After review and subsequent determination of average SFY 2016 per unit (per service) costs, a trend factor will be applied to approximate allowable Medicaid costs at the point of implementation. The trended rates will be further tested and evaluated against “constructed market rates” developed by an outside consultant to ensure compliance with economic and efficient requirements.

Please note that as we move forward beyond these compliance efforts and complete future annual cost report reviews, necessitated due to Certified Public expenditure funding, prospective rates will be reviewed annually to ensure efficient and economic rates sufficient to provide quality care.

The rate narrative above applies to the following services directly administered by the SCDDSN: Respite/Institutional/ICF/MR

Respite/In-Home/Hourly Day Activity

Career Preparation Community Services

Employment Services Individual Employment Services Group Support Center Services

In-Home Support

Private Vehicle Modifications Private Vehicle Assessment/Consult

Supplies/Assistive Technology/Appliances

Assistive Technology and Appliances Assessment/Consult Environmental Modifications

Behavior Support

Waiver case management rates (travel/without travel) were constructed based on the governmental provider’s salary and fringe data, estimates of associated direct operational costs and application of an indirect rate for support costs.

Productivity standards, again supplied by the governmental provider, applied against annual hours per FTE were used to develop the hourly (and billable 15 minute) rate.

Personal Care (I and II), Adult Day Health Care, Adult Day Health Nursing, and Adult Day Health Transportation services provided by a CLTC provider (i.e. private agency) are paid the rate as established for the Community Choices waiver.

Incontinence supplies for the seven waivers administered by SCDHHS are reimbursed from a fee schedule developed based on market analysis and last updated on July 11, 2011.

PERS Installation (and Monthly fee) rates are based on market private pay rates. The original rates have been reduced as technological improvements reduced costs. Installation has always been tied to the cost of one month of service.

Rates for Adult Dental, Adult Vision, Audiology, and Nursing are taken directly from the State Plan service rates for the 21 and under population.

Prospective payment system rates for the ID/RD waiver are included as appendices in the contracts signed by SCDDSN and other CLTC providers rendering services. SCDDSN includes the schedule of services in their provider service portal.

Participants are notified of rate changes by their case managers as appropriate. Participants registering to be included on

the SCDHHS provider distribution list receive alerts and bulletins via email.

South Carolina Waiver# SC.0284.R05.01 

Head and Spinal Cord Injury (HASCI) Waiver

Waiver Name:
Head and Spinal Cord Injury (HASCI) Waiver
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for South Carolina Waiver# SC.0284.R05.01

Cost Neutrality

Cost Neutrality for South Carolina Waiver# SC.0284.R05.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1070 1312

Year 1 Waiver Services

List of Year 1 Waiver Services for South Carolina Waiver# SC.0284.R05.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Preparation Services 1/2 day 11 396 $19.64
Day Activity 1/2 day 11 396 $19.64
Employment Services hour 21 44 $20.43

Year 5 Waiver Services

List of Year 5 Waiver Services for South Carolina Waiver# SC.0284.R05.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Preparation Services 1/2 day 53 402 $31.83
Day Activity 1/2 day 53 402 $31.83
Employment Services hour 26 45 $31.83

Rate Determination Methods

Rate Determination Methods for South Carolina Waiver# SC.0284.R05.01

The SCDHHS, Department of Reimbursement Methodology and Policy, in collaboration with the SCDHHS Division of Community Options, and the SCDDSN, is responsible for the development of waiver service payment rates. The SCDHHS allows the public to offer comments on waiver rates changes and rate setting methodology either through Medical Care Advisory Committee meetings, public hearings, or through meetings with association representatives.

The SCDHHS receives contractually required annual cost report submissions from SCDDSN for the HASCI waiver services provided by the Disabilities and Special Needs Boards (38) across the state. As of October 1, 2012, the date of implementation of our prospective payment system, these reports are used to substantiate Certified Public Expenditures only.

The costs of the Boards are initially accumulated and compiled into four regional consolidated reports. The costs are separated by medical service/waiver. The SCDDSN also contracts with SCDHHS for the services of ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)), TCM (Targeted Case Management), Early Intervention, Rehabilitative Behavioral Health services, as well as three other HCBS waivers. As a comprehensive health care provider, the SCDDSN uses the CMS form 2552 to distribute or step down the cost of general service and supporting cost centers to the benefitting services and waivers. Upon completion of the 2552 format, the SCDDSN then prepares a HASCI waiver specific cost report which further delineates cost among the specific services provided within the waiver. Utilization statistics (units of service) for the specific waiver services are accumulated by SCDDSN for the total population of users of the services and reported in the cost report.

Upon receipt of the annual reports, staff of the Department of Reimbursement Methodology and Policy review the reports for accuracy, reasonableness, and compliance with Medicare cost definitions. Samples of cost and service data from individual Boards (chosen from each region) are reviewed for compliance and then traced into the applicable supporting worksheets within the waiver cost report. Upon the completion and determination of allowable costs, the average cost per unit for each waiver service is calculated by dividing the total allowable cost per service by the total units of service for that service (i.e. for the total population of service recipients). The SCDHHS uses Medicare cost principles as reflected in the CMS Provider Reimbursement Manual (HIM-15) as our guidance for establishing allowable cost definitions for non-institutional cost reports required by SCDHHS.

For the waiver services provided by DDSN’s Boards under contract, the 2010 cost report was used to establish prospective rates as of October 1, 2012. The average SFY 2010 cost per unit for each contracted service becomes the basis for rates effective with October 1, 2012 dates of service. To approximate allowable Medicaid costs, the 2010 rates were trended by a rate of 3.76%. The trend factor was determined by using the Medicare Economic Index (MEI) for Calendar Year 2010 (1.2%) and multiplying the index by the number of years between the midpoint of the cost reporting year (January 2010) and the midpoint of the rate year (February 14, 2013). Note: Cost reporting year = 07/01/09- 06/30/10 and Rate year = 10/01/12-06/30/13.

To provide some background on the current status of cost reports for this waiver (and the three other waiver administered by the contractor SCDDSN), SCDHHS is currently working with SCDDSN, with technical assistance and oversight from CMS, in finalizing the proper treatment of SCDDSN Central Office administrative costs from the SFY 2012 cost report submission among state plan and waiver services. The SCDHHS has completed its review of the SFY 2012 SCDDSN central office administrative cost allocation methodology to ensure compliance with the cost allocation methodology previously agreed to between CMS and SCDHHS and has submitted the results of our review to CMS for comment and official approval.

This process is the initial step of the compliance measures required by a CMS review that included the instruction to remove non-service related SCDDSN Central Office administrative costs from reimbursable service costs for periods January 1, 2011 and forward. Once the initial step of identifying and properly reclassifying the SFY 2012 SCDDSN Central Office administrative costs has been completed, the following processes must be completed to ensure compliance with the CMS review:

1) Waiver service costs previously submitted on the SFY 2011 cost report must be revised to reflect the reduction of SCDDSN Central Office administrative costs for the period January 1, 2011 through June 30, 2011.

2) Waiver cost reports for the SFYs 2013 forward can be filed by SCDDSN using the same cost finding and classification methodology as related to the SCDDSN Central Office administrative costs as was used in the determination of allowable waiver costs for SFY 2012.

3) Prospective waiver rates for the periods October 1, 2012 and currently in effect (based on SFY 2010 cost reports) must be adjusted for a factor which approximates the value of SCDDSN Central Office administrative costs which were included in the original prospective rate determination.

4) Effect all rate revisions in MMIS and outstanding cost settlements (and rate revision settlements) to SCDDSN for the affected cost reporting years and rate periods.

5) An analysis of the current prospective rates, as revised for the deletion of the Central Office Administrative costs, to access the need for a rebasing of rates to align rates to projected current costs. The processes and procedures noted above are extensive and encompass effectively all of the Medicaid services rendered by SCDDSN. As part of this effort, the SCDHHS ensured that indirect costs associated with room and board have been properly determined and removed from allowable Medicaid reimbursable waiver costs. These efforts have required the participation of SCDHHS, SCDDSN and CMS staff.

The SCDDSN SFY 2012 cost report review was completed and submitted to CMS for approval and concurrence that the SCDDSN Central Office administrative cost was allocated in accordance with the previously-approved CMS cost allocation methodology. Only one change was requested by CMS related to the allocation statistics used to allocate information technology costs (CMS requires the use of accumulated costs for this cost center in lieu of time usage between administrative and service functions). SCDHHS has made the appropriate adjustments and has ensured the proper treatment of SCDDSN CO costs when it determines allowable Medicaid reimbursable costs for its SFY 2012 CPE analysis.

The SCDHHS is employing the services of Myers and Stauffer to complete the outstanding SCDDSN cost reports. Myers and Stauffer will be on site at SCDDSN late summer or early fall to help SCDDSN complete and submit the SFY 2016 cost reports. The SCDHHS will use the SFY 2016 cost reports to rebase rates for both state plan and waiver services after ensuring that only allowable Medicaid reimbursable costs are included. Standard desk review procedures as previously described will be applied to the SFY 2016 cost reports to assure adherence with SC Medicaid reimbursement policies relating to accuracy, reasonableness, and compliance with Medicare cost definitions. After review and subsequent determination of average SFY 2016 per unit (per service) costs, a trend factor will be applied to approximate allowable Medicaid costs at the point of implementation. The trended rates will be further tested and evaluated against “constructed market rates” developed by an outside consultant to ensure compliance with economic and efficient requirements.

Please note that as we move forward beyond these compliance efforts and complete future annual cost report reviews, necessitated due to Certified Public expenditure funding, prospective rates will be reviewed annually to ensure efficient and economic rates sufficient to provide quality care.

The rate narrative applies to the following services directly administered by the SCDDSN: Attendant Care* (DSN Boards and UAP)

Career Preparation Employment Services Day Activity

Respite Care (Institutional and Non-Institutional) Health Education

Peer Guidance Psychological Counseling Residential Habilitation

Specialized Medical Equipment and Supplies (manual pricing) Environmental Modifications (manual pricing)

Private Vehicle Modification (manual pricing)

Private Vehicle Assessment/Consultation (manual pricing)

Waiver Case Management rates (with travel and without travel) were constructed based on the governmental provider’s salary and fringe data, estimates of associated direct operational costs, and the application of an indirect rate for support costs. Productivity standards, again supplied by the governmental provider, applied against annual hours per FTE were used to develop the hourly (and billable 15 minute) rate.

* Attendant Care services provided by a CLTC provider (i.e. private agency) are paid the attendant care rate as established for the Community Choices waiver.

RN and LPN services (and enhanced RN and LPN services) are paid at the rates established in the State Plan for similar services.

Incontinence supplies for all waivers administered by SCDHHS are reimbursed from a fee schedule developed based on market analysis and last updated on July 11, 2011.

PERS Installation (and Monthly fee) rates are based on market private pay rates. The original rates have been reduced as technological improvements reduced costs. Installation has always been tied to the cost of one month of service.

The rates for pest control services are based on rates established for South Carolina’s Community Choices waiver. Standard treatment rates for that service were based on a market analysis ($45) and updated on October 1, 2007. Current pest control rates for standard treatment is $42.75 and represents rate reductions effected on April 8, 2011 and July 11, 2011 of 2% and 3% respectively. There is no reimbursement differential for the initial treatment service. The rate cap for pest control/bed bug services is also based on the Community Choices waiver service rate cap for the similar service. Pest control/bed bug services are secured through a bid process with award given to the lowest bid, subject to

$1,000 cap per treatment.

Therapy services (occupational, physical, audiology, and speech) are reimbursed to the private providers of these services based on the State Plan methodologies outlined for these services.

Participants are notified of rate changes by their case managers as appropriate. Participants registering to be included on the SCDHHS provider distribution list receive alerts and bulletins via email.

South Carolina Waiver# SC.0237.R05.02 

SC ID and Related Disabilities

Waiver Name:
SC ID and Related Disabilities
Effective Date:
1/1/2017
Expiration Date:
12/31/2021

Services

List of Services for South Carolina Waiver# SC.0237.R05.02

Cost Neutrality

Cost Neutrality for South Carolina Waiver# SC.0237.R05.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
9630 13630

Year 1 Waiver Services

List of Year 1 Waiver Services for South Carolina Waiver# SC.0237.R05.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Preparation Services 2-3 hours 2600 331 $27.27
Community Services 2-3 hours 578 182 $27.27
Day Activity 2-3 hours 3120 342 $27.27
Employment Services - Group 2-3 hours 1156 308 $27.27
Employment Services - Individual hour 453 57 $65.93

Year 5 Waiver Services

List of Year 5 Waiver Services for South Carolina Waiver# SC.0237.R05.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Preparation Services 2-3 hours 3680 331 $31.82
Community Services 2-3 hours 818 182 $31.82
Day Activity 2-3 hours 4416 342 $31.82
Employment Services - Group 2-3 hours 1636 308 $31.82
Employment Services - Individual hour 641 57 $74.21

Rate Determination Methods

Rate Determination Methods for South Carolina Waiver# SC.0237.R05.02

The SCDHHS, Department of Reimbursement Methodology and Policy, in collaboration with the SCDHHS Division of Community Options, and the SCDDSN, is responsible for the development of waiver service payment rates. The SCDHHS allows the public to offer comments on waiver rates changes and rate setting methodology either through Medical Care Advisory Committee meetings, public hearings, or through meetings with association representatives. The SCDHHS receives contractually required annual cost report submissions from SCDDSN for the ID/RD waiver services provided by the Disabilities and Special Needs Boards (38) across the state. As of October 1, 2012, the date of implementation of our prospective payment system, these reports are used to substantiate Certified Public Expenditures only.

The costs of the Boards are initially accumulated and compiled into four regional consolidated reports. The costs are separated by medical service/waiver. The SCDDSN also contracts with SCDHHS for the services of ICF/IID (Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)), TCM (Targeted Case Management), Early Intervention, Rehabilitative Behavioral Health services, as well as two other HCBS waivers. As a comprehensive health care provider, the SCDDSN uses the CMS form 2552 to distribute or step down the cost of general service and supporting cost centers to the benefitting services and waivers. Upon completion of the 2552 format, the SCDDSN then prepares an ID/RD waiver specific cost report which further delineates cost among the specific services provided within the waiver. Utilization statistics (units of service) for the specific waiver services are accumulated by SCDDSN for the total population of users of the services and reported in the cost report.

Upon receipt of the annual reports, staff of the Department of Reimbursement Methodology and Policy review the reports for accuracy, reasonableness, and compliance with Medicare cost definitions. Samples of cost and service data from individual Boards (chosen from each regional report) are reviewed for compliance and then traced into the applicable supporting worksheets within the waiver cost report. Upon the completion and determination of allowable costs, the average cost per unit for each waiver service is calculated by dividing the total allowable cost per service by the total units of service for that service (i.e. for the total population of service recipients). The SCDHHS uses Medicare cost principles as reflected in the CMS Provider Reimbursement Manual (HIM-15) as our guidance for establishing allowable cost definitions for non-institutional cost reports required by SCDHHS.

For the waiver services provided by DDSN’s Boards under contract, the 2010 cost report was used to establish prospective rates as of October 1, 2012. The average SFY 2010 cost per unit for each contracted service becomes the basis for rates effective with October 1, 2012 dates of service. To approximate allowable Medicaid costs, the 2010 rates were trended by a rate of 3.76%. The trend factor was determined by using the Medicare Economic Index (MEI) for Calendar Year 2010 (1.2%) and multiplying the index by the number of years between the midpoint of the cost reporting year (January 2010) and the midpoint of the rate year (February 14, 2013). Note: Cost reporting year = 07/01/09- 06/30/10 and Rate year = 10/01/12-06/30/13.

To provide some background on the current status of cost reports for this waiver (and the two other waiver administered by the contractor SCDDSN), SCDHHS has been working with SCDDSN, with technical assistance and oversight from CMS, in finalizing the proper treatment of SCDDSN Central Office administrative costs from the SFY 2012 cost report submission among state plan and waiver services. The SCDHHS completed its review of the SFY 2012 SCDDSN central office administrative cost allocation methodology to ensure compliance with the cost allocation methodology previously agreed to between CMS and SCDHHS and submitted the results of our review to CMS for comment and official approval.

This process is the initial step of the compliance measures required by a CMS review that included the instruction to remove non-service related SCDDSN Central Office administrative costs from reimbursable service costs for periods January 1, 2011 and forward. Once the initial step of identifying and properly reclassifying the SFY 2012 SCDDSN Central Office administrative costs has been completed, the following processes must be completed to ensure compliance with the CMS review:

1) Waiver service costs previously submitted on the SFY 2011 cost report must be revised to reflect the reduction of SCDDSN Central Office administrative costs for the period January 1, 2011 through June 30, 2011.

2) Waiver cost reports for the SFYs 2013 forward can be filed by SCDDSN using the same cost finding and classification methodology as related to the SCDDSN Central Office administrative costs as was used in the determination of allowable waiver costs for SFY 2012.

3) Prospective waiver rates for the periods October 1, 2012 and currently in effect (based on SFY 2010 cost reports) must be adjusted for a factor which approximates the value of SCDDSN Central Office administrative costs which were included in the original prospective rate determination.

4) Effect all rate revisions in MMIS and outstanding cost settlements (and rate revision settlements) to SCDDSN for the affected cost reporting years and rate periods.

5) An analysis of the current prospective rates, as revised for the deletion of the Central Office Administrative costs, to access the need for a rebasing of rates to align rates to projected current costs.

The processes and procedures noted above are extensive and encompass effectively all of the Medicaid services rendered by SCDDSN. As part of this effort, the SCDHHS ensured that indirect costs associated with room and board have been properly determined and removed from allowable Medicaid reimbursable waiver costs. These efforts have required the participation of SCDHHS, SCDDSN and CMS staff.

The SCDDSN SFY 2012 cost report review was completed and submitted to CMS for approval and concurrence that the SCDDSN Central Office administrative cost was allocated in accordance with the previously-approved CMS cost allocation methodology. Only one change was requested by CMS related to the allocation statistics used to allocate information technology costs (CMS requires the use of accumulated costs for this cost center in lieu of time usage between administrative and service functions). SCDHHS has made the appropriate adjustments and has ensured the proper treatment of SCDDSN CO costs when it determines allowable Medicaid reimbursable costs for its SFY 2012 CPE analysis.

The SCDHHS is employing the services of Myers and Stauffer to complete the outstanding SCDDSN cost reports. Myers and Stauffer and SCDDSN are completing the SFY 2016 cost reports for submission in the early spring of 2019. The SCDHHS will use the SFY 2016 cost reports to rebase rates for both state plan and waiver services after ensuring that only allowable Medicaid reimbursable costs are included. Standard desk review procedures as previously described will be applied to the SFY 2016 cost reports to assure adherence with SC Medicaid reimbursement policies relating to accuracy, reasonableness, and compliance with Medicare cost definitions. After review and subsequent determination of average SFY 2016 per unit (per service) costs, a trend factor will be applied to approximate allowable Medicaid costs at the point of implementation. The trended rates will be further tested and evaluated against “constructed market rates” developed by an outside consultant to ensure compliance with economic and efficient requirements.

Please note that as we move forward beyond these compliance efforts and complete future annual cost report reviews, necessitated due to Certified Public expenditure funding, prospective rates will be reviewed annually to ensure efficient and economic rates sufficient to provide quality care.

The rate narrative above applies to the following ID/RD services directly administered by the SCDDSN: Respite/Institutional/ICF/MR

Respite/In-Home-Hourly Day Activity

Career Preparation Community Services

Employment Services Individual Employment Services Group Support Center Services

Private Vehicle Modifications Adult Companion Services

Residential Habilitation Services/Daily Residential Habilitation Services/Hourly Adult Attendant Care Services

Special Medical Equipment /Supplies/Assistive Technology Environmental Modifications

Psychological Services Behavior Support

Waiver case management rates (travel/without travel) were constructed based on the governmental provider’s salary and fringe data, estimates of associated direct operational costs and application of an indirect rate for support costs. Productivity standards, again supplied by the governmental provider, applied against annual hours per FTE were used to develop the hourly (and billable 15 minute) rate.

Personal Care (I and II), Adult Day Health Care, Adult Day Health Nursing, and Adult Day Health Transportation services provided by a CLTC provider (i.e. private agency) are paid the rate as established for the Community Choices waiver.

Incontinence supplies for the seven waivers administered by SCDHHS are reimbursed from a fee schedule developed based on market analysis and last updated on July 11, 2011.

PERS Installation (and Monthly fee) rates are based on market private pay rates. The original rates have been reduced as technological improvements reduced costs. Installation has always been tied to the cost of one month of service.

The rates for pest control services are based on rates established for South Carolina’s Community Choices waiver. Standard treatment rates for that service were based on a market analysis ($45) and updated on October 1, 2007. Current pest control rates for standard treatment is $42.75 and represents rate reductions effected on April 8, 2011 and July 11, 2011 of 2% and 3% respectively. There is no reimbursement differential for the initial treatment service. The rate cap for pest control/bed bug services is also based on the Community Choices waiver service rate cap for the similar service. Pest control/bed bug services are secured through a bid process with award given to the lowest bid, subject to

$1,000 cap per treatment.

The rates for Adult Dental, Adult Vision, Audiology, and Nursing are taken directly from the State Plan service rates for the 21 and under population.

Prospective payment system rates for the ID/RD waiver are included as appendices in the contracts signed by SCDDSN and other CLTC providers rendering services. SCDDSN includes the schedule of services in their provider service portal.

Participants are notified of rate changes by their case managers as appropriate. Participants registering to be included on the SCDHHS provider distribution list receive alerts and bulletins via email.

Waiver Name:
SD Choices
Effective Date:
6/1/2018
Expiration Date:
5/31/2023

Services

List of Services for South Dakota Waiver# SD.0044.R08.01

Cost Neutrality

Cost Neutrality for South Dakota Waiver# SD.0044.R08.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2709 2777

Year 1 Waiver Services

List of Year 1 Waiver Services for South Dakota Waiver# SD.0044.R08.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Exploration hour 873 1022.32 $10.62
Day Services hour 1994 1440.4 $7.90
Individual Supported Employment hour 234 236.95 $54.99
Group Supported Employment hour 234 189.75 $53.96

Year 5 Waiver Services

List of Year 5 Waiver Services for South Dakota Waiver# SD.0044.R08.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Career Exploration hour 895 1022.32 $11.65
Day Services hour 2044 1440.4 $8.66
Individual Supported Employment hour 241 236.95 $54.99
Group Supported Employment hour 241 189.75 $53.96

Rate Determination Methods

Rate Determination Methods for South Dakota Waiver# SD.0044.R08.01

The Individual Resource Allocation (IRA) model currently in use supports people and qualified providers to utilize person-centered planning to determine an appropriate array of services and supports. Qualified Providers utilize an internet based information system (Service Record) to identify the services provided to each person. The Service Records are audited onsite, as described in the Quality Improvement section of this appendix, by DHS fiscal staff to ensure that people are receiving the services reported on the Service Record. Waiver services and individualized information can then be entered into the model to generate an individualized rate for each person based on the services and supports the person needs.

If a person experiences a temporary additional but significant need, the qualified provider may request Extraordinary Needs Funding (ENF). These requests require supporting documentation and are reviewed by DHS/DDD staff for approval/denial and are paid using state general fund dollars.

If a person’s needs or preferences change, providers can make a significant change request (SCR) that could adjust the daily service rate to accommodate the change. The SCR requires supporting evidence that the change is person-centered and are reviewed by DHS/DDD staff. If a short-term extraordinary need arises in order to mitigate the likelihood of a crisis including institutionalization, the provider may complete a DHS/DDD issued form to request a one-time 100% general fund payment to cover remaining costs after all other alternatives have been exhausted. The DHS/DDD has an ENF review team that reviews the requests and makes a recommendation for approval/disapproval to the DDD Director. A SCR request allow for a person and their team to request a long-term change to their waiver service(s). If the request is linked to an allowable waiver service not covered by the State Plan, the SCR process is generally used instead of the ENF process.

The person’s case manager will submit a completed SCR form to the state for review and approval after the person’s team agrees on the change. If approved the change is ran through the IRA model to calculate a new IRA. The SCR describes the service(s) being changed, the effective date, the reason for the change, and is signed by involved parties. Generally, SCRs are required for changes expected to last 60 days or longer. An example of a common SCR is when a person’s ICAP scores change due to a change in health, adaptive skills or maladaptive behaviors.

Every participant’s IRA is calculated using the IRA/multiple regression algorithm. The ISP team determines the necessary waiver supports and services needed the achieve a good life for the participant. Those parameters decided by the ISP team are entered into the IRA/multiple regression algorithm which is designed to generate a resource allocation for provider reimbursement. The IRA is calculated as SCRs are submitted to the state or at least annually.

Background of Developing the IRA Model

The rate model draws information from many sources to generate an individualized rate for each person based on the services and supports needed by the individual. Qualified Providers committed significant time to participate in workgroups that developed the model.

1. Cost reports from each qualified provider agency are used to compile the system-wide average cost per service. Each qualified provider is required to submit an annual independent audit. Within the audit is a Statement of Expenses & Revenues which serves as the agency cost report. The DHS/DDD prescribes the format for the Statement of Expenses & Revenues. The cost report format prescribes the listing of accounts with actual and allocated costs for each service center. This information is validated and compiled by DHS fiscal staff. If federal funds of $750,000 or more have been received by the provider the audit shall be conducted in accordance with OMB Uniform Guidance 2 CFR Chapter I, Chapter II, Part 200, et al Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards by an auditor approved by the Auditor General to perform the audit. Audits shall be completed and filed with the Department of Legislative Audit by the end of the fourth month following the end of the fiscal year being audited or 30 days after receipt of the Auditor’s report, whichever is earlier.

2. Activity logging is used to identify the number of units of services provided to each person. That amount is multiplied by the average cost of each service to determine a cost of service for each person. Activity Logging (time study) Data is gathered in anticipation of creating a new Individual Resource Allocation (IRA) model. Qualified Providers utilize an internet based application to submit activity logging information that reports the number of units of each service provided to each waiver participant. This information is gathered for a statistically representative time period. The internet application has on-line edits that prevents errors. Summary edits also identify potential issues that prompt providers to review information prior to submission. DHS/DDD staff conduct on-site visits to provide technical assistance to qualified providers during activity logging and review the information that is gathered and reported. Activity logging is gathered in anticipation of a remodel as recommended by the DD Advisory Group.

3. Case Managers must submit an ICAP (The Inventory for Client and Agency Planning is a standardized tool that assesses an individual's adaptive skills and maladaptive behaviors) for each person receiving HCB services. Certain elements of the ICAP are weighted in the IRA model calculation based upon recommendations made by the DD Advisory Group. As a result, parameter estimates within the IRA model were established in order to weight those elements of the ICAP and applied to more accurately predict an adequate resource allocation.

4. Multiple regression is used to formulate a model which predicts the cost of each waiver service an individual will need based on the services they receive and their needs as assessed by the ICAP. Cost per person serves as the dependent variable and variation in rates are determined based on level of need. Information from Service Records, ICAPs and economic measures serve as potential independent variables.

Providers submit annual cost reports used to compile the system-wide average cost per service. Allowable costs are described within the Cost Report Guidelines updated annually. A time study (activity logging) is used to identify the number of units of service provided to each person within each service category. That amount is then multiplied by the average cost of each service to determine a cost of service for each person. The ICAP is also used within the IRA calculation to consider a person’s specific needs and abilities (adaptive skills and maladaptive behaviors). Stakeholders advised the state to weight certain ICAP components within the IRA calculation.

The cost report template and guidelines are kept current on our website for provider and public access. The link is http://dhs.sd.gov/budgetandfinance.aspx and information can be found under the Community Support Provider section.

The generation of an IRA is based on statistical analyses of activity logging information, cost reports, and ICAP data representing all the people in the service delivery system. These datasets, or predictor measures, are ran through a multiple regression process which calculates a parameter estimate for each predictor measure. Predictor measures are established by the state in close partnership with its stakeholders and are considered key drivers of costs/time/effort within the service delivery system. Parameter estimates represent the predicted costs associated with a specific predictor measure. Each parameter estimate is added to determine the IRA amount. This process allows for the allocation of resources based upon the individual’s intensity of needs, mix of services and the settings in which they are provided, and ICAP scores. To illustrate, the ICAP service score is a predictor measure that has a parameter estimate of a negative value and as such the IRA goes down as ICAP service scores go up because generally a higher service score correlates with lesser needs. Conversely, the parameter estimate for the mobility assistance predictor measure is a positive value because generally the greater need for mobility assistance correlates with higher needs. In this example the parameter estimate values for both ICAP service and mobility assistance are added to calculate the IRA. The state uses a software platform to house and maintain the IRA/multiple regression algorithm.

The conflict-free case management rate was derived in October 2015 from the Community Support Provider cost report data from salaries, benefits, taxes, and overhead for existing case managers. South Dakota Department of Labor wage statistics were used to validate the cost report data. Rate adjustments will be calculated using the inflationary rate approved for qualified providers by the South Dakota State Legislature. The state will rebase the case management rate on a 5-year cycle.

Tennessee Waiver# TN.0357.R04.00 

TN Comprehensive Aggregate Cap Home and Community Based Services (CAC)

Waiver Name:
TN Comprehensive Aggregate Cap Home and Community Based Services (CAC)
Effective Date:
1/1/2020
Expiration Date:
12/31/2024

Services

List of Services for Tennessee Waiver# TN.0357.R04.00

Cost Neutrality

Cost Neutrality for Tennessee Waiver# TN.0357.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1592 1422

Year 1 Waiver Services

List of Year 1 Waiver Services for Tennessee Waiver# TN.0357.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Supports 15 minutes 1246 3047.69 $4.36
Facility Based Day Supports 15 minutes 47 542 $2.73
Intermittent Employment and Community Integration Wrap-Around Supports 15 minutes 1167 2183 $3.92
Supported Employment - Individual Quality Incentive Payment event 35 2 $1816.00
Exploration event 164 1 $1091.00
Discovery event 197 1 $1500.00
Job Development event 132 1 $1600.00
Job Coaching 15 minutes 172 3004 $6.87
Stabilization and Monitoring month 3 12 $130.00
Supported Employment - Small Group Employment Support 15 minutes 2 900 $3.04

Year 5 Waiver Services

List of Year 5 Waiver Services for Tennessee Waiver# TN.0357.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Supports 15 minutes 1112 2830.64 $4.36
Facility Based Day Supports 15 minutes 42 542 $2.73
Intermittent Employment and Community Integration Wrap-Around Supports 15 minutes 1042 2183 $3.92
Supported Employment - Individual Quality Incentive Payment event 60 2 $1816.00
Exploration event 30 1 $1091.00
Discovery event 35 1 $1500.00
Job Development event 23 1 $1600.00
Job Coaching 15 minutes 286 3095 $6.25
Stabilization and Monitoring month 18 11 $130.00
Supported Employment - Small Group Employment Support 15 minutes 2 900 $3.04

Rate Determination Methods

Rate Determination Methods for Tennessee Waiver# TN.0357.R04.00

Proposed service rates are determined by the Department of Intellectual and Developmental Disabilities (DIDD) and are reviewed and approved by TennCare, the State Medicaid Agency, which has oversight of the rate determination process. TennCare keys approved rates into the MMIS for purposes of processing claims for waiver services. The methodology used to determine rates is outlined in Chapter 0465-01-02 of DIDD’s Administrative Rules and can be found at this link: http://publications.tnsosfiles.com/rules/0465/0465-01/0465-01-02.20140312.pdf

Maximum allowable rates are established for each service based on an analysis of provider costs to deliver services and based on experience, as set forth in DIDD Administrative Rule. The rates for this waiver were restructured in 2005 with the average expenses incurred by providers in 2004 used as the cost model. DIDD continues to make adjustments to the 2005 rates, particularly the direct support professional hourly wage component within the rates, based on feedback from providers and current employment trends. The state has appropriated an additional $31.6 million in state funds since state fiscal year 2014 for provider rate increases across all waiver programs.

DIDD has no formal process in place to review provider costs; however, DIDD regularly meets with providers at Statewide Planning and Policy Council meetings as well as other providers meetings and rates are discussed.

Additionally, DIDD has one staff person that routinely reviews cost data for providers who are struggling financially and have requested technical financial assistance.

Rates must be sufficient to recruit an adequate supply of qualified providers for each service to ensure participants statewide have adequate access to waiver services. In setting rates, the rates for similar services in other states and other in-state programs are considered, and rates are adjusted based on the number of waiver participants receiving services in a group arrangement, where applicable. Rates paid in this waiver are the same as those paid in the two other 1915(c) home and community-based waivers for people with intellectual disabilities. Providers are reimbursed up to the maximum allowable rate established for a service.

Stakeholders have the opportunity to provide input into the development and sufficiency of rates through the posting of waiver renewals and amendments for public comment, the DIDD Statewide Planning and Policy Councils, provider meetings, and other public meetings, as well as through the DIDD rule-making hearing process, which includes public notice and a rule-making hearing. Information about payment rates is made public and is available on the DIDD web site, i.e., TennCare Maximum Reimbursement Rate Schedule.

For Supported Employment–Individual Services, fee for service job coaching rates are based on a prospective rate model that reflects a sufficient wage for the level of qualified staff required to deliver the service and all other reasonable and anticipated costs involved in providing the service. For job coaching, this prospective rate is then tiered into three distinct rates based on the level of fading achieved, taking into account the waiver participant’s level of disability and length of time the job has been held. Providers can earn the highest rate for achieving the highest fading targets, the

mid-level rate for achieving the mid-level fading targets, and the base level rate for achieving the base level fading targets. Using this model, providers are appropriately incentivized to fade job coaching supports over time (a key quality metric for supported employment services) while the state can also ensure no waiver participant is excluded from participation in supported employment-individual services based on level of disability or newness to their job. To determine a waiver participant’s acuity tier for job coaching, the Level of Need system that has been in use to determine employment and day service reimbursement will continue to be used. Additionally, where an individual has a need for job coaching that is equal to or less than one hour per week, a monthly “Stabilization and Monitoring” payment will be used to encourage ongoing, effective monitoring of the waiver participant’s employment situations, with minimum monthly contact requirements that will allow for prevention of otherwise avoidable job losses or reductions in work hours.

For Supported Employment-Individual Services the state proposes to pay on an outcome basis, the following rate determination methods were used:

Exploration: Underlying fee-for-service prospective rate for qualified job coach was developed as described above. All components of Exploration service process were defined and the average time necessary for each step was determined, resulting in an average of 40 hours total for all required steps. The underlying fee-for-service prospective rate was multiplied by 40 hours to arrive at the outcome payment. The required Exploration report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time. Discovery: Underlying fee-for-service prospective rate for qualified job developer was developed reflecting a sufficient wage and all other reasonable and anticipated costs involved in providing the service. All components of Discovery service process were defined and the average time necessary for each step was determined, resulting in an average of 50 hours total for all required steps. The underlying fee-for-service prospective rate was multiplied by 50 hours to arrive at the outcome payment. The required Discovery report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time.

Job Development: Underlying fee-for-service prospective rate for qualified job developer was developed reflecting a sufficient wage and all other reasonable and anticipated costs involved in providing the service. Using information from other states and Vocational Rehabilitation, the average amount of hours necessary for completion of job development (securing outcome of paid competitive, integrated employment, consistent with a waiver participants goals, preferences, skills and conditions for success) was determined. This average was used to create three tiered hour levels to reflect waiver participants’ varying levels of disability (acuity). For each tier, the average hours expected to be necessary to complete the service were multiplied by the underlying fee-for-service prospective rate for the qualified job developer to arrive at the three tiered outcome payments. The required Job Development report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time. To determine a waiver participant’s acuity tier for Job Development, the Level of Need system that has been in use to determine employment and day service reimbursement will continue to be used.

Quality Payment for Hours Worked Milestone under Supported Employment-Individual Employment Supports: Payment earned and paid for additional/atypical effort of provider to assist waiver participant to obtain and retain competitive integrated employment where hours worked are substantially higher than the average for all waiver participants. There are two quality payment levels available:

1. The base tier payment is $1,500 and is made based on the waiver participant working in competitive integrated employment between three-hundred ninety (390) and five-hundred nineteen (519) hours in the prior six (6) calendar month period. This is average hourly employment that is at least 15 but less than 20 hours/week.

2. The top tier payment is $2,000 and is made based on the waiver participant working five-hundred and twenty (520) or more hours in the prior six (6) calendar month period. This is average hourly employment that is 20 hours/week or more.

A provider may earn the quality payment up to twice a year.

The reimbursement rates for the new Non-Residential Homebound Support Service match the reimbursement rates for the service this new service is replacing (In Home Day).

Tennessee Waiver# TN.0427.R03.02 

TN Self-Determination Waiver Program

Waiver Name:
TN Self-Determination Waiver Program
Effective Date:
1/1/2018
Expiration Date:
12/31/2022

Services

List of Services for Tennessee Waiver# TN.0427.R03.02

Cost Neutrality

Cost Neutrality for Tennessee Waiver# TN.0427.R03.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
1194 1030

Year 1 Waiver Services

List of Year 1 Waiver Services for Tennessee Waiver# TN.0427.R03.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Supports 15 minutes 575 406 $2.87
Employment and Day Services Community Based Day day 575 71 $68.97
Employment and Day Services In Home Day day 11 70 $79.45
Employment and Day Services Facility Based Day day 450 64 $44.55
Employment and Day Services Supported Employment day 200 87 $85.39
Facility Based Day Supports 15 minutes 180 126 $1.86
Intermittent Employment and Community Integration Wrap- Around 15 minutes 600 290 $2.87
Supported Employment Individual Exploration event 13 1 $1091.00
Supported Employment Individual Discovery event 15 1 $1500.00
Supported Employment Individual Job Development event 10 1 $1680.00
Supported Employment Individual Job Coaching 15 minutes 168 576 $6.13
Supported Employment - Individual Quality Incentive Payment event 1 1 $1500.00
Supported Employment Individual Stabilization and Monitoring month 3 3 $130.00
Supported Employment - Small Group Employment Support 15 minutes 32 507 $2.02

Year 5 Waiver Services

List of Year 5 Waiver Services for Tennessee Waiver# TN.0427.R03.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Supports 15 minutes 711 1330 $2.99
Employment and Day Services Community Based Day day 0 0.01 $1.00
Employment and Day Services In Home Day day 0 0.01 $1.00
Employment and Day Services Facility Based Day day 0 0.01 $1.00
Employment and Day Services Supported Employment day 0 0.01 $1.00
Facility Based Day Supports 15 minutes 20 480 $1.96
Intermittent Employment and Community Integration Wrap- Around 15 minutes 587 1000 $3.08
Supported Employment Individual Exploration event 45 1 $1091.00
Supported Employment Individual Discovery event 40 1 $1500.00
Supported Employment Individual Job Development event 37 1 $1607.55
Supported Employment Individual Job Coaching 15 minutes 260 2612 $5.80
Supported Employment - Individual Quality Incentive Payment event 49 2 $1816.00
Supported Employment Individual Stabilization and Monitoring month 24 12 $130.00
Supported Employment - Small Group Employment Support 15 minutes 21 2525 $2.10

Rate Determination Methods

Rate Determination Methods for Tennessee Waiver# TN.0427.R03.02

Proposed service rates are determined by the Department of Intellectual and Developmental Disabilities (DIDD) and are reviewed and approved by TennCare, the State Medicaid Agency, which has oversight of the rate determination process. TennCare keys approved rates into the MMIS for purposes of processing claims for waiver services. The methodology used to determine rates is outlined in Chapter 0465-01-02 of DIDD’s Administrative Rules and can be found at this link: http://publications.tnsosfiles.com/rules/0465/0465-01/0465-01-02.20140312.pdf

Maximum allowable rates are established for each service based on an analysis of provider costs to deliver services and based on experience, as set forth in DIDD Administrative Rule. The rates for this waiver were restructured in 2005 with the average expenses incurred by providers in 2004 used as the cost model. DIDD continues to make adjustments to the 2005 rates, particularly the direct support professional hourly wage component within the rates, based on feedback from providers and current employment trends. The state has appropriated an additional $ 31.6 million in state funds since state fiscal year 2014 for provider rate increases across all waiver programs.

DIDD has no formal process in place to review provider costs; however, DIDD regularly meets with providers at Statewide Planning and Policy Council meetings as well as other providers meetings and rates are discussed.

Additionally, DIDD has one staff person that routinely reviews cost data for providers who are struggling financially and have requested technical financial assistance.

Rates must be sufficient to recruit an adequate supply of qualified providers for each service to ensure participants statewide have adequate access to waiver services. In setting rates, the rates for similar services in other states and other in-state programs are considered, and rates are adjusted based on the number of waiver participants receiving services in a group arrangement, where applicable. Rates paid in this waiver are the same as those paid in the two other 1915c home and community-based waivers for people with intellectual disabilities. Providers are reimbursed up to the maximum allowable rate established for a service.

Stakeholders have the opportunity to provide input into the development and sufficiency of rates through the posting of waiver renewals and amendments for public comment, the DIDD Statewide Planning and Policy Councils, provider meetings, and other public meetings, as well as through the DIDD rule-making hearing process, which includes public notice and a rule-making hearing. Information about payment rates is made public and is available on the DIDD web site, i.e., TennCare Maximum Reimbursement Rate Schedule.

For Supported Employment–Individual Services, fee for service job coaching rates are based on a prospective rate model that reflects a sufficient wage for the level of qualified staff required to deliver the service and all other reasonable and anticipated costs involved in providing the service. For job coaching, this prospective rate is then tiered into three distinct rates based on the level of fading achieved, taking into account the waiver participant’s level of disability and length of time the job has been held. Providers can earn the highest rate for achieving the highest fading targets, the

mid-level rate for achieving the mid-level fading targets, and the base level rate for achieving the base level fading targets. Using this model, providers are appropriately incentivized to fade job coaching supports over time (a key quality metric for supported employment services) while the state can also ensure no waiver participant is excluded from participation in supported employment-individual services based on level of disability or newness to their job. To determine a waiver participant’s acuity tier for job coaching, the Level of Need system that has been in use to determine employment and day service reimbursement will continue to be used. Additionally, where an individual has a need for job coaching that is equal to or less than one hour per week, a monthly “Stabilization and Monitoring” payment will be used to encourage ongoing, effective monitoring of the waiver participant’s employment situations, with minimum monthly contact requirements that will allow for prevention of otherwise avoidable job losses or reductions in work hours.

For Supported Employment-Individual Services the state proposes to pay on an outcome basis, the following rate determination methods were used:

Exploration: Underlying fee-for-service prospective rate for qualified job coach was developed as described above. All components of Exploration service process were defined and the average time necessary for each step was determined, resulting in an average of 40 hours total for all required steps. The underlying fee-for-service prospective rate was multiplied by 40 hours to arrive at the outcome payment. The required Exploration report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time. Discovery: Underlying fee-for-service prospective rate for qualified job developer was developed reflecting a sufficient wage and all other reasonable and anticipated costs involved in providing the service. All components of Discovery service process were defined and the average time necessary for each step was determined, resulting in an average of 50 hours total for all required steps. The underlying fee-for-service prospective rate was multiplied by 50 hours to arrive at the outcome payment. The required Discovery report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time.

Job Development: Underlying fee-for-service prospective rate for qualified job developer was developed reflecting a sufficient wage and all other reasonable and anticipated costs involved in providing the service. Using information from other states and Vocational Rehabilitation, the average amount of hours necessary for completion of job development (securing outcome of paid competitive, integrated employment, consistent with a waiver participants goals, preferences, skills and conditions for success) was determined. This average was used to create three tiered hour levels to reflect waiver participants’ varying levels of disability (acuity). For each tier, the average hours expected to be necessary to complete the service were multiplied by the underlying fee-for-service prospective rate for the qualified job developer to arrive at the three tiered outcome payments. The required Job Development report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time. To determine a waiver participant’s acuity tier for Job Development, the Level of Need system that has been in use to determine employment and day service reimbursement will continue to be used.

Quality Payment for Hours Worked Milestone under Supported Employment-Individual Employment Supports: Payment earned and paid for additional/atypical effort of provider to assist waiver participant to obtain and retain competitive integrated employment where hours worked are substantially higher than the average for all waiver participants. There are two quality payment levels available:

1. The base tier payment is $1,500 and is made based on the waiver participant working in competitive integrated employment between three-hundred ninety (390) and five-hundred nineteen (519) hours in the prior six (6) calendar month period. This is average hourly employment that is at least 15 but less than 20 hours/week.

2. The top tier payment is $2,000 and is made based on the waiver participant working five-hundred and twenty (520) or more hours in the prior six (6) calendar month period. This is average hourly employment that is 20 hours/week or more.

A provider may earn the quality payment up to twice a year.

The reimbursement rates for the new Non-Residential Homebound Support Service match the reimbursement rates for the service this new service is replacing (In Home Day).

Tennessee Waiver# TN.0128.R06.00 

TN Statewide Home and Community Based Services Waiver

Waiver Name:
TN Statewide Home and Community Based Services Waiver
Effective Date:
1/1/2020
Expiration Date:
12/31/2024

Services

List of Services for Tennessee Waiver# TN.0128.R06.00

Cost Neutrality

Cost Neutrality for Tennessee Waiver# TN.0128.R06.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4648 4113

Year 1 Waiver Services

List of Year 1 Waiver Services for Tennessee Waiver# TN.0128.R06.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Supports 15 minutes 4094 2604.66 $3.50
Facility Based Day Supports 15 minutes 607 552 $2.30
Intermittent Employment and Community Integration Wrap-Around Supports 15 minutes 3444 1858.48 $3.38
Supported Employment Individual Exploration event 520 1 $1091.00
Supported Employment Individual Job Development event 415 1 $1600.00
Supported Employment - Individual Quality Incentive Payment event 218 2 $1816.00
Supported Employment Individual Discovery event 624 1 $1500.00
Supported Employment Individual Stabilization and Monitoring month 31 11 $130.00
Supported Employment Individual Job Coaching 15 minutes 880 2336 $6.25
Supported Employment - Small Group Employment Support 15 minutes 77 2376 $3.04

Year 5 Waiver Services

List of Year 5 Waiver Services for Tennessee Waiver# TN.0128.R06.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Participation Supports 15 minutes 3632 2418.4 $3.50
Facility Based Day Supports 15 minutes 500 504 $2.30
Intermittent Employment and Community Integration Wrap-Around Supports 15 minutes 3053 1858.48 $3.38
Supported Employment Individual Exploration event 260 1 $1091.00
Supported Employment Individual Job Development event 200 1 $1600.00
Supported Employment - Individual Quality Incentive Payment event 385 2 $1816.00
Supported Employment Individual Discovery event 300 1 $1500.00
Supported Employment Individual Stabilization and Monitoring month 153 11 $130.00
Supported Employment Individual Job Coaching 15 minutes 1460 2405 $5.75
Supported Employment - Small Group Employment Support 15 minutes 70 2376 $3.04

Rate Determination Methods

Rate Determination Methods for Tennessee Waiver# TN.0128.R06.00

Proposed service rates are determined by the Department of Intellectual and Developmental Disabilities (DIDD) and are reviewed and approved by TennCare, the State Medicaid Agency, which has oversight of the rate determination process. TennCare keys approved rates into the MMIS for purposes of processing claims for waiver services. The methodology used to determine rates is outlined in Chapter 0465-01-02 of DIDD’s Administrative Rules and can be found at this link: http://publications.tnsosfiles.com/rules/0465/0465-01/0465-01-02.20140312.pdf

Maximum allowable rates are established for each service based on an analysis of provider costs to deliver services and based on experience, as set forth in DIDD Administrative Rule. The rates for this waiver were restructured in 2005 with the average expenses incurred by providers in 2004 used as the cost model. DIDD continues to make adjustments to the 2005 rates, particularly the direct support professional hourly wage component within the rates, based on feedback from providers and current employment trends. The state has appropriated an additional $31.6million in state funds since state fiscal year 2014 for provider rate increases across all waiver programs.

DIDD has no formal process in place to review provider costs; however, DIDD regularly meets with providers at Statewide Planning and Policy Council meetings as well as other providers meetings and rates are discussed.

Additionally, DIDD has one staff person that routinely reviews cost data for providers who are struggling financially and have requested technical financial assistance.

Rates must be sufficient to recruit an adequate supply of qualified providers for each service to ensure participants statewide have adequate access to waiver services. In setting rates, the rates for similar services in other states and other in-state programs are considered, and rates are adjusted based on the number of waiver participants receiving services in a group arrangement, where applicable. Rates paid in this waiver are the same as those paid in the two other 1915(c) home and community-based waivers for people with intellectual disabilities. Providers are reimbursed up to the maximum allowable rate established for a service.

Stakeholders have the opportunity to provide input into the development and sufficiency of rates through the posting of waiver renewals and amendments for public comment, the DIDD Statewide Planning and Policy Councils, provider meetings, and other public meetings, as well as through the DIDD rule-making hearing process, which includes public notice and a rule-making hearing. Information about payment rates is made public and is available on the DIDD web site, i.e., TennCare Maximum Reimbursement Rate Schedule.

For Supported Employment–Individual Services, fee for service job coaching rates are based on a prospective rate model that reflects a sufficient wage for the level of qualified staff required to deliver the service and all other reasonable and anticipated costs involved in providing the service. For job coaching, this prospective rate is then tiered into three distinct rates based on the level of fading achieved, taking into account the waiver participant’s level of disability and length of time the job has been held. Providers can earn the highest rate for achieving the highest fading targets, the

mid-level rate for achieving the mid-level fading targets, and the base level rate for achieving the base level fading targets. Using this model, providers are appropriately incentivized to fade job coaching supports over time (a key quality metric for supported employment services) while the state can also ensure no waiver participant is excluded from participation in supported employment-individual services based on level of disability or newness to their job. To determine a waiver participant’s acuity tier for job coaching, the Level of Need system that has been in use to determine employment and day service reimbursement will continue to be used. Additionally, where an individual has a need for job coaching that is equal to or less than one hour per week, a monthly “Stabilization and Monitoring” payment will be used to encourage ongoing, effective monitoring of the waiver participant’s employment situations, with minimum monthly contact requirements that will allow for prevention of otherwise avoidable job losses or reductions in work hours.

For Supported Employment-Individual Services the state proposes to pay on an outcome basis, the following rate determination methods were used:

Exploration: Underlying fee-for-service prospective rate for qualified job coach was developed as described above. All components of Exploration service process were defined and the average time necessary for each step was determined, resulting in an average of 40 hours total for all required steps. The underlying fee-for-service prospective rate was multiplied by 40 hours to arrive at the outcome payment. The required Exploration report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time. Discovery: Underlying fee-for-service prospective rate for qualified job developer was developed reflecting a sufficient wage and all other reasonable and anticipated costs involved in providing the service. All components of Discovery service process were defined and the average time necessary for each step was determined, resulting in an average of 50 hours total for all required steps. The underlying fee-for-service prospective rate was multiplied by 50 hours to arrive at the outcome payment. The required Discovery report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time.

Job Development: Underlying fee-for-service prospective rate for qualified job developer was developed reflecting a sufficient wage and all other reasonable and anticipated costs involved in providing the service. Using information from other states and Vocational Rehabilitation, the average amount of hours necessary for completion of job development (securing outcome of paid competitive, integrated employment, consistent with a waiver participants goals, preferences, skills and conditions for success) was determined. This average was used to create three tiered hour levels to reflect waiver participants’ varying levels of disability (acuity). For each tier, the average hours expected to be necessary to complete the service were multiplied by the underlying fee-for-service prospective rate for the qualified job developer to arrive at the three tiered outcome payments. The required Job Development report, necessary for authorization of payment, contains a section that tracks actual hours and miles driven, to allow the state to monitor the appropriateness of the outcome payment over time. To determine a waiver participant’s acuity tier for Job Development, the Level of Need system that has been in use to determine employment and day service reimbursement will continue to be used.

Quality Payment for Hours Worked Milestone under Supported Employment-Individual Employment Support: Payment earned and paid for additional/atypical effort of provider that results in a waiver participant working in competitive integrated employment achieving above average hours worked in a six-month period.. There are two quality payment levels available:

• The base tier payment is $1,500 and is made based on the waiver participant working in competitive integrated employment between three-hundred ninety (390) and five-hundred nineteen (519) hours in the prior six (6) calendar month period. This is average hourly employment that is at least 15 but less than 20 hours/week.

• The top tier payment is $2,000 and is made based on the waiver participant working five-hundred and twenty (520) or more hours in the prior six (6) calendar month period. This is average hourly employment that is 20 hours/week or more.

A provider may earn the quality payment up to twice a year.

The reimbursement rates for the new Non-Residential Homebound Support Service match the reimbursement rates for the service this new service is replacing (In Home Day).

Texas Waiver# TX.0221.R06.01 

TX Community Living Assistance & Support Services (CLASS)

Waiver Name:
TX Community Living Assistance & Support Services (CLASS)
Effective Date:
9/1/2019
Expiration Date:
8/31/2024

Services

List of Services for Texas Waiver# TX.0221.R06.01

Cost Neutrality

Cost Neutrality for Texas Waiver# TX.0221.R06.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5878 5878

Year 1 Waiver Services

List of Year 1 Waiver Services for Texas Waiver# TX.0221.R06.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services Per Hour 379 727 $14.13
Supported Employment non CDS Per Hour 1 448 $28.33
Supported Employment CDS Per Hour 15 363 $25.78
Employment Assistance non CDS Per Hour 1 44 $28.33
Employment Assistance CDS Per Hour 1 200 $25.78

Year 5 Waiver Services

List of Year 5 Waiver Services for Texas Waiver# TX.0221.R06.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services Per Hour 379 727 $15.29
Supported Employment non CDS Per Hour 1 448 $30.66
Supported Employment CDS Per Hour 15 363 $27.91
Employment Assistance non CDS Per Hour 1 44 $30.66
Employment Assistance CDS Per Hour 1 200 $27.91

Rate Determination Methods

Rate Determination Methods for Texas Waiver# TX.0221.R06.01

HHSC, the single State Medicaid agency, determines payment rates every two years, coincident with the State's legislative biennium. Payment rates are determined for each service. The rates for services are prospective and uniform statewide. HHSC reimburses providers for contracted client services through reimbursement amounts determined as described in Title 1 of the Texas Administrative Code, Part 15, Chapter 355, and in reimbursement methodologies for each program. HHSC determines payment rates after analysis of financial and statistical information, and the effect of the payment rates on achievement of program objectives, including economic conditions and budgetary considerations. Statewide, uniform reimbursements and reimbursement ceilings are approved by HHSC. Methodology rules are developed and recommended for approval to HHSC. HHSC has oversight authority with respect to the state's reimbursement methodology and cost determination rules. The rates for the CLASS waiver are available on the HHSC Rate Analysis Department webpage.

In order to ensure adequate financial and statistical information upon which to base reimbursement, HHSC requires each contracted provider to submit a periodic cost report or supplemental report. HHSC uses cost reports to determine rates for the following services: residential habilitation services; prevocational services; employment assistance; supported employment; cognitive rehabilitation therapy; respite care; nursing; physical therapy; occupational therapy; speech and language pathology; case management; behavioral support; auditory integration training/auditory enhancement training; and dietary services. Providers of these services are required to submit biennial cost reports to the HHSC Rate Analysis Department. Providers are responsible for eliminating all unallowable expenses from the cost report prior to submission of the cost report. The HHSC Cost Report Review Unit reviews all cost reports and a sample of cost reports are reviewed on-site. The HHSC Cost Report Review Unit removes any unallowable costs and corrects any errors detected on the cost report in the course of the review or on-site audit. Audited cost reports are used in the determination of statewide prospective rates.

Unit of service reimbursements are determined as described in Title 1 of the Texas Administrative Code, Part 15, Chapter 355, Section 355.505. In general, recommended unit of service rates for each service are determined as follows and are used as a historical cost basis: 1) total allowable costs for each provider are determined from the audited cost report; 2) each provider's total allowable costs are projected from the historical cost reporting period to the prospective reimbursement period; 4) payroll taxes and benefits are allocated to each salary item; 5) total projected allowable costs are divided by the number of units of service to determine the projected cost per unit of service; 6) the allowable costs per unit of service for each contracted provider are arrayed and weighted by the number of units of service and the median cost per unit of service is calculated; and 7) the median cost per unit of service for each waiver service is multiplied by 1.044.

When historical costs are unavailable, such as in the case of changes in program requirements, payment rates may be based on a pro forma approach. This approach involves using historical costs of delivering similar services, where appropriate data are available, and estimating the basic types and costs of products and services necessary to deliver services meeting federal and state requirements. The rates for transition assistance services, continued family services, support family services, and support consultation are modeled using a pro forma approach.

Minor home modifications, adaptive aids, dental treatment, and prescriptions are paid at cost. Specialized therapies are paid at cost up to maximum dollar amount.

The CLASS providers are given additional payments for their efforts in acquiring specialized therapies for individuals; these payments are called requisition fees. The rates for the requisition fees are modeled using a pro forma approach that uses the historical data of provider’s costs to deliver services.

In setting the rates for financial management services provided under the consumer directed services option, the reimbursement rate to the financial management services provider, the financial management services agency legal entity, is a flat monthly fee, determined by modeling the estimated cost to carry out the financial management responsibilities of the financial management services agency legal entity. The payment rate available for the individual's budget for the self-directed service is modeled based on the payment rate to the traditional agency less an adjustment for the traditional agency's indirect costs.

The Financial Management Services Agency (FMSA) is responsible for providing this information to the CDS employer. For individuals not in the CDS option, the document created during the service planning team meeting, the individual plan of care (IPC), contains the rates for each service. This form is reviewed and signed by the individual and/or LAR. HHSC publishes notice of proposed adjustments at the earliest feasible date but not later than 10 state working days before the effective date of the adjustment, in the Texas Register. HHSC holds a public hearing before it approves rates, to allow interested persons to present comments relating to the proposed rates, and HHSC provides notice of the hearing to the public. The notice of the public hearing includes the location, date, and time for the hearing; information about the proposed rate changes and identifies the name, address, and telephone number of the staff member to contact for the materials pertinent to the proposed rates. At least ten working days before the public hearing takes place, material pertinent to the proposed statewide uniform rates is made available to the public. The public may present comments at the hearing or submit written comments regarding the proposed rates. Information about payment rates is made available to waiver participants through the HHSC website as well as through the Texas Register via a public notice.

Providers of residential habilitation services have the option of participating in the Attendant Compensation Rate Enhancement. The 76th Texas Legislature directed the Texas Department of Human Services (a legacy agency for DADS) to provide incentives for increased wages and benefits for community care attendants. In response, HHSC adopted rules at Title 1 of the Texas Administrative Code, Part 15, Chapter 355, Section 112 to establish procedures for community care providers to obtain additional funds for increased attendant wages, benefits, insurance, and mileage reimbursement. Community care providers who choose to participate in Attendant Compensation Rate Enhancement and receive additional funds must demonstrate compliance with enhanced spending requirements. For providers who choose not to participate in Attendant Compensation Rate Enhancement, the attendant compensation rate will remain constant over time, except for adjustments necessitated by increases in the federal minimum wage.

Participation in the Attendant Compensation Rate Enhancement is voluntary. Enrollment in Attendant Compensation Enhancement Rate is held in July prior to the rate year. Providers may choose to participate in Attendant Compensation Rate Enhancement by submitting to HHSC a signed Enrollment Contract Amendment choosing to enroll and indicating the level of enhanced add-on rate they desire to receive. Requested add-on rate levels will be granted beginning with the lowest level and granting successive levels until requested enhancements are granted within available funds. Funding for the enhancement add-on rate levels is limited by biennial legislative appropriations.

Providers participating in the Attendant Compensation Rate Enhancement agree to spend approximately 90 percent of their total attendant revenues, including their enhanced add-on rate revenues, on attendant compensation. Attendant compensation includes salaries, payroll taxes, benefits, and mileage reimbursement. Participating providers must submit reports to HHSC documenting their spending on attendant compensation.

Determination of each provider's compliance with the attendant compensation spending requirement will be made on an annual basis from reports submitted to HHSC. Participants failing to meet their spending requirement for the reporting period will have their enhanced add-on revenues associated with the unmet spending requirements recouped. At no time will a participating provider’s attendant care rate after their spending recoupment be less than the rate paid to providers not participating in receiving the enhanced add-on rates.

The CLASS rates were first established when the waiver was originally approved by CMS on September 1, 1991. Rates are updated and rebased when legislative appropriations are available. For services that use cost reports to determine rates, the state used the most recent audited cost report available to develop the estimates for this waiver renewal.

Among the specialized therapies, the staff person with the highest qualifications is a physical therapist so the PT rate determines the ceiling. Waiver providers can bill up to the ceiling but are only permitted to bill what they actually pay the service provider. The consumer directed services rates are modeled and are based on the payment rates paid to contracted agencies for providing services to consumers who do not participate in CDS, and then removing from those rates amounts needed to fund the FMSA’s responsibilities.

Texas Waiver# TX.0281.R05.00 

TX Deaf Blind w/Multiple Disabilities

Waiver Name:
TX Deaf Blind w/Multiple Disabilities
Effective Date:
3/1/2018
Expiration Date:
2/28/2023

Services

List of Services for Texas Waiver# TX.0281.R05.00

Cost Neutrality

Cost Neutrality for Texas Waiver# TX.0281.R05.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
381 378

Year 1 Waiver Services

List of Year 1 Waiver Services for Texas Waiver# TX.0281.R05.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation hour 38 877 $14.31
Supported Employment hour 3 377 $33.10
Consumer Directed Supported Employment hour 3 377 $32.10
Employment Assistance hour 3 377 $33.10
Consumer Directed Employment Assistance hour 3 377 $32.10

Year 5 Waiver Services

List of Year 5 Waiver Services for Texas Waiver# TX.0281.R05.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation hour 37 908.06 $16.38
Supported Employment hour 3 404.93 $34.10
Consumer Directed Supported Employment hour 3 404.93 $33.28
Employment Assistance hour 3 404.93 $34.10
Consumer Directed Employment Assistance hour 3 404.93 $33.28

Rate Determination Methods

Rate Determination Methods for Texas Waiver# TX.0281.R05.00

HHSC, the State Medicaid Agency, determines payment rates every two years, coincident with the State's legislative biennium. Payment rates are determined for each service. The rates for services are prospective and uniform statewide. HHSC reimburses providers for contracted client services through reimbursement amounts determined as described in Title 1 of the Texas Administrative Code, Part 15, Chapter 355, and in reimbursement methodologies for each program. There are no variances from any portion of the rate methodology. HHSC determines payment rates after analysis of financial and statistical information, and the effect of the payment rates on achievement of program objectives, including economic conditions and budgetary considerations. Texas uses existing service rate methodologies from other HCBS waivers to set service rates for DBMD. Reimbursement methodology rules are developed and recommended for approval by HHSC. HHSC has oversight authority with respect to the state's reimbursement methodology and cost determination rules. The rates for the DBMD program are available on the HHSC Rate Analysis webpage.

HHSC models the rates for the following services from other Medicaid HCBS waiver programs that use cost reports to determine rates: day habilitation; residential habilitation; respite services in the individual’s or respite provider’s private residence; respite services in an intermediate care facility; respite in an assisted living home; respite in a camp; supported employment; audiology services; behavioral support; chore service; dietary services; employment assistance; intervener; nursing services; occupational therapy services; physical therapy services; and speech, hearing and language therapy services.

The Community Living Assistance and Support Services (CLASS) (TX.0221) Habilitation rate is used for Day Habilitation and Residential Habilitation services.

All respite services (including respite services in the individual’s or respite provider’s private residence, respite services in an intermediate care facility, respite in an assisted living home and respite in a camp), supported employment, audiology services, behavioral support, dietary services, employment assistance, nursing services, occupational therapy services, physical therapy services, and speech, hearing and language therapy are services that are available in multiple 1915(c) HCBS Waivers. The State sets a single rate for each of these services. The cost report data from all of these waiver programs is combined into a single database for rate calculation. The methodology for these services is detailed in Title 1 of the Texas Administrative Code (1 TAC), Chapter 355, §355.502.

The Medicaid State Plan Personal Assistance Services (Primary Home Care) non-priority rate is used for the Chore service rate.

The 90th percentile CLASS (TX.0221) Habilitation rate is used for the intervener rate.

CLASS and Primary Home Care providers are required to submit biennial cost reports to the HHSC Rate Analysis Department. Providers are responsible for eliminating all unallowable expenses from the cost report prior to submission of the cost report. The HHSC Cost Report Review Unit completes a desk review sample of cost reports, with a subgroup of cost reports audited on-site. The Cost Report Review Unit removes any unallowable costs and corrects any errors detected on the cost report in the course of the review or on-site audit. Audited cost reports are used in the determination of statewide prospective rates.

The allowable and unallowable costs are detailed in the Texas Administrative Code: Title 1, Part 15, Chapter 355, Subchapter A, §355.102 (relating to General Principles of Allowable and Unallowable Costs) and Title 1, Part 15, Chapter 355, Subchapter A, §355.103 (relating to Specifications for Allowable and Unallowable Costs). Both may be found here: http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=1&pt=15&ch=355&sch=A&rl=Y.

In general, recommended unit of service rates for each service are determined as follows: 1) total allowable costs for each provider are determined from the audited cost report; 2) each provider’s total allowable costs are projected from the historical cost reporting period to the prospective reimbursement period; 3) payroll taxes and benefits are allocated to each salary item; 4) total projected allowable costs are divided by the number of units of service to determine the projected cost per unit of service; 5) the allowable costs per unit of service for each contracted provider are arrayed and weighted by the number of units of service and the median cost per unit of service is calculated; and 6) the median cost per unit of service for each waiver service is multiplied by 1.044.

When comparable services do not currently exist, reimbursement rates will be determined using a pro forma approach. This approach involves using historical costs of delivering similar services, where appropriate data are available, and estimating the basic types and costs of products and services necessary to deliver services meeting federal and state requirements to set waiver rates. HHSC models rates as specified below.

The rate for case management is determined by modeling the salary for a case manager staff position. This rate is periodically updated for inflation.

The rates for assisted living are determined by modeling using a pro forma approach.

The rate for orientation and mobility services is determined by modeling the salary for an orientation and mobility staff position. This rate is updated periodically for inflation.

Prescription drugs, minor home modifications, adaptive aids and medical supplies, and dental services are paid at cost. The DBMD providers are given additional payments for the cost of acquiring minor home modifications, adaptive aids and medical supplies, and dental services for participants; these payments are called requisition fees. The rates for the requisition fees are modeled using a pro forma approach.

Appendix C states the maximum allowable amount under the limits section of Prescribed Drugs, Minor Home Modification, Adaptive Aids and Medical Supplies, and Dental Treatment. Prescribed Drugs has no limit. Minor Home Modification has a maximum lifetime expenditure of $10,000. After the lifetime maximum is reached, $300 is allowed per service plan year per individual for repairs, replacements, or additional modifications. The maximum amount of funds available for adaptive aids is $10,000 per individual per service plan year. The total amount allowable for the dental treatment service is limited to a maximum expenditure of $2,500.00 per service plan year for routine preventive, therapeutic, orthodontic, or emergency treatment and $2,000.00 per individual per service plan year for sedation. The rates for Prescribed Drugs, Minor Home Modification, Adaptive Aids and Medical Supplies, and Dental Treatment are not fixed, but rather are the actual costs to the provider. The maximum allowable amount for Prescribed Drugs, Minor Home Modification, Adaptive Aids and Medical Supplies, and Dental Treatment is based on legislative and leadership direction.

The rates for support consultation, Intervener I, Intervener II, Intervener III and transition assistance services are determined by modeling the estimated salary for a person with similar skills and training requirements. These rates are updated periodically for inflation.

In setting the rates for financial management services provided under the consumer directed services option, the reimbursement rate to the financial management services agency, is a flat monthly fee determined by modeling the estimated cost to carry out the financial management responsibilities of the financial management services agency. The payment rate available for the individual’s budget for the self-directed service is modeled based on the payment rate to the traditional agency less an adjustment for the traditional agency’s indirect costs.

HHSC holds a public hearing before it approves rates. The purpose of the hearing is to give interested parties an opportunity to comment on the proposed rates. Notice of the hearing is provided to the public. The notice of the public hearing includes information about the proposed rate changes and identifies the name, address, and telephone number of the staff member to contact for the materials pertinent to the proposed rates. At least ten working days before the public hearing takes place, material pertinent to the proposed statewide uniform rates is made available to the public. The public may present comments at the hearing or submit written comments regarding the proposed rates. Information about payment rates is made available to waiver participants through HHSC websites as well as through the Texas Register via a public notice.

Waiver Name:
TX HCBS Program
Effective Date:
9/1/2018
Expiration Date:
8/31/2023

Services

List of Services for Texas Waiver# TX.0110.R07.02

Cost Neutrality

Cost Neutrality for Texas Waiver# TX.0110.R07.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
27689 27689

Year 1 Waiver Services

List of Year 1 Waiver Services for Texas Waiver# TX.0110.R07.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Intermittent day 5065 159 $26.16
Day Habilitation Extensive day 3933 184 $34.67
Day Habilitation Pervasive Plus day 161 195 $150.07
Day Habilitation Limited day 9665 175 $28.92
Day Habilitation Pervasive day 1832 180 $46.16
Supported Employment CDS per hour 8 153 $32.10
Supported Employment Provider Managed per hour 476 45 $33.72
Employment Assistance CDS per hour 2 351 $32.10
Employment Assistance Provider Managed per hour 127 32 $33.39

Year 5 Waiver Services

List of Year 5 Waiver Services for Texas Waiver# TX.0110.R07.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Intermittent day 5065 159 $28.54
Day Habilitation Extensive day 3933 184 $37.82
Day Habilitation Pervasive Plus day 161 195 $163.72
Day Habilitation Limited day 9665 175 $31.54
Day Habilitation Pervasive day 1832 180 $50.35
Supported Employment CDS per hour 8 153 $35.02
Supported Employment Provider Managed per hour 476 45 $36.78
Employment Assistance CDS per hour 8 351 $35.02
Employment Assistance Provider Managed per hour 476 32 $36.42

Rate Determination Methods

Rate Determination Methods for Texas Waiver# TX.0110.R07.02

HHSC, the State Medicaid Agency, determines payment rates every two years. Payment rates are determined for each service, and the rates for services are prospective and uniform statewide. HHSC determines payment rates after analysis of financial and statistical information, and the effect of the payment rates on achievement of program objectives, including economic conditions and budgetary considerations. Information about adopted payment rates is available on the HHSC Rate Analysis webpage.

All providers are required to submit biennial cost reports to HHSC Rate Analysis Department, as required. Providers are responsible for eliminating all unallowable expenses from the cost report prior to submission of the cost report. The cost report contains information on direct service costs, including direct service wages, benefits, contract services and staffing information; facility costs; operations costs; and administrations costs of the providers. Cost reports are subject to audit by the HHSC Cost Report Review Unit (CCRU) and a sample of cost reports are reviewed on- site. The HHSC CCRU removes any unallowable costs and corrects any errors detected on the cost report in the course of the review or on-site audit. Some cost reports are returned for correction and the revised cost reports are reviewed to determine if appropriate changes are made. Audited cost reports are used in the determination of statewide prospective rates.

Costs reported on the cost reports are projected to the applicable rate period. HHSC determines reasonable methods for projecting each provider's costs to allow for significant changes in cost-related conditions anticipated as occurring between the historical cost reporting period and the prospective rate period.

HHSC uses the projected costs from cost reports to rebase modeled rates for the following services: day habilitation, respite, supported employment, host home/companion care, supervised living, residential support services, social work, and supported home living. The initial model-based rates for these services were determined using cost, financial, statistical and operational information collected during site visits performed by an independent consultant. The data was collected from cost reports and the service providers' accounting systems. Additionally, the state fiscal year (SFY) 1996 state wage data, the SFY 1994 cost data and the SFY 1995 data from service providers was reviewed and analyzed. The base model rate year was calendar year 1997. Data from SFY 1994-1996 were used to develop the current rate structure; rates are rebased every biennium from the most recent projected cost report data, within available appropriations.

Current rates are based on cost report data from providers’ fiscal years ending in 2010.

Nursing, speech and language pathology, audiology, occupational therapy, physical therapy, dietary, and behavioral support services are provided under more than one Home and Community-based 1915(c) waiver. The rates for these services are determined using the cost reports of providers with Medicaid provider agreements in the Community Living Assistance and Support Services (CLASS) (TX.0221), Home and Community-based Services (HCS) (TX.0110) and Texas Home Living (TxHmL) (TX.0403) waivers to calculate the rates for the common services. The allowable costs per unit of service for each of these services are combined into arrays. Each array is then weighted by the number of units of service and the median cost per unit of service is calculated. Weighting by units of service gives the costs of providers with more units of service a higher relative weight. This methodology is used for all of the common services, the State does not vary from this methodology for the common services.

Prescribed drugs are paid at cost.

When historical costs are unavailable, such as in the case of changes in program requirements, payment rates may be based on a pro forma approach. This approach involves using historical costs of delivering similar services, where appropriate data are available, and determining the types and costs of products and services necessary to deliver services meeting federal and state requirements. Data sources may include: cost report data; state and national salary data; administrative costs of providers and staff who will deliver the service; and other data applicable to the service or specific industry. HHSC models rates as specified below.

The reimbursement for transition assistance services is modeled using this pro forma approach utilizing costs for similar services with similar staff requirements.

Minor home modifications, adaptive aids, and dental treatment services are paid at cost. Providers are given additional payments for the cost of acquiring minor home modifications, adaptive aids, and dental treatment services for individuals; these payments are called requisition fees. The rates for the requisition fees are determined by modeling the estimated time required for staff to conduct the assessment of the need for the service, purchase the item, and complete any necessary follow-up. In setting the rates for financial management services provided under the consumer directed services option, the reimbursement rate to the financial management services provider is a flat monthly fee, determined by modeling the estimated cost to carry out the financial management responsibilities of the financial management services provider. The payment rate available for the individual's budget for the self-directed service is modeled based on the payment rate to the traditional agency less an adjustment for the traditional agency's indirect costs.

The rate for support consultation is determined using the statewide average salary of a non-nurse supervisor in the State Plan Primary Home Care (PHC) program, as these staff have similar skills and training requirements. This rate is updated periodically for inflation using the chained price index of total U.S. personal consumption expenditures data from Global Insight. The State updates inflation these factors as needed. The modeled inputs for the support consultation rate are evaluated based on the most recently audited cost reports every two years.

Providers have the option of participating in the attendant compensation rate enhancement for the following services: day habilitation, respite, supported employment, supervised living/residential support services, and supported home living. HHSC adopted rules in Title 1 of the Texas Administrative Code, Part 15, Chapter 355, Subchapter A to establish procedures for providers to obtain additional funds for increased attendant wages, benefits/insurance, and mileage reimbursement. As per these rules, providers who choose to participate in the attendant compensation rate enhancement and receive additional funds must demonstrate compliance with enhanced spending requirements. For providers who choose not to participate in the enhancement program, the attendant compensation rate component will remain constant over time, except for adjustments necessitated by increases in the federal minimum wage.

Participation in the attendant compensation rate enhancement is voluntary. Providers may choose to participate in the attendant compensation rate enhancement by submitting to HHSC a signed Enrollment Contract Amendment choosing to enroll and indicating the level of enhanced add-on rate they desire to receive. Requested add-on rate levels are granted beginning with the lowest level and granting successive levels until requested enhancements are granted within available funds.

Enrollment in the attendant compensation rate enhancement is held in July, prior to the rate year. Funding for the enhancement add-on rate levels is limited by appropriations.

Providers are notified of the open enrollment period for the attendant compensation rate enhancement program electronically or by other appropriate means as determined by HHSC. New providers are notified of the program and enrollment requirements as HHSC is notified of the contract award. A webinar to review the program and respond to questions is held during the open enrollment period. Changes to the rule related to the program at Title 1 of the Texas Administrative Code, Part 15, Chapter 355, §355.112 are published in the Texas Register for public comment.

Providers participating in the attendant compensation rate enhancement agree to spend approximately 90 percent of their total attendant revenues, including their enhanced add-on rate revenues, on attendant compensation. Attendant compensation includes salaries, payroll taxes, benefits, and mileage reimbursement. Participating providers must submit reports to HHSC documenting their spending on attendant compensation.

Determination of each provider's compliance with the attendant compensation spending requirement will be made on an annual basis from the cost reports submitted to HHSC. Individuals failing to meet their spending requirement for the reporting period will have their enhanced add-on revenues associated with the unmet spending requirements recouped. At no time will a participating provider's attendant care rate after their spending recoupment be less than the rate paid to providers not participating in receiving the enhanced add-on rates. The federal portion of any recouped funds is returned to the federal government.

HHSC has developed an add-on to the direct care portion of the supervised living and residential support services rates. This add-on will increase the direct care portion of the supervised living and residential support services rates until current data is available to determine whether the historical model is appropriate. The add-on will be effective until August 31, 2021. During the time period the add-on is in effect, HHSC is implementing a mandatory spending requirement for the supervised living and residential support services direct care add-on to ensure that providers spend these funds on direct care staff. This spending requirement is separate from the attendant compensation rate enhancement. Providers are required to spend 90 percent of their total supervised living and residential support services direct care add-on revenues on attendant compensation.

Texas Waiver# TX.0403.R03.04 

TX Home Living Program

Waiver Name:
TX Home Living Program
Effective Date:
3/1/2017
Expiration Date:
2/28/2022

Services

List of Services for Texas Waiver# TX.0403.R03.04

Cost Neutrality

Cost Neutrality for Texas Waiver# TX.0403.R03.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
6540

Year 1 Waiver Services

List of Year 1 Waiver Services for Texas Waiver# TX.0403.R03.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation daily 2861 135 $28.08
Day Habilitation CDS daily 78 102 $24.43
Supported Employment CDS hour 8 115 $32.10
Supported Employment hour 120 42 $33.77
Community Support hour 1795 86 $22.86
Community Support CDS hour 0 0 $0.01
Employment Assistance hour 81 20 $33.95
Employment Assistance CDS hour 0 0 $0.01

Year 5 Waiver Services

List of Year 5 Waiver Services for Texas Waiver# TX.0403.R03.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation daily 2861 135 $28.08
Day Habilitation CDS daily 78 100 $24.43
Supported Employment CDS hour 8 115 $32.10
Supported Employment hour 120 42 $33.77
Community Support hour 1795 85 $22.86
Community Support CDS hour 0 0 $0.01
Employment Assistance hour 81 20 $33.95
Employment Assistance CDS hour 0 0 $0.01

Rate Determination Methods

Rate Determination Methods for Texas Waiver# TX.0403.R03.04

HHSC, the single State Medicaid agency, determines payment rates every two years, coincident with the State's legislative biennium. Payment rates are determined for each service. The rates for services are prospective and uniform statewide. HHSC reimburses providers for contracted client services through reimbursement amounts determined as described in Title 1 of the Texas Administrative Code, Part 15, Chapter 355, and in reimbursement methodologies for each program. HHSC determines payment rates after analysis of financial and statistical information, and the effect of the payment rates on achievement of program objectives, including economic conditions and budgetary considerations. Statewide, uniform reimbursements and reimbursement ceilings are approved by HHSC. Methodology rules are developed and adopted by HHSC. HHSC has oversight authority with respect to the state's reimbursement methodology and cost determination rules. The rates for the TxHmL waiver are available on the HHSC Rate Analysis Department webpage.

In order to ensure adequate financial and statistical information upon which to base reimbursement, HHSC requires each contracted provider to submit a periodic cost report or supplemental report. The cost report contains information on direct service costs, including direct service wages, benefits, contracted services and staffing information; facility costs; operations costs; and administrations costs of the providers. Providers are responsible for eliminating all unallowable expenses from the cost report prior to submission of the cost report. HHSC conducts a desk review of all cost reports. HHSC removes any unallowable costs and corrects any errors detected on the cost report in the course of the review. Reviewed cost reports are used in the determination of statewide prospective rates.

Costs reported on the cost reports are projected to the applicable rate period. HHSC determines reasonable methods for projecting each provider's costs to allow for significant changes in cost-related conditions anticipated as occurring between the historical cost reporting period and the prospective rate period.

HHSC uses the projected costs from the latest, desk-reviewed cost reports to rebase modeled rates for the following services: Day Habilitation, Respite, Supported Employment, Audiology Services, Behavioral Support, Community Support, Dietary Services, Employment Assistance, Occupational Therapy Services, Physical Therapy Services, Nursing and Speech-Language Pathology. The initial model-based rates for these services were determined using cost, financial, statistical and operational information collected during site visits performed by an independent consultant. The data was collected from cost reports and the service providers' accounting systems. Additionally, the state fiscal year (SFY) 1996 state wage data, the SFY 1994 cost data and the SFY 1995 data from service providers was reviewed and analyzed. The base model rate year was calendar year 1997. Data from SFY 1994-1996 were used to develop the current rate structure; rates are rebased every biennium from the most recent projected cost report data, within available appropriations.

Supported Employment, Audiology, Behavioral Support, Dietary, Employment Assistance, Occupational Therapy, Physical Therapy, Nursing and Speech/Language Pathology are provided under more than one Home and Community- based 1915(c) waiver. The rates for these services are determined by combining the allowable costs per unit of service for the providers with Medicaid provider agreements in all the waivers offering these services into an array. The array is weighted by the number of units of service and the median cost per unit of service is calculated.

When historical costs are unavailable, such as in the case of changes in program requirements, payment rates may be based on a pro forma approach. This approach involves using historical costs of delivering similar services, where appropriate data are available, and estimating the basic types and costs of products and services necessary to deliver services meeting federal and state requirements. The rate for support consultation is modeled using a pro forma approach.

Prescription Medications, Adaptive Aids, Dental Treatment and Minor Home Modifications, are paid at cost.

The TxHmL providers are given additional payments for their efforts in acquiring Adaptive Aids, Dental Treatment and Minor Home Modifications for individuals; these payments are called requisition fees. The rates for the requisition fees are modeled using a pro forma approach that uses the historical data of provider’s costs to deliver services.

In setting the rates for Financial Management Services provided under the consumer directed services option, the reimbursement rate to the financial management services provider, the financial management services agency, is a flat monthly fee, determined by modeling the estimated cost to carry out the financial management responsibilities of the financial management services agency. The payment rate available for the individual's budget for the self-directed service is modeled based on the payment rate to the traditional agency less an adjustment for the traditional agency's indirect costs.

The financial management services agency is responsible for providing rate information to the consumer directed services option employer. For individuals not in the consumer directed services option, the document created during the service planning team meeting, the individual plan of care, contains the rates for each service. This form is reviewed and signed by the individual and/or legally authorized representative.

HHSC publishes notice of proposed adjustments at the earliest feasible date but not later than ten state working days before the effective date of the adjustment, in the Texas Register. HHSC holds a public hearing before it approves rates, to allow interested persons to present comments relating to the proposed rates, and HHSC provides notice of the hearing to the public. The notice of the public hearing includes the location, date, and time for the hearing; information about the proposed rate changes and identifies the name, address, and telephone number of the staff member to contact for the materials pertinent to the proposed rates. At least ten working days before the public hearing takes place, material pertinent to the proposed statewide uniform rates is made available to the public. The public may present comments at the hearing or submit written comments regarding the proposed rates. Information about payment rates is made available to waiver participants through HHSC websites as well as through the Texas Register via a public notice.

Providers of Day Habilitation, Respite, Supported Employment, Community Support and Employment Assistance services have the option of participating in the Attendant Compensation Rate Enhancement. The 81st Texas Legislature directed HHSC to provide incentives for increased wages and benefits for community care attendants. In response, HHSC adopted rules in Title 1 of the Texas Administrative Code, Part 15, Chapter 355, Section 112 to establish procedures for community care providers to obtain additional funds for increased attendant wages, benefits, insurance, and mileage reimbursement. Community care providers who choose to participate in Attendant Compensation Rate Enhancement and receive additional funds must demonstrate compliance with enhanced spending requirements. For providers who choose not to participate in Attendant Compensation Rate Enhancement, the attendant compensation rate will remain constant over time, except for adjustments necessitated by increases in the federal minimum wage.

Participation in the Attendant Compensation Rate Enhancement is voluntary. Enrollment in Attendant Compensation Enhancement Rate is held in July prior to the rate year. Providers may choose to participate in Attendant Compensation Rate Enhancement by submitting to HHSC an electronic Enrollment Contract Amendment choosing to enroll and indicating the level of enhanced add-on rate they desire to receive. Requested add-on rate levels will be granted beginning with the lowest level and granting successive levels until requested enhancements are granted within available funds. Funding for the enhancement add-on rate levels is limited by biennial legislative appropriations.

Providers participating in the Attendant Compensation Rate Enhancement agree to spend approximately 90 percent of their total attendant revenues, including their enhanced add-on rate revenues, on attendant compensation. Attendant compensation includes salaries, payroll taxes, benefits, and mileage reimbursement. Participating providers must submit reports to HHSC documenting their spending on attendant compensation.

Determination of each provider's compliance with the attendant compensation spending requirement will be made based on reports submitted to HHSC on a biennial basis. Participants failing to meet their spending requirement for the reporting period will have their enhanced add-on revenues associated with the unmet spending requirements recouped. At no time will a participating provider's attendant care rate after their spending recoupment be less than the rate paid to providers not participating in receiving the enhanced add-on rates.

Utah Waiver# UT.0292.R05.00 

UT Acquired Brain Injury

Waiver Name:
UT Acquired Brain Injury
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Utah Waiver# UT.0292.R05.00

Cost Neutrality

Cost Neutrality for Utah Waiver# UT.0292.R05.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
142 142

Year 1 Waiver Services

List of Year 1 Waiver Services for Utah Waiver# UT.0292.R05.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports - daily (6 hr avg) day 49 188 $83.92
Day Supports (Site/Non-site) - 15 Minutes 15 minutes 11 2744 $10.92
Supported Employment 15 min 15 minutes 23 844 $10.92
Supported Employment Daily day 7 172 $44.90

Year 5 Waiver Services

List of Year 5 Waiver Services for Utah Waiver# UT.0292.R05.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Supports - daily (6 hr avg) day 49 188 $83.92
Day Supports (Site/Non-site) - 15 Minutes 15 minutes 11 2744 $10.92
Supported Employment 15 min 15 minutes 23 844 $10.92
Supported Employment Daily day 7 172 $44.90

Rate Determination Methods

Rate Determination Methods for Utah Waiver# UT.0292.R05.00

There are four principal methods used in setting the DHS Maximum Allowable Rate level. Each method is designed to determine a fair market rate. Four different methodologies are in place to accommodate the different market factors that exist for different types of services. With all new services and any inflationary increases or decreases to existing service rates, the SMA reviews and approves all proposed rates prior to the rates being loaded into the MMIS.

Adjustments to the following processes may be deemed necessary on occasion to comply with funding changes allocated through the legislative process. When funding is expressly committed to a service or sub-set of services, the SMA and OA work to establish the new rate amount based on funding allocated.

Additionally, the process may be adjusted on occasion to account for common factors such as the geographical location of service delivery, absentee factors, or division budget constraints, etc. Rates may also be adjusted at the direction of the Utah State Legislature.

1. Existing Market Survey or Cost Survey of Current Providers.

This methodology surveys existing providers to determine their actual cost to render a service. This would include direct labor, supervision, administration, non-labor costs allocated to the purchased service and the basis of cost allocations. The surveys are designed to assure all providers are reporting costs in a standardized manner and within allowable costs parameters established by DHS. Surveys are examined to determine if cost definitions, allocations and reporting are consistent among respondents and accurately include reasonable costs of business. The rate is set using a measure of central tendency such as median, mode or weighted average and adjusted if necessary to reflect prevailing market conditions. (For example, a large provider may distort data and smaller providers may have substantially different costs. Failure to adjust for market realities may result in lack of available providers if the rate is set too low, or unnecessarily paying too much if the rate is set too high.)

2. Component Cost Analysis

The estimated cost of each of the various components of a service code (rent, treatment, administration, direct labor, non-labor costs allocated to the service, etc.) are determined and added together to determine a provisional rate. This method is often used for a new or substantially modified service that does not currently exist in the market place.

Provisional rates are designed to determine a fair market rate until historical data becomes available. At a later date when historical cost data does become available a market survey may be undertaken to confirm or adjust the rate.

3. Comparative Analysis

This method may be used when a similar service exists. Adjustments are made to reflect any differences in the new service. Where possible and to provide consistency of payments in the provider community, rates are set to maintain common rates for common services purchased by various agencies. If a proposed service duplicates an existing service being used by another agency or program, the existing rate may be used to provide consistency of payments in the provider community, if the companion agency rate is considered to be in line with the market.

4. Community Price Survey

Where a broad based market exists for a service outside of DHS, existing service providers may be surveyed to determine the prevailing market price for the service. Again, measures of central tendency such as median, mode or weighted average are used and adjusted if necessary to reflect prevailing market.

The State solicited public comment during the drafting of the waiver renewal application. The State Medicaid Agency and the Division of Services for People with Disabilities completed the initial draft application November, 2013. The revised draft was submitted to a broad network of consumers, advocates, providers and Tribal Governments and the Medical Care Advisory Committee (MCAC). The entities were sent an electronic copy of the application and were asked to disseminate copies broadly. Entities had 30 days in which to submit comments or questions about all aspects of the ABI Waiver Application.

Payment rates are made available to participants so that they can make informed choices regarding their self- administered services in two ways. One: Support coordinators provide payment rate information to participants during their enrollment in self-administered services. Two: Annually, DSPD sends an approved payment rate letter to the FMS providers. The FMS providers then communicate this information to all participants they serve.

The method used to establish the rate for each waiver service is provided below, along with information regarding how the service is reimbursed to the provider:

ABI Waiver Support Coordination - Comparative Analysis - Fixed/Predetermined Day Supports - Comparative Analysis - Fixed/Predetermined

Homemaker - Comparative Analysis - Fixed/Predetermined

Residential Habilitation - Comparative Analysis - Varies by client based upon their acuity/supervision needs Respite - Comparative Analysis - Fixed/Predetermined

Supported Employment- Comparative Analysis - Fixed/Predetermined (payment for 1:1 service and small group use the same methodology but adjust for staffing ratios; co-worker supports are paid to eligible employers and may be a pass- through to the worker directly assisting the waiver participant)

Financial Management Services - Comparative Analysis - Fixed/Predetermined Behavior Consultation I - Comparative Analysis - Fixed/Predetermined Behavior Consultation II - Comparative Analysis - Fixed/Predetermined Behavior Consultation Service III - Comparative Analysis - Fixed/Predetermined Chore Services - Comparative Analysis - Fixed/Predetermined

Companion Services - Comparative Analysis - Fixed/Predetermined Environmental Adaptations – Home - Community Price Survey - Based on Episode

Environmental Adaptations – Vehicle - Community Price Survey - Based on Episode Extended Living Supports - Comparative Analysis - Fixed/Predetermined

Living Start-Up Costs - Comparative Analysis - Fixed/Predetermined Massage Therapy - Comparative Analysis - Fixed/Predetermined

Personal Budget Assistance - Comparative Analysis - Fixed/Predetermined

Personal Emergency Response System - Existing Market Survey - Fixed/Predetermined Professional Medication Monitoring - Comparative Analysis - Fixed/Predetermined

Specialized Medical Equipment/Supplies/Assistive Technology - Purchase - Community Price Survey - Fixed/Predetermined

Specialized Medical Equipment/Supplies/Assistive Technology- Monthly Fee - Community Price Survey - Fixed/Predetermined

Supported Living - Comparative Analysis - Fixed/Predetermined

Transportation Services (non-medical) - Comparative Analysis - Fixed/Predetermined

The difference in rate payment between agency and self-direction is primarily the anticipated amount used for administration/overhead, otherwise the methodologies remain similar.

The State has compared service requirements and reimbursement to several surrounding states including: Wyoming, Nevada, North Dakota, Oregon, Idaho, Colorado, Arizona, New Mexico, and Montana. The State has used this methodology as nearby states may have similar challenges with respect to urban/rural service delivery; similar labor markets; service descriptions/qualifications; etc. The State has used this method in order to validate whether payment rates established fall within reason after accounting for differences which may exist in provider qualifications (ex.

Requirement service is delivered by a Registered Nurse); how reimbursement is made (daily, hourly, episodic); cost of living; etc.

The State reviews rates at least once each waiver cycle and has enlisted the assistance of a CPA firm to assist in administering a cost survey to providers. The second year of this project is nearing its end at which point the SMA and OA intend to review the data provided and determine if any rate rebasing may be required.

Utah Waiver# UT.0158.R07.00 

UT Community Supports Waiver for Individuals w/ID and Other Related Conditions

Waiver Name:
UT Community Supports Waiver for
Individuals w/ID and Other Related Conditions
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for Utah Waiver# UT.0158.R07.00

Cost Neutrality

Cost Neutrality for Utah Waiver# UT.0158.R07.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5900 5900

Year 1 Waiver Services

List of Year 1 Waiver Services for Utah Waiver# UT.0158.R07.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Center-Based Prevocational Services day 250 183 $81.36
Day Supports (Site/Non-Site) daily day 2967 183 $81.36
Day Supports (Site/Non-site) - 15 Minutes 15 minutes 209 2324 $6.98
Supported Employment Daily day 309 198 $41.90
Supported Employment 15 min 15 minutes 730 795 $9.28

Year 5 Waiver Services

List of Year 5 Waiver Services for Utah Waiver# UT.0158.R07.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Center-Based Prevocational Services day 250 183 $81.36
Day Supports (Site/Non-Site) daily day 2967 183 $81.36
Day Supports (Site/Non-site) - 15 Minutes 15 minutes 209 2324 $6.98
Supported Employment Daily day 309 198 $41.90
Supported Employment 15 min 15 minutes 730 795 $9.28

Rate Determination Methods

Rate Determination Methods for Utah Waiver# UT.0158.R07.00

The following rates are paid based on the invoiced amount for the service:

Environmental Adaptations (Home / Vehicle) Living Start-Up Costs

Personal Emergency Response Systems Specialized Medical Equipment

Non-Medical Transportation (Bus Pass / UTA) Respite Care – Session

There are caps on the ‘invoiced charge’ codes and also a process to evaluate the request for appropriateness including multiple bids, verification that the good/service cannot be paid through other payers (Medicare, State Plan, TPL, etc.) and that lower cost alternatives have been explored prior to paying through the waiver.

The following rates are reviewed every 5 years based on cost survey data to ensure that reimbursement for the service falls between 100% and 120% of allowable costs for the industry:

Residential Habilitative Supports Host Home / Professional Parent Day Supports

Center Based Employment

Non-Medical Transportation Daily

The following rates are reviewed every 5 years to ensure that they fall between the range of rates paid in surrounding states for a similar service:

Respite (Routine) – 15 minute Massage Therapy

Supported Employment – 15 minute Supported Living

Waiver Support Coordination Professional Medication Monitoring - RN Personal Care

The following rates are tied to existing rates in other programs within the State as listed below: Financial Management Services is equal to the State Plan rate for the same service

Chore and Homemaker Services is equal to the State Plan rate for Personal Care (S5125) Companion Services is equal to 95% of the State Plan rate for Personal Care (S5125) Behavioral Consultation III is equal to 90% of the BCBA Rate paid under the State Plan (97153) Family and Individual Training and Preparation is equal to the Behavioral Consultation I rate Non-Medical Transportation – Per Mile

The following rates are tied to existing rates in this program:

Respite (Intensive) – Daily is equal to 6 hours of the equivalent 15 minute service Professional Medication Monitoring – LPN is equal to 70% of the RN rate for this service Supported Employment – Daily is equal to 4 units of the 15 minute rate for this service Respite (Routine Group) is equal to 52% of the individual rate for this service

Respite (Routine) – Daily is equal to 6.75 hours of the equivalent 15 minute service Personal Budget Assistance – 15 minute is equivalent to the supported living rate Personal Budget Assistance – Session is equivalent to 2 units of the 15 minute service Respite (Routine Group) – Daily is equivalent to 6 hours of the quarter hour rate

Respite (Out of Home) Room and Board is 12% higher than the daily rate without room and board Extended Living Supports- 15 minute is equivalent to 1:1 staffing for residential habilitative supports Behavioral Consultation II is equal to 65% of Behavioral Consultation III

Behavioral Consultation I is equal to 38% of Behavioral Consultation III

With all new services and any inflationary increases or decreases to existing service rates, the SMA reviews and approves all proposed rates prior to the rates being loaded into the MMIS. Payment rates may also be subject to changes mandated by the State Legislature.

The State solicited public comment during the drafting of the waiver application. The State Medicaid Agency and the Division of Services for People with Disabilities completed the initial draft application in February 2020. The revised draft was submitted to a broad network of consumers, advocates, providers and Tribal Governments and the Medical Care Advisory Committee (MCAC). The entities were sent an electronic copy of the application and were asked to disseminate copies broadly. Entities had 30 days in which to submit comments or questions about all aspects of the application.

Payment rates are made available to participants so that they can make informed choices regarding their self- administered services in two ways. One: Support coordinators provide payment rate information to participants during their enrollment in self-administered services. Two: Annually, DSPD sends an approved payment rate letter to the FMS providers. The FMS providers then communicate this information to all participants they serve.

Utah Waiver# UT.1666.R00.00 

UT Community Transitions Waiver 

Waiver Name:
UT Community Transitions Waiver 
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for Utah Waiver# UT.1666.R00.00

Cost Neutrality

Cost Neutrality for Utah Waiver# UT.1666.R00.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
150 250

Year 1 Waiver Services

List of Year 1 Waiver Services for Utah Waiver# UT.1666.R00.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Center Based Prevocational Services 15 minute 15 minutes 1 1 $7.80
Center Based Prevocational Services Daily day 1 1 $78.86
Day Supports 15 minute 15 minutes 5 2398 $7.80
Day Supports Daily day 79 187 $78.86
Supported Employment 15 minute 15 minutes 14 1002 $9.95
Supported Employment Daily day 9 195 $45.63

Year 5 Waiver Services

List of Year 5 Waiver Services for Utah Waiver# UT.1666.R00.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Center Based Prevocational Services 15 minute 15 minutes 2 1 $7.80
Center Based Prevocational Services Daily day 2 1 $78.86
Day Supports 15 minute 15 minutes 8 2398 $7.80
Day Supports Daily day 132 187 $78.86
Supported Employment 15 minute 15 minutes 23 1002 $9.95
Supported Employment Daily day 15 195 $45.63

Rate Determination Methods

Rate Determination Methods for Utah Waiver# UT.1666.R00.00

Rates in the waiver are equivalent to those paid for the same services defined in the Community Supports Waiver (UT.0158).

Family and Individual Training and Preparation (Tier II) is equal to the rate for 'Family and Individual Training and Preparation Services'

Family and Individual Training and Preparation (Tier I) is equal to the rate for 'Family Training and Preparation Services'

The services defined in this waiver that are not currently defined in the CSW are Professional Nursing Services and Center Based Employment (CBE). Those rates were constructed as follows:

Professional Nursing Services: Rate was established by using the hourly reimbursement for State Plan Private Duty Nursing in FY2019. This amount was reduced to 75% of the hourly amount in order to acknowledge the cost savings/economies of scale which will likely be present due to the routine nature of this service, use of skilled nursing delegation, and the potential for providers to serve multiple members, potentially within the same home, or nearby areas. A ‘high tier’ of the service adds an additional 50% reimbursement for individuals with significant medical complexity and when delegation may not be sufficient to meet health and safety needs. The State consulted with Residential and Day Support providers when drafting the requirements for this service definition, service delivery unit, and reimbursement.

While the medical need of the individual may be significant, there is a presumption that many skilled tasks will be considered routine for the individual, pose little potential risk to the individual and will produce predictable outcomes for the individual. With this presumption in mind, the State has structured this service with the idea that many tasks can be delegated to unlicensed assistive personnel per the Utah Nurse Practice Act and can be routinely performed by staff already working with the individual, with ongoing supervision from the delegating licensed nurse. Through delegation, a single nurse may be leveraged to provide training, oversight and monitoring of the care of several individuals.

Center-Based Prevocational Services: Uses the current reimbursement methodology used for Day Support Services.

There are four principal methods used in setting the DHS Maximum Allowable Rate level. Each method is designed to determine a fair market rate. Four different methodologies are in place to accommodate the different market factors that exist for different types of services. With all new services and any inflationary increases or decreases to existing service rates, the SMA reviews and approves all proposed rates prior to the rates being loaded into the MMIS. Payment rates may also been subject to changes mandated by the State Legislature.

Adjustments to the following processes may be deemed necessary on occasion to comply with funding requirements. Additionally, the process may be adjusted on occasion to account for the geographical location of service delivery, absentee factors, or division budget constraints, etc.

1. Existing Market Survey or Cost Survey of Current Providers.

This methodology surveys existing providers to determine their actual cost to render a service. This would include direct labor, supervision, administration, non-labor costs allocated to the purchased service and the basis of cost allocations. The surveys are designed to assure all providers are reporting costs in a standardized manner and within allowable costs parameters established by DHS. Surveys are examined to determine if cost definitions, allocations and reporting are consistent among respondents and accurately include reasonable costs of business. The rate is set using a measure of central tendency such as median, mode or weighted average and adjusted if necessary to reflect prevailing market conditions. (For example, a large provider may distort data and smaller providers may have substantially different costs. Failure to adjust for market realities may result in lack of available providers if the rate is set too low, or unnecessarily paying too much if the rate is set too high.) During cost reporting, providers are required to separate revenues received from waiver payments versus room and board payments from participants. Providers are required to establish rental/lease/room and board agreements with participants in residential services. All costs associated with room and board are excluded from allowable costs in the State’s review of rate adequacy.

2. Component Cost Analysis

The estimated cost of each of the various components of a service code (rent, treatment, administration, direct labor, non-labor costs allocated to the service, etc.) are determined and added together to determine a provisional rate. This method is often used for a new or substantially modified service that does not currently exist in the market place.

Provisional rates are designed to determine a fair market rate until historical data becomes available. At a later date when historical cost data does become available a market survey may be undertaken to confirm or adjust the rate. During cost reporting, providers are required to separate revenues received from waiver payments versus room and board payments from participants. Providers are required to establish rental/lease/room and board agreements with participants in residential services. All costs associated with room and board are excluded from allowable costs in the State’s review of rate adequacy.

3. Comparative Analysis

This method may be used when a similar service exists. Adjustments are made to reflect any differences in the new service. Where possible and to provide consistency of payments in the provider community, rates are set to maintain common rates for common services purchased by various agencies. If a proposed service duplicates an existing service being used by another agency or program, the existing rate may be used to provide consistency of payments in the provider community, if the companion agency rate is considered to be in line with the market.

4. Community Price Survey

Where a broad-based market exists, service providers may be surveyed regarding market price for the service.

The State solicited public comment during the drafting of the waiver application. The State Medicaid Agency and the Division of Services for People with Disabilities completed the initial draft application in September 2019. The revised draft was submitted to a broad network of consumers, advocates, providers and Tribal Governments and the Medical Care Advisory Committee (MCAC). The entities were sent an electronic copy of the application and were asked to disseminate copies broadly. Entities had 30 days in which to submit comments or questions about all aspects of the CTW Application.

Payment rates are made available to participants so that they can make informed choices regarding their self administered services in two ways. 1. Support coordinators provide payment rate information to participants during their enrollment in self administered services. 2. Annually, DSPD sends an approved payment rate letter to the FMS providers. The FMS providers provide this information to all participants they serve.

The State does not adjust any services based on a standard acuity score. Services that have separate tiers based on assessed participant needs define the separation in their service definitions in Appendix C.

The method used to establish the rate for each waiver service is provided below, along with information regarding how the service is reimbursed to the provider:

CSW Support Coordination - Comparative Analysis - Fixed/Predetermined Day Supports - Comparative Analysis - Fixed/Predetermined

Homemaker - Comparative Analysis - Fixed/Predetermined Personal Care - Comparative Analysis - Fixed/Predetermined

Residential Habilitation - Comparative Analysis - Varies by client based upon their acuity/supervision needs Respite - Comparative Analysis - Fixed/Predetermined

Supported Employment- Comparative Analysis - Fixed/Predetermined

Family Training Services (Family and Individual Training/Prep) - Comparative Analysis - Fixed/Predetermined Financial Management Services - Comparative Analysis - Fixed/Predetermined

Behavior Consultation I - Comparative Analysis - Fixed/Predetermined Behavior Consultation II - Comparative Analysis - Fixed/Predetermined Behavior Consultation Service III - Comparative Analysis - Fixed/Predetermined Chore Services - Comparative Analysis - Fixed/Predetermined

Companion Services - Comparative Analysis - Fixed/Predetermined Environmental Adaptations - Community Price Survey - Based on Episode Extended Living Supports - Comparative Analysis - Fixed/Predetermined Living Start-Up Costs - Comparative Analysis - Fixed/Predetermined Massage Therapy - Comparative Analysis - Fixed/Predetermined

Personal Budget Assistance - Comparative Analysis - Fixed/Predetermined

Personal Emergency Response System - Existing Market Survey - Fixed/Predetermined Professional Medication Monitoring - Comparative Analysis - Fixed/Predetermined Service Animal - Community Price Survey - Based on Episode

Specialized Medical Equipment/Supplies/Assistive Technology - Purchase - Community Price Survey - Fixed/Predetermined

Specialized Medical Equipment/Supplies/Assistive Technology- Monthly Fee - Community Price Survey - Fixed/Predetermined

Supported Living - Comparative Analysis - Fixed/Predetermined

Transportation Services (non-medical) - Comparative Analysis - Fixed/Predetermined

The following rates described in Appendix J are average cost per unit:

Center-Based Prevocational Services, Supported Employment Individual/Self-Employment, Day Supports, Residential Habilitation, Environmental Adaptations - Home, Environmental Adaptations - Vehicle, Specialized Medical Equipment/Supplies/Assistive Technology—Monthly Fee, Specialized Medical, Equipment/Supplies/Assistive Technology—Purchase

The following rates are standard rates:

Homemaker, Personal Assistance, Respite – Routine, Waiver Support Coordination, Chore Services, Community Transition Services, Family and Individual Training and Preparation Service - Tier I, Family and Individual Training and Preparation Service - Tier II, Financial Management Services, Massage Therapy, Personal Budget Assistance, Personal Emergency Response System, Professional Medication Monitoring (RN/LPN), Professional Nursing Services (Tier 1/Tier 2), Respite Care – Intensive, Respite Care – Session, Respite – Routine Group, Supported Living, Transportation Services (non-medical), Extended Living Supports, Companion Services, Supported Employment Day, Behavior Consultation I, Behavior Consultation II, Behavior Consultation III

The State pays individualized rates based on documented and assessed needs for the following services: Center-Based Prevocational Services

Day Supports Residential Habilitation

Supported Employment Individual/Self-Employment

These rates are negotiated with providers and are based on the assessed needs of the individual being served.

The State pays individual rates based on the cost of adaptations or items within the established MAR for the following services:

Environmental Adaptations - Home Environmental Adaptations - Vehicle

Specialized Medical Equipment/Supplies/Assistive Technology—Monthly Fee Specialized Medical Equipment/Supplies/Assistive Technology—Purchase

Adaptations or items must be the least costly alternative based on individualized documented and assessed needs, and supported by clinical recommendations as appropriate.

The State pays set rates based on acuity for the following services: Professional Medication Monitoring- RN and LPN

Professional Nursing Services- Tier I and Tier II

The differentiation between these services is defined in Appendix C

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Virginia Waiver# VA.0430.R03.02 

VA Building Independence Waiver 

Waiver Name:
VA Building Independence Waiver 
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Virginia Waiver# VA.0430.R03.02

Cost Neutrality

Cost Neutrality for Virginia Waiver# VA.0430.R03.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
400 420

Year 1 Waiver Services

List of Year 1 Waiver Services for Virginia Waiver# VA.0430.R03.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Day Services hour 400 696 $11.58
Individual Supported Employment hour 6 100.3 $65.39
Benefits Planning hour 3 14 $35.71
Community Coaching hour 49 130 $30.07
Community Engagement hour 378 249.4 $16.86
Community Guide hour 19 60 $41.28
Group Supported Employment hour 42 897.8 $13.12

Year 5 Waiver Services

List of Year 5 Waiver Services for Virginia Waiver# VA.0430.R03.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Day Services hour 420 696 $11.58
Individual Supported Employment hour 6 100.3 $65.39
Benefits Planning hour 3 14 $35.71
Community Coaching hour 50 130 $30.07
Community Engagement hour 392 249.4 $16.86
Community Guide hour 20 60 $41.28
Group Supported Employment hour 44 897.8 $13.12

Rate Determination Methods

Rate Determination Methods for Virginia Waiver# VA.0430.R03.02

Rate determination and oversight is a shared responsibility between the Department of Medical Assistance Services (DMAS) and the Department of Behavioral Health and Developmental Services (DBHDS). The DMAS Provider Reimbursement Division ensures that rates are based on the approved methodologies; are in accordance with authorized funding; and consistent with economy, efficiency, and quality of care’ and are sufficient to attract a sufficient number of providers. A complete listing of all current waiver services rates are maintained on the DMAS Web site (http://www.dmas.virginia.gov/Content_pgs/pr-rsetting.aspx) and is available to the public for review. Individuals may call DMAS to request a written copy of the rate schedule.

Services are reimbursed on a prospective, fee-for-service basis, with the exceptions discussed below. Rates vary by region with higher rates paid for services in Northern Virginia to account for higher wage and other costs compared to the rest of the Commonwealth. All providers – including public providers – are paid the same rates for waiver services. There is no rate reconciliation methodology for public providers or Medicaid cost report for these services. In general, rates are adequate to attract a sufficient number of providers to furnish services to individuals.

DBHDS engaged Burns & Associates, Inc. (B&A), a national consultant experienced in developing provider reimbursement rates for home and community based services, to conduct a rate study. The rate study process began in 2014 and the same process is used in new rates. The rate study encompassed several activities, including varied opportunities for public comment.

• DBHDS identified policy goals that could be affected by the rates. These goals included providing adequate funding for direct support professionals’ wages, benefits, and training to reduce turnover and professionalize the workforce; moving away from one-size-fits-all rates to better support members across the continuum of needs, including those transitioning from institutional settings; and encouraging individualized and person-centered supports, consistent with the home and community based services rule.

• A rate-setting advisory group comprised of providers was convened several times during the rate-setting process to serve as a ‘sounding board’ to discuss project goals and materials.

• All providers were invited to complete a survey related to their service design and costs. A second survey directed towards consumer-directed services facilitation providers was administered in 2016 in order to finalize those rate models.

• Benchmark data was identified and researched, including the Bureau of Labor Statistics’ cross-industry wage and benefit data as well as rates for comparable services in other waiver programs.

• Proposed rate models that outline the specific assumptions related to each category of costs were developed.

• Analysis was conducted to use Supports Intensity Scale® (SIS®) assessment data to create ‘tiered’ rates for residential and day habilitation services to recognize the need for more intensive staffing for individuals with more significant needs. Specifically, each member is assigned to one of seven levels based on assessment results in the areas of home living support needs, community living support needs, health and safety needs, medically-related support needs, and behaviorally-related support needs. These seven levels, in turn, are cross-walked to four rate categories: low needs (level 1), modest needs (level 2), moderate to significant needs (levels 3 and 4), and highest needs (levels 5, 6, and 7.

• The proposed rate models and supporting documentation were posted on a dedicated website. Providers and other stakeholders were notified of the posting via email. A webinar was conducted and recorded to explain the proposals. A dedicated email address was created to accept comments and suggestions for a period of approximately one month. DBHDS reviewed every comment submitted and prepared a written document summarizing its response to each, including any resulting revision to the rate models or an explanation for why no change was made. This non-required comment period occurred before the proposed rates were formally incorporated into the waiver application. The entire application, including the rates, was then subject to a formal comment period overseen by DMAS.

Based on the rate study, B&A developed independent rate models intended to reflect the costs that providers face in delivering a given service. Specific assumptions are made for these various costs, including:

• The wage of the direct support professional

• Benefits for the direct support professional

• The productivity of the direct support professional (to account for non-billable responsibilities)

• Other direct care costs, such as transportation and program supplies

• Agency overhead costs

• Programmatic factors that impact per-person costs, such as staffing ratios

Specific cost assumptions were based on provider-reported data as well as other benchmarks. Wage and benefit assumptions were derived primarily from BLS data to ensure waiver providers’ competitiveness. Assumptions related to agency overhead costs are based primarily on cost data from private (non-public) providers. Specifically, overhead is divided into administrative and program support. Administrative costs are those associated with the operation of an organization, but which are not program-specific, including general management, financial/accounting, and human resource staff. Program support costs are expenses that are neither direct care nor administrative. Such activities are program-specific, but not on behalf of an individual member, such as training of direct care workers, program development, supervision, and quality assurance. The rate models assume that 11 percent of the total rates support agency administrative costs. Another 10 percent (on average) of the total rate is assumed to cover program support costs.

The rate setting methodology described above was used to establish benchmark rates for the following services:

• Independent Living Supports

• Shared living

• Crisis Supports (Community-based Crisis supports, Center-based Crisis Supports, Crisis Support Services)

• PERS

• Group supported employment

• Community engagement

• Group day support

• Benefits planning services

The rate model assumptions are used to construct the fee-for-services rates, but the individual assumptions are not prescriptive to service providers. For instance, providers are not required to pay the wages assumed in the rate models. Rather, providers have the flexibility within the total rate to design programs that meet members’ needs, consistent with service requirements and members’ individual support plans.

While there is no formal schedule for annual cost of living increases to the rates, the use of detailed and transparent rate models allows for periodic review and adjustment of the rates. For example, the rate models were revised in March 2016 to account for more current BLS wage information and a change in the Internal Revenue Services. Rates are not increased automatically for inflation but may be increased if authorized by the state budget through the VA General Assembly. Rate increases are subject to funding by the General Assembly as part of the state budgeting process. Recommendations for rate adjustments as part of budget deliberations may come from DMAS and DBHDS or service recipients, providers, and other members of the public.

Rate and reimbursement methodologies for services not included in the rate-setting effort described above are as follows:

• For Supported Employment-Individual services, providers are reimbursed at the same rate as their agreements with the Department of Aging and Rehabilitative Services (DARS) in order to encourage the seamless delivery of employment supports. DARS establishes each provider’s Supported Employment rates on an annual basis through a Purchase of Service Application, which is similar to a cost report. The hourly rate is calculated by dividing budgeted costs by budgeted service hours. Budgeted costs include employee compensation allocated to services, professional fees, supplies, communications, building expenses, rental and maintenance of equipment, printing and publications, travel, training, membership dues, non-mortgage interest and capital depreciation.

• Reimbursement for Environmental Modifications, Assistive Technology, and Electronic Home-Based Supports is based on approved cost up to a $5,000 annual limit. Reimbursement for Transition Services is based on approved cost up to a $5,000 lifetime limit. .

• For Personal Emergency Response Services, which has low utilization and few providers, the Commonwealth’s rates were compared to the rates paid by other states in order to ensure reasonableness. PERS monthly monitoring rates were identified in 1915(c) waivers for persons with intellectual and developmental disabilities in twenty-two other states for validation. This comparison found that the average Virginia rate falls within the third or middle quintile of these other states.

Rates for Community Guide and Employment and Community Transportation services followed a similar process as the overall rate setting methodology as described above except that there was not a provider survey (because the services are new, there was nothing to survey).

Similar to other DD services, Virginia developed the Community Guide, Peer Mentoring Supports, and Community Transportation using independent rate models. These models reflect the costs that provider face in delivering these services. The models account for various costs, including:

• The wage of the direct support professional

• Benefits for the direct support professional

• The productivity of the direct support professional (to account for non-billable responsibilities)

• Other direct care costs, such as transportation and program supplies

• Agency overhead costs

• Programmatic factors that affect per-person costs, such as staffing ratios

For Employment and Community Transportation, the state researched public and private transportation costs for various regions throughout the state. Transportation options included: bus, “Dial A Ride”, Metrorail (Northern Virginia), taxi, and Uber. The research analyzed peak and non-peak fares for senior/disabled individuals, along with regular fares. The findings from this research were incorporated into this rate model.

The rate models for Community Guide, Peer Mentoring Supports, and Community Transportation are fully funded.

For Benefits Planning services, the waiver has adopted the rates paid by the Commonwealth’s vocational rehabilitation program for the same services.

Benefits Planning consists of four categories: Pre-employment benefits review, Work Incentives Development or Revision, Resolution of SSA benefits issues, and Other services. There are a total of 17 allowable activities that are encompassed within the overall four categories. A person-centered plan is developed and based on the individual's needs and hours for each activity authorized. The service is reimbursed based on a single hourly rate.

1. The State intends to utilize hourly units of service. All service areas have the same hourly rate. The annual limit for services is $3,000 per year. The services will be authorized and reimbursed based on the person-centered planning process used to determine the activities needed and corresponding service hours.

2. Reimbursement may occur upon completion of each unit hourly unit of service.

Virginia Waiver# VA.0372.R04.00 

VA Community Living (CL) Waiver

Waiver Name:
VA Community Living (CL) Waiver
Effective Date:
7/1/2019
Expiration Date:
6/30/2024

Services

List of Services for Virginia Waiver# VA.0372.R04.00

Cost Neutrality

Cost Neutrality for Virginia Waiver# VA.0372.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
11736 12323

Year 1 Waiver Services

List of Year 1 Waiver Services for Virginia Waiver# VA.0372.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Day Services hour 7637 792.3 $13.05
Group Day Services Customized Rate hour 2 1143.3 $31.18
Individual Supported Employment hour 258 132.3 $60.42
Benefits Planning hour 78 60 $41.28
Community Coaching hour 1462 129.6 $30.25
Community Coaching Customized Rate hour 5 130 $53.06
Community Engagement hour 7637 286.8 $18.10
Community Guide hour 83 60 $41.28
Group Supported Employment hour 871 913.9 $13.12
Workplace Assistance Services hour 617 520 $30.10

Year 5 Waiver Services

List of Year 5 Waiver Services for Virginia Waiver# VA.0372.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Day Services hour 8019 792.6 $13.06
Group Day Services Customized Rate hour 2 1143.3 $31.18
Individual Supported Employment hour 271 132.3 $60.42
Benefits Planning hour 82 60 $41.28
Community Coaching hour 1535 129.6 $30.25
Community Coaching Customized Rate hour 5 130 $53.06
Community Engagement hour 8019 286.8 $18.10
Community Guide hour 88 60 $41.28
Group Supported Employment hour 914 913.9 $13.12
Workplace Assistance Services hour 648 520 $30.10

Rate Determination Methods

Rate Determination Methods for Virginia Waiver# VA.0372.R04.00

Rate determination and oversight is a shared responsibility between the Department of Medical Assistance Services (DMAS) and the Department of Behavioral Health and Developmental Services (DBHDS). The DMAS Provider Reimbursement Division ensures that rates are based on the approved methodologies; are in accordance with authorized funding; and consistent with economy, efficiency, and quality of care’ and are sufficient to attract a sufficient number of providers. A complete listing of all current waiver services rates are maintained on the DMAS Web site (http://www.dmas.virginia.gov/Content_pgs/pr-rsetting.aspx) and is available to the public for review. Individuals may call DMAS to request a written copy of the rate schedule.

Services are reimbursed on a prospective, fee-for-service basis, with the exceptions discussed below. Rates vary by region with higher rates paid for services in Northern Virginia to account for higher wage and other costs compared to the rest of the Commonwealth. All providers – including public providers – are paid the same rates for waiver services. There is no rate reconciliation methodology for public providers or Medicaid cost report for these services. In general, rates are adequate to attract a sufficient number of providers to furnish services to individuals.

DBHDS engaged Burns & Associates, Inc. (B&A), a national consultant experienced in developing provider reimbursement rates for home and community based services, to conduct a rate study. The rate study process began in 2014 and the same process is used in new rates. The rate study encompassed several activities, including varied opportunities for public comment.

• DBHDS identified policy goals that could be affected by the rates. These goals included providing adequate funding for direct support professionals’ wages, benefits, and training to reduce turnover and professionalize the workforce; moving away from one-size-fits-all rates to better support members across the continuum of needs, including those transitioning from institutional settings; and encouraging individualized and person-centered supports, consistent with the home and community based services rule.

• A rate-setting advisory group comprised of providers was convened several times during the rate-setting process to serve as a ‘sounding board’ to discuss project goals and materials.

• All providers were invited to complete a survey related to their service design and costs. A second survey directed towards consumer-directed services facilitation providers was administered in 2016 in order to finalize those rate models.

• Benchmark data was identified and researched, including the Bureau of Labor Statistics’ cross-industry wage and benefit data as well as rates for comparable services in other waiver programs.

• Proposed rate models that outline the specific assumptions related to each category of costs were developed.

• Analysis was conducted to use Supports Intensity Scale® (SIS®) assessment data to create ‘tiered’ rates for residential and day habilitation services to recognize the need for more intensive staffing for individuals with more significant needs. Specifically, each member is assigned to one of seven levels based on assessment results in the areas of home living support needs, community living support needs, health and safety needs, medically-related support needs, and behaviorally-related support needs. These seven levels, in turn, are cross-walked to four rate categories: low needs (level 1), modest needs (level 2), moderate to significant needs (levels 3 and 4), and highest needs (levels 5, 6, and 7).

• The proposed rate models and supporting documentation were posted on a dedicated website. Providers and other stakeholders were notified of the posting via email. A webinar was conducted and recorded to explain the proposals. A dedicated email address was created to accept comments and suggestions for a period of approximately one month. DBHDS reviewed every comment submitted and prepared a written document summarizing its response to each, including any resulting revision to the rate models or an explanation for why no change was made. This non-required comment period occurred before the proposed rates were formally incorporated into the waiver application. The entire application, including the rates, was then subject to a formal comment period overseen by DMAS.

Based on the rate study, B&A developed independent rate models intended to reflect the costs that providers face in delivering a given service. Specific assumptions are made for these various costs, including:

• The wage of the direct support professional

• Benefits for the direct support professional

• The productivity of the direct support professional (to account for non-billable responsibilities)

• Other direct care costs, such as transportation and program supplies

• Agency overhead costs

• Programmatic factors that impact per-person costs, such as staffing ratios

Specific cost assumptions were based on provider-reported data as well as other benchmarks. Wage and benefit assumptions were derived primarily from BLS data to ensure waiver providers’ competitiveness. Assumptions related to agency overhead costs are based primarily on cost data from private (non-public) providers. Specifically, overhead is divided into administrative and program support. Administrative costs are those associated with the operation of an organization, but which are not program-specific, including general management, financial/accounting, and human resource staff. Program support costs are expenses that are neither direct care nor administrative. Such activities are program-specific, but not on behalf of an individual member, such as training of direct care workers, program development, supervision, and quality assurance. The rate models assume that 11 percent of the total rates support agency administrative costs. Another 10 percent (on average) of the total rate is assumed to cover program support costs.

The rate setting methodology described above was used to establish benchmark rates for the following services:

• Shared living

• Supported living residential

• In-Home Support

• Sponsored residential

• Group home residential

• Skilled and Private Duty Nursing

• Therapeutic Consultation

• Crisis Supports (crisis support services, community-based crisis supports, center-based crisis supports)

• PERS

• Group supported employment

• Community engagement

• Group day support

• Workplace assistance services

• Personal assistance (agency and consumer direction)

• Respite Care (agency and consumer direction)

• Companion Care (agency and consumer direction)

• Service Facilitation

• Benefits Planning Services (added for amendment effective 7/1/18)

The rate model assumptions are used to construct the fee-for-services rates, but the individual assumptions are not prescriptive to service providers. For instance, providers are not required to pay the wages assumed in the rate models. Rather, providers have the flexibility within the total rate to design programs that meet members’ needs, consistent with service requirements and members’ individual support plans.

While there is no formal schedule for annual cost of living increases to the rates, the use of detailed and transparent rate models allows for periodic review and adjustment of the rates. For example, the rate models were revised in March 2016 to account for more current BLS wage information and a change in the Internal Revenue Services. Rates are not increased automatically for inflation but may be increased if authorized by the state budget through the VA General Assembly. Rate increases are subject to funding by the General Assembly as part of the state budgeting process.

Recommendations for rate adjustments as part of budget deliberations may come from DMAS and DBHDS or service recipients, providers, and other members of the public.

Most of the rate models have been fully funded, but for certain services a lesser ‘adopted’ rate has been implemented:

• Skilled Nursing rates for registered nurses are funded at 61 percent of the rate model for Northern Virginia and 63 percent for the rest of the state.

• Skilled Nursing rates for licensed practical nurses are funded at 71 percent of the rate model for Northern Virginia and 71 percent for the rest of the state.

• Private Duty Nursing rates for registered nurses are funded at 61 percent of the rate model for Northern Virginia and 63 percent for the rest of the state.

• Private Duty Nursing rates for licensed practical nurses are funded at 73 percent of the rate model for Northern Virginia and 74 percent for the rest of the state.

• Agency rates for Personal Assistance, Respite, and Companion Care are funded at 65 percent of the rate model for Northern Virginia and 67 percent for the rest of the state.

• Consumer-directed rates for Personal Assistance, Respite, and Companion Care are funded at 69 percent of the rate model for Northern Virginia and 66 percent for the rest of the state.

• Across all consumer-directed services facilitation supports, rates are funded at an average of 88 percent of the rate model for Northern Virginia and 83 percent for the rest of the state. Rate and reimbursement methodologies for services not included in the rate-setting effort described above are as follows:

• For Supported Employment-Individual services, providers are reimbursed at the same rate as their agreements with the Department of Aging and Rehabilitative Services (DARS) in order to encourage the seamless delivery of employment supports. DARS establishes each provider’s Supported Employment rates on an annual basis through a Purchase of Service Application, which is similar to a cost report. The hourly rate is calculated by dividing budgeted costs by budgeted service hours. Budgeted costs include employee compensation allocated to services, professional fees, supplies, communications, building expenses, rental and maintenance of equipment, printing and publications, travel, training, membership dues, non-mortgage interest and capital depreciation.

• Reimbursement for Environmental Modifications, Assistive Technology, and Electronic Home-Based Supports is based on approved cost up to a $5,000 annual limit. Reimbursement for Transition Services is based on approved cost up to a $5,000 lifetime limit. Reimbursement for Individual and Family/ Caregiver Training is based on approved cost up to a $4,000 annual limit.

• For Personal Emergency Response Services, which has low utilization and few providers, the Commonwealth’s rates were compared to the rates paid by other states in order to ensure reasonableness. PERS monthly monitoring rates were identified in 1915(c) waivers for persons with intellectual and developmental disabilities in twenty-two other states for validation. This comparison found that the average Virginia rate falls within the third or middle quintile of these other states.

Please see Main module for information related to customized rate methodology.

• Rates for Community Guide and Employment and Community Transportation services followed a similar process as the overall rate setting methodology as described above except that there was not a provider survey (because the services are new, there was nothing to survey).

Continued in Main Optional B

Virginia Waiver# VA.0358.R04.02 

VA Family and Individual Support Waiver

Waiver Name:
VA Family and Individual Support Waiver
Effective Date:
7/1/2018
Expiration Date:
6/30/2023

Services

List of Services for Virginia Waiver# VA.0358.R04.02

Cost Neutrality

Cost Neutrality for Virginia Waiver# VA.0358.R04.02

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2176 3132

Year 1 Waiver Services

List of Year 1 Waiver Services for Virginia Waiver# VA.0358.R04.02

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Day Services hour 318 914.8 $12.35
Individual Supported Employment hour 131 137.5 $61.86
Benefits Planning hour 15 14 $35.71
Community Coaching hour 65 130 $30.53
Community Engagement hour 318 214.8 $17.32
Community Guide hour 33 60 $41.28
Group Supported Employment hour 65 648.2 $13.17
Workplace Assistance Services hour 83 520 $30.16

Year 5 Waiver Services

List of Year 5 Waiver Services for Virginia Waiver# VA.0358.R04.02

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Group Day Services hour 458 914.8 $12.35
Individual Supported Employment hour 188 137.5 $61.86
Benefits Planning hour 21 14 $35.71
Community Coaching hour 125 130 $30.53
Community Engagement hour 458 214.8 $17.32
Community Guide hour 48 60 $41.28
Group Supported Employment hour 94 648.2 $13.17
Workplace Assistance Services hour 119 520 $30.16

Rate Determination Methods

Rate Determination Methods for Virginia Waiver# VA.0358.R04.02

Rate determination and oversight is a shared responsibility between the Department of Medical Assistance Services (DMAS) and the Department of Behavioral Health and Developmental Services (DBHDS). The DMAS Provider Reimbursement Division ensures that rates are based on the approved methodologies; are in accordance with authorized funding; and consistent with economy, efficiency, and quality of care’ and are sufficient to attract a sufficient number of providers. A complete listing of all current waiver services rates are maintained on the DMAS Web site (http://www.dmas.virginia.gov/Content_pgs/pr-rsetting.aspx) and is available to the public for review. Individuals may call DMAS to request a written copy of the rate schedule.

Services are reimbursed on a prospective, fee-for-service basis, with the exceptions discussed below. Rates vary by region with higher rates paid for services in Northern Virginia to account for higher wage and other costs compared to the rest of the Commonwealth. All providers – including public providers – are paid the same rates for waiver services. There is no rate reconciliation methodology for public providers or Medicaid cost report for these services. In general, rates are adequate to attract a sufficient number of providers to furnish services to individuals.

DBHDS engaged Burns & Associates, Inc. (B&A), a national consultant experienced in developing provider reimbursement rates for home and community based services, to conduct a rate study. The rate study process began in 2014 and the same process is used in new rates. The rate study encompassed several activities, including varied opportunities for public comment.

• DBHDS identified policy goals that could be affected by the rates. These goals included providing adequate funding for direct support professionals’ wages, benefits, and training to reduce turnover and professionalize the workforce; moving away from one-size-fits-all rates to better support members across the continuum of needs, including those transitioning from institutional settings; and encouraging individualized and person-centered supports, consistent with the home and community based services rule.

• A rate-setting advisory group comprised of providers was convened several times during the rate-setting process to serve as a ‘sounding board’ to discuss project goals and materials.

• All providers were invited to complete a survey related to their service design and costs. A second survey directed towards consumer-directed services facilitation providers was administered in 2016 in order to finalize those rate models.

• Benchmark data was identified and researched, including the Bureau of Labor Statistics’ cross-industry wage and benefit data as well as rates for comparable services in other waiver programs.

• Proposed rate models that outline the specific assumptions related to each category of costs were developed.

• Analysis was conducted to use Supports Intensity Scale® (SIS®) assessment data to create ‘tiered’ rates for residential and day habilitation services to recognize the need for more intensive staffing for individuals with more significant needs. Specifically, each member is assigned to one of seven levels based on assessment results in the areas of home living support needs, community living support needs, health and safety needs, medically-related support needs, and behaviorally-related support needs. These seven levels, in turn, are cross-walked to four rate categories: low needs (level 1), modest needs (level 2), moderate to significant needs (levels 3 and 4), and highest needs (levels 5, 6, and 7).

• The proposed rate models and supporting documentation were posted on a dedicated website. Providers and other stakeholders were notified of the posting via email. A webinar was conducted and recorded to explain the proposals. A dedicated email address was created to accept comments and suggestions for a period of approximately one month. DBHDS reviewed every comment submitted and prepared a written document summarizing its response to each, including any resulting revision to the rate models or an explanation for why no change was made. This non-required comment period occurred before the proposed rates were formally incorporated into the waiver application. The entire application, including the rates, was then subject to a formal comment period overseen by DMAS.

Based on the rate study, B&A developed independent rate models intended to reflect the costs that providers face in delivering a given service. Specific assumptions are made for these various costs, including:

• The wage of the direct support professional

• Benefits for the direct support professional

• The productivity of the direct support professional (to account for non-billable responsibilities)

• Other direct care costs, such as transportation and program supplies

• Agency overhead costs

• Programmatic factors that impact per-person costs, such as staffing ratios

Specific cost assumptions were based on provider-reported data as well as other benchmarks. Wage and benefit assumptions were derived primarily from BLS data to ensure waiver providers’ competitiveness. Assumptions related to agency overhead costs are based primarily on cost data from private (non-public) providers. Specifically, overhead is divided into administrative and program support. Administrative costs are those associated with the operation of an organization, but which are not program-specific, including general management, financial/accounting, and human resource staff. Program support costs are expenses that are neither direct care nor administrative. Such activities are program-specific, but not on behalf of an individual member, such as training of direct care workers, program development, supervision, and quality assurance. The rate models assume that 11 percent of the total rates support agency administrative costs. Another 10 percent (on average) of the total rate is assumed to cover program support costs.

The rate setting methodology described above was used to establish benchmark rates for the following services:

• Shared living

• Supported living residential

• In-Home Support

• Skilled and Private Duty Nursing

• Therapeutic Consultation

• Crisis Support

• PERS

• Group supported employment

• Community engagement

• Group day support

• Workplace assistance services

• Personal assistance (agency and consumer direction)

• Respite Care (agency and consumer direction)

• Companion Care (agency and consumer direction)

• Service Facilitation

• Benefits Planning Services

The rate model assumptions are used to construct the fee-for-services rates, but the individual assumptions are not prescriptive to service providers. For instance, providers are not required to pay the wages assumed in the rate models. Rather, providers have the flexibility within the total rate to design programs that meet members’ needs, consistent with service requirements and members’ individual support plans.

While there is no formal schedule for annual cost of living increases to the rates, the use of detailed and transparent rate models allows for periodic review and adjustment of the rates. For example, the rate models were revised in March 2016 to account for more current BLS wage information and a change in the Internal Revenue Services. Rates are not increased automatically for inflation but may be increased if authorized by the state budget through the VA General Assembly. Rate increases are subject to funding by the General Assembly as part of the state budgeting process. Recommendations for rate adjustments as part of budget deliberations may come from DMAS and DBHDS or service recipients, providers, and other members of the public.

Most of the rate models have been fully funded, but for certain services a lesser ‘adopted’ rate has been implemented:

• Skilled Nursing rates for registered nurses are funded at 61 percent of the rate model for Northern Virginia and 63 percent for the rest of the state.

• Skilled Nursing rates for licensed practical nurses are funded at 71 percent of the rate model for Northern Virginia and 71 percent for the rest of the state.

• Private Duty Nursing rates for registered nurses are funded at 61 percent of the rate model for Northern Virginia and 63 percent for the rest of the state.

• Private Duty Nursing rates for licensed practical nurses are funded at 73 percent of the rate model for Northern Virginia and 74 percent for the rest of the state.

• Agency rates for Personal Assistance, Respite, and Companion Care are funded at 65 percent of the rate model for Northern Virginia and 67 percent for the rest of the state.

• Consumer-directed rates for Personal Assistance, Respite, and Companion Care are funded at 69 percent of the rate model for Northern Virginia and 66 percent for the rest of the state.

• Across all consumer-directed services facilitation supports, rates are funded at an average of 88 percent of the rate model for Northern Virginia and 83 percent for the rest of the state.

Rate and reimbursement methodologies for services not included in the rate-setting effort described above are as follows:

• For Supported Employment-Individual services, providers are reimbursed at the same rate as their agreements with the Department of Aging and Rehabilitative Services (DARS) in order to encourage the seamless delivery of employment supports. DARS establishes each provider’s Supported Employment rates on an annual basis through a Purchase of Service Application, which is similar to a cost report. The hourly rate is calculated by dividing budgeted costs by budgeted service hours. Budgeted costs include employee compensation allocated to services, professional fees, supplies, communications, building expenses, rental and maintenance of equipment, printing and publications, travel, training, membership dues, non-mortgage interest and capital depreciation.

• Reimbursement for Environmental Modifications, Assistive Technology, and Electronic Home-Based Supports is based on approved cost up to a $5,000 annual limit. Reimbursement for Transition Services is based on approved cost up to a $5,000 lifetime limit. Reimbursement for Individual and Family/ Caregiver Training is based on approved cost up to a $4,000 annual limit.

• For Personal Emergency Response Services, which has low utilization and few providers, the Commonwealth’s rates were compared to the rates paid by other states in order to ensure reasonableness. PERS monthly monitoring rates were identified in 1915(c) waivers for persons with intellectual and developmental disabilities in twenty-two other states for validation. This comparison found that the average Virginia rate falls within the third or middle quintile of these other states.

See Optional Attachment.

Washington Waiver# WA.0411.R03.04 

Community Protection Waiver

Waiver Name:
Community Protection Waiver
Effective Date:
9/1/2017
Expiration Date:
8/31/2022

Services

List of Services for Washington Waiver# WA.0411.R03.04

Cost Neutrality

Cost Neutrality for Washington Waiver# WA.0411.R03.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
464 504

Year 1 Waiver Services

List of Year 1 Waiver Services for Washington Waiver# WA.0411.R03.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Individual Supported Employment/Group Supported Employment each 332 436.74 $16.50
Prevocational Services each 1 3440.4 $12.50

Year 5 Waiver Services

List of Year 5 Waiver Services for Washington Waiver# WA.0411.R03.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Individual Supported Employment/Group Supported Employment each 361 436.47 $16.50
Prevocational Services each 0 0 $12.50

Rate Determination Methods

Rate Determination Methods for Washington Waiver# WA.0411.R03.04

The State publishes its fee schedules at: https://www.dshs.wa.gov/altsa/management-services-division/office-rates- management.

All negotiated rates comply with Federal and Washington State minimum wage requirements.

The DDA and the Health Care Authority follow the federal guidelines found in 42 U.S.C. § 1396a(a)(30)(A) when establishing rates so that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist providers for services to ensure adequate access to care for Medicaid recipients. Steps taken to ensure rates comply with federal requirements include: workgroups, stakeholder meetings, consultation with program managers, consultation with professional organizations, analysis of market rates, rates paid by other states for comparable services, and the budget impacts of rates. For example, for nursing services, comparable services in the private sector and in other states include private duty nursing/in-home nursing as provided by LPNs or RNs.

Payment cannot exceed 1) the prevailing charges in the locality for comparable services under comparable circumstances, or 2) the rates charged for comparable services funded by other sources. Methods for determining reasonable rates include periodic market surveys, cost analysis and price comparison. HCA conducts these activities every two to four years, per requests by the Legislature and/or indications that access to services is being impacted by current rates. For DDA rates, this information has been added below under each set of services.

Waiver service definitions and provider qualifications are standardized. This helps ensure that rates are comparable (not necessarily identical) across the state for those services that are negotiated on a regional basis by DDA staff, as rates are for identical services with providers meeting the same qualifications.

HCA rates are updated every January with any possible new codes, and rates are changed every July to align with the new relative value units (RVUs), State geographic price cost index (GPCI), and State specific conversion factor. For codes that do not have RVUs, rates are usually set at a flat rate. If analysis shows they need to be updated, that happens every July with the other codes. The most recent update was in July 2014, and will be updated again this coming July.

With respect to rates established by DDA, the most recent rate comparison was conducted in the spring of 2014.

For HCA-based rates, an amendment to the rates is triggered by directive and/or funding by the Legislature, and/or a change to RVUs, and the Legislature is responsible for funding rate changes. The HCA identifies the need for a rate change using indicators listed below. Without additional funding, rate changes must be budget neutral. If a rate change is not budget neutral, it would be made only if funding was provided by the Legislature or the Legislature required service coverage changes to save the funding needed for the rate change.

For DDA, specifics regarding when rates are adjusted & the criteria used to evaluate the need for rate adjustments are at the end of the discussion of each set of services. When funding is available, the Legislature mandates rate increases for specific types of vendors (e.g., individual providers, residential providers, adult family homes) and/or services.

Regarding criteria for HCA to adjust rates, RVU driven rates are updated yearly per new RVUs. For flat rates, a significant (e.g., 25%) drop in the use of services by Medicaid participants, a significant (e.g., 25%) drop in the number of enrolled providers, an indication that payment rates are substantially (e.g., 40%) below third-party insurer rates, and/or a request by the Legislature for an analysis of rate adequacy are indicators of the need for rate adjustments.

Rates are adjusted with approval from the Legislature.

Rates negotiated with employee unions are static during the life of the contract & are the rates identified within the contract. These rates are only adjusted as written within the contract.

Regarding the cost allocation plan, DSHS does not establish indirect rates for Title XIX administration. A Public Assistance Cost allocation plan allocates administrative costs through various allocation methodologies (see attachment for the most current submission). The Public Assistance Cost Allocation plans for DDA & ALSTA describe the cost allocation methodologies to the CFDA (Medicaid) grant level & does not list specific waivers.

OPPORTUNITY FOR PUBLIC COMMENT IN THE RATE DETERMINATION PROCESS:

The Administrative Procedure Act, Chapter 34.05 RCW, is followed when soliciting public comments on rate determination methods. Changes to rates that are made by the legislature in the biennial and supplemental budget process are part of public hearings on budget and policy legislation. Rates are posted on public web sites.

Day Habilitation- Fee schedule

o Prevocational: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations.

Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties. No waiver participants will be added to pre-vocational services effective 7/1/2015 onward, as pre-vocational services do not meet the requirements for a home and community setting. Individuals already receiving prevocational services as of 7/1/2015 will be phased out over a four-year period and transitioned to other services, including supported employment and/or individual technical assistance or community access services.

o Supported Employment- Fee Schedule

Group Supported Employment: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

Individual Supported Employment: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties. Assistive Technology, Specialized Clothing, Specialized Medical Equipment & Supplies, Therapeutic Equipment & Supplies, and community-based settings for respite services: Rates are based on usual & customary charges for the products/services as paid by the general public. Charges are adjusted by the supplier based on overhead, staff wages & the local demand for the products/services. To maintain availability of these products/services for waiver participants, DDA adjusts rates if rate comparisons indicate prevailing market rates have increased significantly (e.g., 20%+).

Positive Behavior Support and Consultation- Fee Schedule Rate: Regional DDA staff negotiate rates on a provider- specific basis within an identified rate range which is based upon WA state average salaries. Variations in rates are due to differences among providers related to overhead, staff wages, the local demand for services and provider performance. Rate ranges are reviewed every five years and rates for each provider are reviewed within their identified rate range at the time of reconstructing, or every three years.

Behavioral Health Stabilization Services (privately-contracted), Risk Assessments, Specialized Psychiatric Services, & Staff/Family Consultation & Training: Rates are negotiated by DDA regional staff with individual providers/agencies. Variations in rates are due to provider differences related to overhead, staff wages, & the local demand for services.

Rate changes may be proposed by providers or by DDA. Criteria for rate changes include funding provided by the Legislature & the rates paid for similar services in the geographic area, which in turn are based on provider overhead, staff wages (if applicable) & the local demand for services. DDA adjusts rates annually if necessary. To increase contracted rates, rate comparisons must indicate prevailing market rates have increased significantly (e.g., 20%+).

Environmental Adaptations: Payments are based upon bids received by potential contractors. Variations in payments are due to differences among providers related to overhead, staff wages, and the local demand for services. Payments are adjusted as the bids change over time, which in turn are based on the local cost of goods & labor & the demand for the service. Providers initiate the change in payment by the bids they submit. Competitive bids are reviewed by DDA staff.

DDA determined the rate setting methodology in consultation with Management Services Division (MSD) of Aging and Long Term Support Administration (ALTSA), DDA is the entity responsible for the rate determination and DDA conducts the oversight of the rate determination process for Chemical Extermination of Bed Bugs and Behavioral Health Crisis Diversion Bed Services – Privately Contracted. DDA uses rate based on current market rate as the rate setting methodology for Chemical Extermination of Bed Bugs. DDA uses a negotiated rate methodology for Behavioral Health Crisis Diversion Bed Services – Privately Contracted.

State has multiple processes for stakeholder involvement in the development of rates. For Respite and Personal Care, rates are negotiated directly with the Services Employees International Union (SEIU). For Individual and Group Employment, Prevocational Services, Community Access and Individualized Technical Assistance, State discusses rates with the Association of County Human Services. Participants are involved in the development of rates through their participation in the Waiver Quality Assurance Advisory Committee which meets quarterly to review all aspects of waiver services, including

provider rates.

Waiver Name:
WA Core Waiver
Effective Date:
9/1/2017
Expiration Date:
8/31/2022

Services

List of Services for Washington Waiver# WA.0410.R03.06

Cost Neutrality

Cost Neutrality for Washington Waiver# WA.0410.R03.06

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
4938 5338

Year 1 Waiver Services

List of Year 1 Waiver Services for Washington Waiver# WA.0410.R03.06

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Inclusion each 758 479.66 $7.76
Individual Supported Employment/Group Supported Employment each 2186 422.66 $17.29
Prevocational Services each 70 1132.75 $13.34
Community Guide hour 5 15.59 $19.05

Year 5 Waiver Services

List of Year 5 Waiver Services for Washington Waiver# WA.0410.R03.06

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Inclusion each 820 479.48 $7.76
Individual Supported Employment/Group Supported Employment each 2364 422.64 $17.29
Prevocational Services each 0 0 $13.34
Community Guide hour 5 16.86 $19.05

Rate Determination Methods

Rate Determination Methods for Washington Waiver# WA.0410.R03.06

The State publishes its fee schedules at: https://www.dshs.wa.gov/altsa/management-services-division/office-rates- management.

The DDA and the Health Care Authority follow the federal guidelines found in 42 U.S.C. § 1396a(a)(30)(A) when establishing rates so that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist providers for services to ensure adequate access to care for Medicaid recipients. Steps taken to ensure rates comply with federal requirements include: workgroups, stakeholder meetings, consultation with program managers, consultation with professional organizations, analysis of market rates, rates paid by other states for comparable services, and the budget impacts of rates. For example, for nursing services, comparable services in the private sector and in other states include private duty nursing/in-home nursing as provided by LPNs or RNs.

Payment cannot exceed 1) the prevailing charges in the locality for comparable services under comparable circumstances, or 2) the rates charged for comparable services funded by other sources. Methods for determining reasonable rates include periodic market surveys, cost analysis and price comparison. HCA conducts these activities every two to four years, per requests by the Legislature and/or indications that access to services is being impacted by current rates. For DDA rates, this information has been added below under each set of services.

Waiver service definitions and provider qualifications are standardized. This helps ensure that rates are comparable (not necessarily identical) across the state for those services that are negotiated on a regional basis by DDA staff, as rates are for identical services with providers meeting the same qualifications.

HCA rates are updated every January with any possible new codes, and rates are changed every July to align with the new relative value units (RVUs), State geographic price cost index (GPCI), and State specific conversion factor. For codes that do not have RVUs, rates are usually set at a flat rate. If analysis shows they need to be updated, that happens every July with the other codes. The most recent update was in July 2014, and will be updated again this coming July.

With respect to rates established by DDA, the most recent rate comparison was conducted in the spring of 2014.

For HCA-based rates, an amendment to the rates is triggered by directive and/or funding by the Legislature, and/or a change to RVUs, and the Legislature is responsible for funding rate changes. The HCA identifies the need for a rate change using indicators listed below. Without additional funding, rate changes must be budget neutral. If a rate change is not budget neutral, it would be made only if funding was provided by the Legislature or the Legislature required service coverage changes to save the funding needed for the rate change.

For DDA, specifics regarding when rates are adjusted & the criteria used to evaluate the need for rate adjustments are at the end of the discussion of each set of services. When funding is available, the Legislature mandates rate increases for specific types of vendors (e.g., individual providers, residential providers, adult family homes) and/or services.

Regarding criteria for HCA to adjust rates, RVU driven rates are updated yearly per new RVUs. For flat rates, a significant (e.g., 25%) drop in the use of services by Medicaid participants, a significant (e.g., 25%) drop in the number of enrolled providers, an indication that payment rates are substantially (e.g., 40%) below third-party insurer rates, and/or a request by the Legislature for an analysis of rate adequacy are indicators of the need for rate adjustments.

Rates are adjusted with approval from the Legislature.

Rates negotiated with employee unions are static during the life of the contract & are the rates identified within the contract. These rates are only adjusted as written within the contract.

Regarding the cost allocation plan, DSHS does not establish indirect rates for Title XIX administration. A Public Assistance Cost allocation plan allocates administrative costs through various allocation methodologies (see attachment for the most current submission). The Public Assistance Cost Allocation plans for DDA & ALSTA describe the cost allocation methodologies to the CFDA (Medicaid) grant level & does not list specific waivers.

OPPORTUNITY FOR PUBLIC COMMENT IN THE RATE DETERMINATION PROCESS:

The Administrative Procedure Act, Chapter 34.05 RCW, is followed when soliciting public comments on rate determination methods. Changes to rates that are made by the legislature in the biennial and supplemental budget process are part of public hearings on budget and policy legislation. Rates are posted on public web sites.

Day Habilitation- Fee schedule

o Community Inclusion: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

o Prevocational: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations.

Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties. No waiver participants have been added to pre- vocational services effective 7/1/2015 onward, as pre-vocational services do not meet the requirements for a home and community setting. Individuals already receiving prevocational services as of 7/1/2015 will be phased out over a four- year period and transitioned to other services, including supported employment and/or individual technical assistance or community inclusion services.

o Supported Employment- Fee Schedule

Group Supported Employment: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

Individual Supported Employment: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

Specialized Medical Equipment & Supplies, and community-based settings for respite services: Rates are based on usual & customary charges for the products/services as paid by the general public. Charges are adjusted by the supplier based on overhead, staff wages & the local demand for the products/services. To maintain availability of these products/services for waiver participants, DDA adjusts rates if rate comparisons indicate prevailing market rates have increased significantly (e.g., 20%+).

Respite- Fee Schedule: Individual personal care and respite rates are based on a per hour unit and are determined by the State legislature, based on negotiations between the Governor’s Office and the union representing Individual Providers. The collective bargaining agreement is negotiated each State fiscal biennium. The bargained rate includes wages, L & I, vacation pay, mileage reimbursement, comprehensive medical, training, and seniority pay. For individual providers who have completed the home care aide certification, the hourly rate also includes a certification differential payment. Due to the agency parity law [RCW 74.39A.310(1)(a)(v)] the home care agency vendor rates are equivalent to that of the individual provider rate.

RCW 41.56.026 establishes collective bargaining rights for individual providers of personal care and respite. The collective bargaining agreement is negotiated every two years and is subject to funding by the state legislature. If changes are made within the bargaining agreement that affect the rate methodology, a waiver amendment will be submitted. Due to the agency parity law [RCW 74.39A.310(1)(a)(v)] the home care agency vendor rates are equivalent to that of the individual provider rate.

Rates for community-based settings such as senior centers and summer camps are a fee schedule that is based upon usual and customary charges, which are impacted by overhead, staff wages, and consumer demand.

Positive Behavior Support and Consultation- Fee Schedule Rate: Regional DDA staff negotiate rates on a provider- specific basis within an identified rate range which is based upon WA state average salaries. Variations in rates are due to differences among providers related to overhead, staff wages, the local demand for services and provider performance. Rate ranges are reviewed every five years and rates for each provider are reviewed within their identified rate range at the time of reconstructing, or every three years. Behavioral Health Stabilization Services (privately-contracted), Risk Assessments, Specialized Psychiatric Services, & Staff/Family Consultation & Training: Rates are negotiated by DDA regional staff with individual providers/agencies. Variations in rates are due to provider differences related to overhead, staff wages, & the local demand for services. Rate changes may be proposed by providers or by DDA. Criteria for rate changes include funding provided by the Legislature & the rates paid for similar services in the geographic area, which in turn are based on provider overhead, staff wages (if applicable) & the local demand for services. DDA adjusts rates annually if necessary. To increase contracted rates, rate comparisons must indicate prevailing market rates have increased significantly (e.g., 20%+).

Description continues in Main. B. Optional

Waiver Name:
WA Basic Plus Waiver
Effective Date:
9/1/2017
Expiration Date:
8/31/2022

Services

List of Services for Washington Waiver# WA.0409.R03.04

Cost Neutrality

Cost Neutrality for Washington Waiver# WA.0409.R03.04

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
9413 10716

Year 1 Waiver Services

List of Year 1 Waiver Services for Washington Waiver# WA.0409.R03.04

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Inclusion each 447 453 $7.69
Individual Supported Employment/Group Supported Employment each 5114 387 $17.44
Prevocational Services each 70 501 $13.34
Community Guide hour 5 15.59 $19.05

Year 5 Waiver Services

List of Year 5 Waiver Services for Washington Waiver# WA.0409.R03.04

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Inclusion each 517 453.29 $7.69
Individual Supported Employment/Group Supported Employment each 6514 387.26 $17.44
Prevocational Services each 0 0 $13.34
Community Guide hour 6 15.03 $19.05

Rate Determination Methods

Rate Determination Methods for Washington Waiver# WA.0409.R03.04

The State publishes its fee schedules at: https://www.dshs.wa.gov/altsa/management-services-division/office-rates- management.

** Effective July 1, 2015, personal care is available only to waiver participants who are unable to access personal care through the 1915(k) state plan option because they reside in settings that are being addressed through the statewide transition plan process as not yet meeting all HCB settings requirements. As part of this change, adult residential care will no longer be included as stand-alone services in this waiver.

The DDA and the Health Care Authority follow the federal guidelines found in 42 U.S.C. § 1396a(a)(30)(A) when establishing rates so that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist providers for services to ensure adequate access to care for Medicaid recipients. Steps taken to ensure rates comply with federal requirements include: workgroups, stakeholder meetings, consultation with program managers, consultation with professional organizations, analysis of market rates, rates paid by other states for comparable services, and the budget impacts of rates. For example, for nursing services, comparable services in the private sector and in other states include private duty nursing/in-home nursing as provided by LPNs or RNs.

Payment cannot exceed 1) the prevailing charges in the locality for comparable services under comparable circumstances, or 2) the rates charged for comparable services funded by other sources. Methods for determining reasonable rates include periodic market surveys, cost analysis and price comparison. HCA conducts these activities every two to four years, per requests by the Legislature and/or indications that access to services is being impacted by current rates. For DDA rates, this information has been added below under each set of services.

Waiver service definitions and provider qualifications are standardized. This helps ensure that rates are comparable (not necessarily identical) across the state for those services that are negotiated on a regional basis by DDA staff, as rates are for identical services with providers meeting the same qualifications.

HCA rates are updated every January with any possible new codes, and rates are changed every July to align with the new relative value units (RVUs), State geographic price cost index (GPCI), and State specific conversion factor. For codes that do not have RVUs, rates are usually set at a flat rate. If analysis shows they need to be updated, that happens every July with the other codes. The most recent update was in July 2014, and will be updated again this coming July.

With respect to rates established by DDA, the most recent rate comparison was conducted in the spring of 2014.

For HCA-based rates, an amendment to the rates is triggered by directive and/or funding by the Legislature, and/or a change to RVUs, and the Legislature is responsible for funding rate changes. The HCA identifies the need for a rate change using indicators listed below. Without additional funding, rate changes must be budget neutral. If a rate change is not budget neutral, it would be made only if funding was provided by the Legislature or the Legislature required service coverage changes to save the funding needed for the rate change.

For DDA, specifics regarding when rates are adjusted & the criteria used to evaluate the need for rate adjustments are at the end of the discussion of each set of services. When funding is available, the Legislature mandates rate increases for specific types of vendors (e.g., individual providers, residential providers, adult family homes) and/or services.

Regarding criteria for HCA to adjust rates, RVU driven rates are updated yearly per new RVUs. For flat rates, a significant (e.g., 25%) drop in the use of services by Medicaid participants, a significant (e.g., 25%) drop in the number of enrolled providers, an indication that payment rates are substantially (e.g., 40%) below third-party insurer rates, and/or a request by the Legislature for an analysis of rate adequacy are indicators of the need for rate adjustments.

Rates are adjusted with approval from the Legislature.

Rates negotiated with employee unions are static during the life of the contract & are the rates identified within the contract. These rates are only adjusted as written within the contract.

Regarding the cost allocation plan, DSHS does not establish indirect rates for Title XIX administration. A Public Assistance Cost allocation plan allocates administrative costs through various allocation methodologies (see attachment for the most current submission). The Public Assistance Cost Allocation plans for DDA & ALSTA describe the cost allocation methodologies to the CFDA (Medicaid) grant level & does not list specific waivers. OPPORTUNITY FOR PUBLIC COMMENT IN THE RATE DETERMINATION PROCESS:

The Administrative Procedure Act, Chapter 34.05 RCW, is followed when soliciting public comments on rate determination methods. Changes to rates that are made by the legislature in the biennial and supplemental budget process are part of public hearings on budget and policy legislation. Rates are posted on public web sites.

Personal Care- Fee Schedule

Personal care rates are based on a per hour unit and is determined by the State legislature, based on negotiations between the Governor’s Office and the union representing Individual Providers. The collective bargaining agreement is negotiated each State fiscal biennium. The bargained rate includes wages, L & I, vacation pay, mileage reimbursement, comprehensive medical, training, and seniority pay. For individual providers who have completed the home care aide certification, the hourly rate also includes a certification differential payment. Due to the agency parity law [RCW 74.39A.310(1)(a)(v)] the home care agency vendor rates are equivalent to that of the individual provider rate.

RCW 41.56.026 establishes collective bargaining rights for individual providers of personal care and respite. The collective bargaining agreement is negotiated every two years and is subject to funding by the state legislature. If changes are made within the bargaining agreement that affect the rate methodology, a waiver amendment will be submitted. Due to the agency parity law [RCW 74.39A.310(1)(a)(v)] the home care agency vendor rates are equivalent to that of the individual provider rate.

Day Habilitation- Fee schedule

o Community Inclusion: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

o Prevocational: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations.

Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties. No waiver participants have been added to pre- vocational services effective 7/1/2015 onward, as pre-vocational services do not meet the requirements for a home and community setting. Individuals already receiving prevocational services as of 7/1/2015 will be phased out over a four- year period and transitioned to other services, including supported employment and/or individual technical assistance or community access services.

o Supported Employment- Fee Schedule

Group Supported Employment: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

Individual Supported Employment: The state uses a fee schedule model of rate setting with two rate ranges reflecting urban and rural settings. The operating budget is set by the State legislature. Unit rates are negotiated annually between the counties and their providers within the parameters established by the county Service Guidelines and the county allocations. Variations in rates are due to differences among providers related to overhead, staff wages, and the local demand for services. Rates are available to the public through the counties.

Specialized Medical Equipment & Supplies, and community-based settings for respite services: Rates are based on usual & customary charges for the products/services as paid by the general public. Charges are adjusted by the supplier based on overhead, staff wages & the local demand for the products/services. To maintain availability of these products/services for waiver participants, DDA adjusts rates if rate comparisons indicate prevailing market rates have increased significantly (e.g., 20%+).

Respite- Fee Schedule: Individual personal care and respite rates are based on a per hour unit and are determined by the State legislature, based on negotiations between the Governor’s Office and the union representing Individual Providers. The collective bargaining agreement is negotiated each State fiscal biennium. The bargained rate includes wages, L & I, vacation pay, mileage reimbursement, comprehensive medical, training, and seniority pay. For individual providers who have completed the home care aide certification, the hourly rate also includes a certification differential payment. Due to the agency parity law [RCW 74.39A.310(1)(a)(v)] the home care agency vendor rates are equivalent to that of the individual provider rate.

RCW 41.56.026 establishes collective bargaining rights for individual providers of personal care and respite. The collective bargaining agreement is negotiated every two years and is subject to funding by the state legislature. If changes are made within the bargaining agreement that affect the rate methodology, a waiver amendment will be submitted. Due to the agency parity law [RCW 74.39A.310(1)(a)(v)] the home care agency vendor rates are equivalent to that of the individual provider rate.

Rates for community-based settings such as senior centers and summer camps are a fee schedule that is based upon usual and customary charges, which are impacted by overhead, staff wages, and consumer demand.

Additional Rate Determination Methods content is found at: Main. B. Optional

West Virginia Waiver# WV.0133.R07.00 

WV Intellectual/ Developmental Disability Waiver

Waiver Name:
WV Intellectual/ Developmental Disability Waiver
Effective Date:
7/1/2020
Expiration Date:
6/30/2025

Services

List of Services for West Virginia Waiver# WV.0133.R07.00

Cost Neutrality

Cost Neutrality for West Virginia Waiver# WV.0133.R07.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
5964 5964

Year 1 Waiver Services

List of Year 1 Waiver Services for West Virginia Waiver# WV.0133.R07.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Facility-Based Day Habilitation 15 minutes 467 1234 $3.89
Prevocational Services 15 minutes 1398 2947 $3.98
Supported Employment 15 minutes 496 1032 $4.69
Job Development 15 minutes 1864 9168 $2.74

Year 5 Waiver Services

List of Year 5 Waiver Services for West Virginia Waiver# WV.0133.R07.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Facility-Based Day Habilitation 15 minutes 467 1234 $3.89
Prevocational Services 15 minutes 1398 2947 $3.98
Supported Employment 15 minutes 496 1032 $4.69
Job Development 15 minutes 22 474 $5.01

Rate Determination Methods

Rate Determination Methods for West Virginia Waiver# WV.0133.R07.00

The current rate structure has been developed to reflect service definitions, provider requirements, operational service delivery and administrative considerations. The following components were used to determine the current IDDW rates: Bureau for Labor Statistics wage information; employee related expenses; productivity adjustment factor; and administrative overhead. This methodology was applied to all HCPCS Level II codes and were last updated in November 2006; for HCPCS Level I codes RBRVS reimbursement rates were applied (RBRVS rates are updated on January 1 of each year). Mileage reimbursement is based on the approved mileage rate as published by the West Virginia Division of Purchasing, Travel Management Office. The described rate methodology is consistently applied to all waiver services.

The current rate methodology provides consistency with the provisions of section 1902(a)30(A) and 42 CFR section 447.200-205. The state of West Virginia does not use a formula to base increase for inflation, and at this time does not anticipate rate increases.

Wisconsin Waiver# WI.0367.R04.00 

WI Family Care Waiver

Waiver Name:
WI Family Care Waiver
Effective Date:
1/1/2020
Expiration Date:
12/31/2024

Services

List of Services for Wisconsin Waiver# WI.0367.R04.00

Cost Neutrality

Cost Neutrality for Wisconsin Waiver# WI.0367.R04.00

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
65311 73973

Year 1 Waiver Services

List of Year 1 Waiver Services for Wisconsin Waiver# WI.0367.R04.00

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Services hours 7309 800.7 $13.30
Prevocational Services hours 6239 604.31 $11.29
Supported Employment - Individual Employment Support hours 2453 189.05 $23.27
Supported Employment - Small Group Employment Support hours 501 334.9 $11.98
Vocational Futures Planning and Support hours 27 23.27 $62.67

Year 5 Waiver Services

List of Year 5 Waiver Services for Wisconsin Waiver# WI.0367.R04.00

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Day Habilitation Services hours 8278 803.95 $14.40
Prevocational Services hours 7066 606.76 $12.22
Supported Employment - Individual Employment Support hours 2779 189.82 $25.19
Supported Employment - Small Group Employment Support hours 567 336.26 $12.96
Vocational Futures Planning and Support hours 31 23.36 $67.84

Rate Determination Methods

Rate Determination Methods for Wisconsin Waiver# WI.0367.R04.00

The payment method to reimburse the PIHPs is a per member per month (PMPM) capitation developed by the SMA’s contracted actuary to be actuarially sound. The rate methodology submitted with the CMS managed care rate setting checklist is approved by CMS. Therefore, payment requirements identified in the SMA contract for the provision of member services are incorporated into the above rate development process. The PIHP is responsible for establishing service provider rates for waiver services for which it contracts. The incentive to negotiate and establish competitive rates that result in cost effective services to meet identified member outcomes is critical to the financial viability of the PIHP. The SMA contract with the PIHP outlines the payment requirements for the PIHP with their contracted service providers. In addition, analyses to assess the level of provider rate increases from one year to the next are conducted. The level of provider rate increases allowed to flow into the base costs during the rate setting process has been limited, by policy decision, in prior years to support the development of the trend (this process is described in Section IV of the 2014 capitation rate report: https://www.dhs.wisconsin.gov/non-dhs/dms/fcratereport2014.pdf). This analysis and limitation, in conjunction with the contract requirement listed above, represent the SMA’s primary oversight mechanisms of the provider rate setting process for waiver services.

The SMA’s contract with PIHPs contains provisions with respect to the appropriate payment of providers. Given that Family Care is a managed care program, a PIHP has some flexibility in the establishment of its provider fee schedule, as long as it is in compliance with these contract provisions. The SMA works closely with its contracted actuarial firm during the annual capitation rate development process to analyze the full set of encounter data that is submitted by the PIHPs. Self-directed services encounters are included in the full set of encounter data submitted by the PIHPs and used in the annual capitation rate development process by the contracted actuarial firm.

Analyses are carried out to ensure that the Medicaid fee schedule is being employed where required, per the SMA contract and the CMS managed care rate setting checklist.

The SMA approves care management rates for care management services provided directly by the PIHP. Care management is a significant and distinct service under the program model. SMA review of the rates is based on PIHP submission of direct costs and allocated costs and includes a description of the allocated cost methodology to achieve the proposed unit rate. Total annual projected costs are divided by projected annual units of service to derive a unit cost. In addition, the review and approval includes benchmarking against other PIHP rates and program experience over time for the same internally provided services. PIHP unit rates reflect the PIHP costs associated with the provision of this service based on the SMA contractual requirements. PIHP unit rates for care management are incorporated into the actuarially sound capitation rate methodology.

The annual audit process is used to verify actual costs and cost allocation to those services.

Indian Health Care Providers (IHCPs) of waiver services receive an initial payment from the PIHP at a rate negotiated between the PIHP and the IHCP. The SMA makes a wraparound payment/recoupment to/from the IHCP for waiver services to Indian members so that the total of the payments the IHCP received from PIHPs, the member, Medicare, third party payers, and the SMA equals the IHCP’s full cost of providing waiver services directly contracted or through self- direction to Indian members. The IHCP’s costs for providing waiver services to Indian members will be determined based on cost reports the IHCP submits to the SMA. The SMA will determine the amount of the wraparound payment/recoupment by comparing the IHCP’s costs from the cost report to revenue the IHCP received from members, Medicare, third party payers, and the payments the PIHPs made to the IHCP based on Indian member encounter records. The list of Indian members will come from the IHCP and will be cross-referenced against the SMA’s Medicaid eligibility files.

Wisconsin Waiver# WI.0484.R02.03 

Self Directed Support Waiver - Intellectual/Developmental Disability and Aged/Physical Disability

Waiver Name:
Self Directed Support Waiver - Intellectual/Developmental Disability and Aged/Physical Disability
Effective Date:
5/1/2016
Expiration Date:
4/30/2021

Services

List of Services for Wisconsin Waiver# WI.0484.R02.03

Cost Neutrality

Cost Neutrality for Wisconsin Waiver# WI.0484.R02.03

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
15934 24786

Year 1 Waiver Services

List of Year 1 Waiver Services for Wisconsin Waiver# WI.0484.R02.03

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services hours 923 706.33 $8.55
Supported Employment - Individual hours 381 216.31 $21.71
Day Services hours 1483 247.34 $37.08
Supported Employment - Small Group hours 60 277.64 $14.36
Vocational and Futures Planning hours 11 95.13 $45.78

Year 5 Waiver Services

List of Year 5 Waiver Services for Wisconsin Waiver# WI.0484.R02.03

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Prevocational Services hours 1521 711.63 $8.90
Supported Employment - Individual hours 626 216.58 $22.56
Day Services hours 2439 248.96 $38.58
Supported Employment - Small Group hours 100 280.04 $14.95
Vocational and Futures Planning hours 18 96.16 $47.58

Rate Determination Methods

Rate Determination Methods for Wisconsin Waiver# WI.0484.R02.03

IRIS INDIVIDUAL BUDGET ALLOCATION ALGORITHM

Currently and until April 1, 2016, IRIS individual budget allocations (IBAs) are established through a model based on the historic cost experience in Family Care. A subset of the Family Care base data is developed for the IRIS IBA model by removing members and services from the Family Care base data that are not eligible in the IRIS benefit package, such as institutional services. The Department’s contracted actuaries then develop target group specific regression models to determine which attributes from the State’s Long-Term Care Functional Screen (LTCFS) are most predictive of a member’s costs as well as the amount of funding predicted by each attribute. An IRIS member’s IBA is calculated by seeing which attributes the member has on the LTCFS, and adding up the funding the regression model has associated with those attributes. This is calculation is completed automatically as part of the LTCFS system. Beginning April 1, 2016, the IBA regression model will be established using historic cost experience from the IRIS program.

Within this renewal period the rates ranges established for the IRIS program will be done by the IRIS Section in collaboration with the BLTCF. The rate ranges established for the IRIS waiver services will be based on actual historical costs based on geographic region. The methods used to establish these rates will be identical in all jurisdictions where the IRIS program is furnished. The methods and standards used to establish the rates will be equivalent and any variation in rates would only be due to geographical complexities such as qualified provider availability. Providers will be able to comment on rate setting methodology and standards.

The state establishes guidelines for a suggested payment range based on market and geographic complexities of providers and analysis of historical costs per unit and trending program expenditures. These guidelines are shared with the ICAs who in turn educate participant’s on these historical costs and trending to ensure Participants have the tools resources and information to negotiate the most cost effective rate with their providers including those providers employed directly by the participant. Participants may exceed these parameters in their rate agreements with service providers, but the total of all service expenses may not exceed the total the individual budget amount. If the participant's individual budget is not sufficient to meet the needs of the participant, budget amendment or one-time expense request can be made to the DHS. A committee within the DHS reviews these request using a standard set of criteria to determine if the request will be approved, partially approved, or denied. Additionally, documentation must be part of the participant's record when pay ranges exceed the expected range.

The state contracts directly with two types of service providers, IRIS Consultant Agencies and IRIS Fiscal Employer Agents (Reference Appendix C for service definitions). The state has established monthly rate for service for these services based on historical costs of services and participant enrollment in the program. As the state continues to promote and introduce competition through choice of provider of these services, the state will require implementation of best service delivery models from these providers in order to realize the most cost effective methods of delivering these services. The intention of the state is to implement the best practice methods and standards identified through competition of providers to ensure the most cost effective method of service delivery. Once the state has identified the best practice it will modify the certification criteria so all other providers adhere to the same best practice. If this best practice results in a rate driver reduction, the State would also reduce the rate of the provider based on the statewide implementation of the best practice. The addition of competition to the market of ICA and FEA providers will also help inform the state’s rate setting methods for these services.

ICA and FEA Rate Setting

The methodology and the rate amount did not change for CY2016. The ICA and FEA rates were established for CY2015 using actual historical costs of CY2013-2014.

Public Comment on Rate Methods

The rate methodology was established and approved prior to CMS requiring public comment. The methodology and rate did not change as part of this renewal request and therefore there was not new or additional information provided in the waiver renewal regarding the ICA and FEA rates. The state also did not receive any request via public comment on how the ICA or FEA rates were established. Most of the public comment and concern centered around participant budgets, and employer authority, rather than the rates established by DHS for the ICA and FEA to administer the program. Each time the methodology changes by which ICA and FEA rates are calculated, the SMA will obtain public comment. Public comment is not necessary when the rate changes but the methodology does not. The state does not have established mandated rates for those services provided by participant hired workers. If the state established and mandated such rates the state would be viewed as the employer of the participant hired worker instead of the participant. The state has established the rates for two waiver services IRIS Consultant Agencies Services and IRIS Fiscal / Employer Agent Services. The methodology used to establish these rates included a review of historical costs associated with these services relevant to enrollment at the time the services were provided.

The rate for ICA and FEA services will be uniform across all counties in 2014 and 2015. The state may wish to adjust rates in future years based on ICA or FEA performance, regional variation, etc. If the state does implement a rate change, it will included in the certification criteria. The rates and/or methodology is included in the certification criteria which was publicly released in 2014.

WISITS will house the rate ranges for all services by region. Once the provider and participant have negotiated and agreed on a rate and the participant's plan has been approved, the FEAs will receive a prior authorization for each service generated by WISITS. The ICAs and the participants will have access to these rate averages via WISITS. The state will also provide ICAs a reference tool that has the rate averages for waiver services per region to help inform the participants and the ICAs of the average cost of services.

NEGOTIATION OF RATES

As part of the participant education information given to participants during their orientation to the program, participants receive education on how to negotiate rates with providers.

Rate negotiations are overseen by the consultant to ensure that the rate negotiated is usual and customary for the service in that region of the state.

The parameters dictating the negotiations are the participant’s budget; and supply and demand of service providers in that region of the state.

The participant is the primary negotiator. As part of the participant education information given to participants during their orientation to the program, the participants receive education on how to negotiate rates with providers.

Rate negotiations vary based on the methodology used by the individual participant.

There are only two rates set in the IRIS program - the ICA and the FEA rates. The SMA is responsible for conducting rate determination oversight. However, these two services are not paid out of the participant’s budget because they are required of all participants. Participants negotiate rates for all other services. The negotiated rates are overseen by the consultant to ensure that the rate negotiated is usual and customary for the service in that region of the state. There is not an established rate model for other services in the IRIS program. This is for multiple reasons. The nature of the program ensures full budget authority and full employer authority (the participant is the employer).

RATE PER UNIT CALCULATION

Average cost per unit is calculated by dividing projected total costs each year by projected total units each year for each service. Total costs and total units are pulled from CY2014 encounter data and grouped by service and target population. The total costs and units for each service in each target group are divided by CY2014 member months to arrive at the average service cost PMPM and average units PMPM bases. To calculate projected total cost for each waiver year, the CY2014 base service costs PMPM are trended forward using the target group specific trend factor in the individual budget allocation model and then multiplied by the projected member months for each waiver year. The ICF-IID target population is trended at approximately 1.0%. The Nursing Facility target population is trended at approximately 0.5%. To calculate total units, the CY2014 base average units PMPM for each target group are multiplied by the projected member months for each year and target group. No trend factors are applied to average units PMPM as utilization patterns are assumed to remain constant. The target groups' costs are combined by service line and the target groups' total units are combined by service line to determine total cost and total units for each service. Total cost for each service is divided by total units for each service to arrive at the average cost per unit.

Rate Determination Oversight There are only two rates set in the IRIS program - the ICA and the FEA rates. The SMA is responsible for conducting rate determination oversight. Participants negotiate rates for all other services. The negotiated rates are overseen by the consultant to ensure that the rate negotiated is usual and customary for the service in that region of the state. However, there is not an established rate model for other services in the IRIS program. This is for multiple reasons. The nature of the program ensures full budget authority and full employer authority (the participant is the employer). If the SMA dictates the rate, they cross the line of employer authority and become the employer and participants would lose their ability to directly employ their participant hired workers. It should also be noted that 80% of the services rendered in IRIS are done by participant hired workers directly employed by the participant.

Wyoming Waiver# WY.1061.R01.01 

Comprehensive Waiver

Waiver Name:
Comprehensive Waiver
Effective Date:
4/1/2019
Expiration Date:
3/31/2024

Services

List of Services for Wyoming Waiver# WY.1061.R01.01

Cost Neutrality

Cost Neutrality for Wyoming Waiver# WY.1061.R01.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
2150 2150

Year 1 Waiver Services

List of Year 1 Waiver Services for Wyoming Waiver# WY.1061.R01.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Support Services Basic (15 Minute Unit) 15 minutes 92 1188 $2.83
Community Support Services Intermediate (15 Minute Unit) 15 minutes 280 2041 $4.28
Community Support Services High (15 Minute Unit) 15 minutes 147 1435 $9.16
Community Support Services Basic (Daily) day 10 260 $67.92
Community Support Services Intermediate (Daily) day 10 260 $102.72
Community Support Services High (Daily) day 10 260 $219.84
Supported Employment Individual 15 minutes 177 761 $8.12
Supported Employment Group 15 minutes 77 1831 $2.69
Supported Employment SEFA 15 minutes 1 100 $8.12
Individual Habilitation Training 15 minutes 127 740 $7.53

Year 5 Waiver Services

List of Year 5 Waiver Services for Wyoming Waiver# WY.1061.R01.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Support Services Basic (15 Minute Unit) 15 minutes 100 1312 $2.83
Community Support Services Intermediate (15 Minute Unit) 15 minutes 259 2253 $4.28
Community Support Services High (15 Minute Unit) 15 minutes 163 1382 $9.16
Community Support Services Basic (Daily) day 10 260 $67.92
Community Support Services Intermediate (Daily) day 10 260 $102.72
Community Support Services High (Daily) day 10 260 $219.84
Supported Employment Individual 15 minutes 196 840 $8.12
Supported Employment Group 15 minutes 85 2021 $2.69
Supported Employment SEFA 15 minutes 1 100 $8.12
Individual Habilitation Training 15 minutes 139 817 $7.53

Rate Determination Methods

Rate Determination Methods for Wyoming Waiver# WY.1061.R01.01

In 2008, the Department of Health was required by state statute (W.S. 42-4-120 (g)) to establish a cost-informed reimbursement system to pay providers of services and supplies under home and community based waiver programs for persons with developmental disabilities or acquired brain injury. This state statue also required that rates be rebased at least once every four (4) years, but not more than once in any two (2) year period. DHCF does not intend to update rates between the required rebasing. As Wyoming’s state statute requires a cost-informed rate methodology, provider cost surveys are collected to inform the rate model.

In 2017, the Department of Health contracted with Navigant Consulting to conduct a rate study for Wyoming’s (HCBS) waivers. The objectives of the rate model included in this study were to:

•Recognize reasonable and necessary costs of providers

•Standardize rates

•Reflect participant needs

•Increase transparency

•Facilitate regular updates

•Provide fiscal stability for providers and the state

Navigant and the DD Section worked with key stakeholders from June 2017 to January 2018 to conduct the rate study and develop proposed waiver program rates. Stakeholder involvement included the following workgroups:

•Provider Team – Composed of small and large providers and case management agencies who reviewed the survey design and materials, gave input on rate component assumptions, and developed related recommendations for consideration by the Steering Committee.

•Steering Committee – Composed of key state agency staff, legislators, and consumer and provider representatives who reviewed and selected key rate assumptions based on materials developed by Navigant and recommendations from the Provider Team.

•Small provider focus group – developed to gather input on how to more effectively gather wage data from small providers (those receiving less than $1 million in Medicaid payments annually).

•Case manager focus group – developed to gather input on how case managers spend their time on activities related to the provision of case management services.

Rate Components:

An independent rate build-up methodology based on cost and wage data from providers and other state and national data sources was used. The independent rate build-up methodology comprises direct care and indirect care components, and uses assumptions about types of employees; wage rates; benefits; program support and administration costs; supervisor span of control; staffing patterns; and direct care work productivity factors. Some components vary between services while others are the same across the services. This rate determination methodology was used to calculate rates for the following services:

•Adult Day Services

•Case Management Services (15 Minute Unit)

•Community Living Services

•Community Support Services

•Homemaker

•Individual Habilitation Training

•Personal Care

•Respite

•Supported Employment

•Child Habilitation Services

•Cognitive Retraining

•Companion Services

•Crisis Intervention Support

Direct Care Unit Cost= (direct care inflated wage/Units per hour/staffing ratio)*(1 + benefits factor)*productivity factor*FTE factor

Direct Care Supervision Costs= (supervisor inflated wage/units per hour/supervisor span of control)*(1 + benefits factor)*productivity factor*FTE factor

Total Direct Care Costs= direct care unit cost + direct care supervision costs

Non-Direct Care Cost= total direct care costs*administration factor*program support factor Proposed Rate= (total direct care costs + non-direct care cost)*incentive factor or reduction factor

Direct Care Cost Rate Components

Staff Wages: For the direct care worker wage, an average of the 75th percentile of two BLS occupational categories was used: Home Health Aide (BLS occupational category 31-1011) and Personal Care Aide (BLS occupational category 39- 9021). Provider wage survey data was used to identify the wage for job coaches and vocational trainers and shift and unit supervisors. The median wage for Rehabilitation Counselor (BLS occupational category 21-101) was used to identify the wage for rehabilitation counselors as the survey data were not sufficient. All wage data were inflated to the midpoint of SFY 2019 using a two-year moving average of the quarterly Wyoming Cost of Living Index values (provided by the Wyoming Economic Analysis Division) equal to a 1.55 percent inflation factor for wages collected through the provider survey and 4 percent for BLS wages. BLS wages were identified using May 2017 BLS data.

Employee Related Expense (ERE) Factor: The ERE factor reflects the cost of program employee benefits, specifically:

•Federally required benefits such as FICA, FUTA, SUTA, and workers compensation

•Health and dental insurance

•Retirement benefits

•Long- and short-term disability benefits

Health insurance costs were identified using the Medical Expenditure Panel Survey (MEPS) average employer portion (Wyoming 2016 MEPS Table II.C.1 minus Table II.C.2) with a six percent inflation factor added to update insurance costs to the midpoint of SFY 2019 (using Quarterly Index Levels in the CMS Prospective Payment System Price Index using Global Insights, Inc. Forecast Assumptions, by Expense Category 1996-2024). Retirement benefits were based on June 2017 BLS data for retirement costs as a percent of salary and wages for private industry health care and social assistance "service" workers. Federally required benefits were calculated using national and state percentages, and additional benefits were based on provider cost report data.

Full Time Equivalent (FTE) Factor: The FTE factor represents costs associated with payroll hours required to cover for staff when they are not available to provide direct services (i.e., vacation days, sick time, training). Approximately 22 days per year were included for the FTE factor based on the average number of paid time off and paid training hours per employee reported in the provider cost and wage surveys.

Productivity Adjustment: The rate model includes service-specific productivity factors to account for non-face-to-face time necessary to deliver services (planning, meetings, recordkeeping, etc.). The Provider Team provided productivity factor recommendations to the Steering Committee based on provider experience, service requirements and a review of the productivity factors used in the SFY 2016 study. The proposed factors were reviewed and any changes that were needed were made based on service requirements.

Indirect Care Cost Rate Components

Administration Factor: The administration factor reflects costs associated with operating a provider agency. These costs include: administrative employees’ salaries, office supplies and services, information technology expenses, central corporate office other administration expenses allocated to the local level, licenses/taxes, liability and other insurance, background checks, and non-service related transportation. Provider cost data specific to non-case management service providers was used to calculate an admin factor representing approximately 16 to 18 percent of the rate (varies by service). The community living services host home and special family habilitation home service rate does not include an administrative component.

Program Support Factor: The program support factor reflects the costs that support direct care services, such as non- payroll program support costs, non-payroll facility, vehicle and equipment expenses, maintenance costs, and program supplies. The Program Support Factor was tailored by service to reflect if service provision required facility and/or vehicle costs. Costs related to room and board for participants including facility maintenance, upkeep, and improvement related to community living (residential) program services were excluded from the total costs collected for the rate determination. Additionally, cost outliers from provider costs and wage surveys were excluded and the program support portion of the rate for community living services was capped at the level 4 amount. Program support factors vary by service and range from three percent to approximately 17 percent of the rate. Transportation services are calculated without a program support factor as the program support portion of the rate is provided through the mileage payment adjustment. Transportation Services

Transportation rates were developed using the rate methodology described above that combined direct and indirect cost components, with an add-on payment for mileage at the Federal per-mile business rate of $0.535/mile. Previously, a per- mile rate that did not include staff time was used; the current rate is a tiered per-event rate that includes staff time and a per-mile cost based on the Federal per-mile business rate. The tiers reflect the varying distances that Wyoming providers may need to travel. Tier 1 is based on 5 miles and Tier 2 is based on 10 miles.

Skilled Nursing and assessment; Dietitian; OT; PT; Speech – These services were not included in the updated rate methodology. These rates shall be based on the rates paid through the Medicaid State Plan.

Incentive Factor (or Reduction Factor) – The service rate calculation for Child Habilitation Ages 0-12 includes a $0.75 reduction to the calculated rate to account for time that a child would normally receive services from school or other child care.

Case Management Monthly Rates: These rates were developed using a similar methodology as described above, and adjusted over time using appropriations from the State legislature.

Due to the variable nature of some services, the determination of a standardized reimbursement rate is not possible. Case managers must obtain at least two competitive bids for environmental modification and specialized equipment services. Payment is authorized to the provider with the most cost-effective bid which meets the needs of the participant.

Please see additional information box in Main Section for information on Behavioral Support Services.

For self-directed services, the participant does not utilize the provider-managed rate methodology. Instead, s/he pays staff a wage that covers the needed services and can be paid within his/her IBA. The cost to the participant’s IBA is the wage, which includes employer payroll taxes, state and federal unemployment taxes. The participant may increase the wage to assist with employee medical benefits. The wage minimum is based upon the federal minimum wage and the wage maximum is based upon what the IBA will support.

Public Notice

Rate determination methods and rates are reviewed and approved by the SMA. In addition to the public process described above, DHCE also solicits public comments by means of a public notice when changes in methods and standards for establishing payment rates under the Waiver are proposed. The notice is published in accordance with federal requirements at 42 CFR 447.205, which prescribes the content and publication criteria for the notice. Whenever rates change, DHCF makes listings of all covered services and corresponding rates available to clients and their families and service providers.

Information on payment rates are available to participants during team meetings. Rates are posted on DHCFs website and are available upon request.

DHCF monitors provider enrollment data on a quarterly basis. Provider enrollment is monitored on a regional basis to assess the provider network adequacy in all areas of Wyoming. Fluctuations in the provider network precipitates further analysis to determine the cause, which would include provider payment rates.

Waiver Name:
WY Supports Waiver
Effective Date:
4/1/2019
Expiration Date:
3/31/2024

Services

List of Services for Wyoming Waiver# WY.1060.R01.01

Cost Neutrality

Cost Neutrality for Wyoming Waiver# WY.1060.R01.01

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 Table
Cost Neutrality Year 1 Cost Neutrality Year 5
618 676

Year 1 Waiver Services

List of Year 1 Waiver Services for Wyoming Waiver# WY.1060.R01.01

Year 1 Waiver Services Table
Year 1 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Support Services Basic (15 Minute Unit) 15 minutes 28 1351 $2.83
Community Support Services Intermediate (15 Minute Unit) 15 minutes 16 1238 $4.28
Community Support Services High (15 Minute Unit) 15 minutes 4 1038 $9.16
Community Support Services Basic (Daily) day 1 260 $67.92
Community Support Services Intermediate (Daily) day 10 260 $102.72
Community Support Services High (Daily) day 10 260 $219.84
Supported Employment Individual 15 minutes 14 530 $8.12
Supported Employment Group 15 minutes 9 1544 $2.69
Supported Employment SEFA 15 minutes 1 4 $8.12
Individual Habilitation Training 15 minutes 79 410 $7.53

Year 5 Waiver Services

List of Year 5 Waiver Services for Wyoming Waiver# WY.1060.R01.01

Year 5 Waiver Services Table
Year 5 Waiver Service Unit # of Users Avg. Units Per User Average Cost
Community Support Services Basic (15 Minute Unit) 15 minutes 32 1492 $2.83
Community Support Services Intermediate (15 Minute Unit) 15 minutes 16 1367 $4.28
Community Support Services High (15 Minute Unit) 15 minutes 4 1146 $9.16
Community Support Services Basic (Daily) day 2 260 $67.92
Community Support Services Intermediate (Daily) day 11 260 $102.72
Community Support Services High (Daily) day 11 260 $219.84
Supported Employment Individual 15 minutes 14 585 $8.12
Supported Employment Group 15 minutes 10 1706 $2.69
Supported Employment SEFA 15 minutes 1 4 $8.12
Individual Habilitation Training 15 minutes 87 454 $7.53

Rate Determination Methods

Rate Determination Methods for Wyoming Waiver# WY.1060.R01.01

In 2008, the Department of Health was required by state statute (W.S. 42-4-120 (g)) to establish a cost-informed reimbursement system to pay providers of services and supplies under home and community based waiver programs for persons with developmental disabilities or acquired brain injury. This state statue also required that rates be rebased at least once every four (4) years, but not more than once in any two (2) year period. DHCF does not intend to update rates between the required rebasing. As state statute requires a cost-informed rate methodology, provider cost surveys are collected to inform the rate model.

In 2017, the Department of Health contracted with Navigant Consulting to conduct a rate study for Wyoming’s (HCBS) waivers. The objectives of the rate model included in this study were to:

•Recognize reasonable and necessary costs of providers

•Standardize rates

•Reflect participant needs

•Increase transparency

•Facilitate regular updates

•Provide fiscal stability for providers and the state

Navigant and the DD Section worked with key stakeholders from June 2017 to January 2018 to conduct the rate study and develop proposed waiver program rates. Stakeholder involvement included the following workgroups:

•Provider Team – Composed of small and large providers and case management agencies who reviewed the survey design and materials, gave input on rate component assumptions, and developed related recommendations for consideration by the Steering Committee.

•Steering Committee – Composed of key state agency staff, legislators, and consumer and provider representatives who reviewed and selected key rate assumptions based on materials developed by Navigant and recommendations from the Provider Team.

•Small provider focus group – developed to gather input on how to more effectively gather wage data from small providers (those receiving less than $1 million in Medicaid payments annually).

•Case manager focus group – developed to gather input on how case managers spend their time on activities related to the provision of case management services.

Rate Components:

An independent rate build-up methodology based on cost and wage data from providers and other state and national data sources was used. The independent rate build-up methodology comprises direct care and indirect care components, and uses assumptions about types of employees; wage rates; benefits; program support and administration costs; supervisor span of control; staffing patterns; and direct care work productivity factors. Some components vary between services while others are the same across the services. This rate determination methodology was used to calculate rates for the following services:

•Adult Day Services

•Case Management Services (15 Minute Unit)

•Community Living Services

•Community Support Services

•Homemaker

•Individual Habilitation Training

•Personal Care

•Respite

•Supported Employment

•Child Habilitation Services

•Cognitive Retraining

•Companion Services

•Crisis Intervention Support

Direct Care Unit Cost= (direct care inflated wage/Units per hour/staffing ratio)*(1 + benefits factor)*productivity factor*FTE factor

Direct Care Supervision Costs= (supervisor inflated wage/units per hour/supervisor span of control)*(1 + benefits factor)*productivity factor*FTE factor

Total Direct Care Costs= direct care unit cost + direct care supervision costs

Non-Direct Care Cost= total direct care costs*administration factor*program support factor Proposed Rate= (total direct care costs + non-direct care cost)*incentive factor or reduction factor

Direct Care Cost Rate Components

Staff Wages: For the direct care worker wage, an average of the 75th percentile of two BLS occupational categories was used: Home Health Aide (BLS occupational category 31-1011) and Personal Care Aide (BLS occupational category 39- 9021). Provider wage survey data was used to identify the wage for job coaches and vocational trainers and shift and unit supervisors. The median wage for Rehabilitation Counselor (BLS occupational category 21-101) was used to identify the wage for rehabilitation counselors as the survey data were not sufficient. All wage data were inflated to the midpoint of SFY2019 using a two-year moving average of the quarterly Wyoming Cost of Living Index values (provided by the Wyoming Economic Analysis Division) equal to a 1.55 percent inflation factor for wages collected through the provider survey and 4 percent for BLS wages. BLS wages were identified using May 2017 BLS data.

Employee Related Expense (ERE) Factor: The ERE factor reflects the cost of program employee benefits, specifically:

•Federally required benefits such as FICA, FUTA, SUTA, state workers compensation

•Health and dental insurance

•Retirement benefits

•Long- and short-term disability benefits

Health insurance costs were identified using the Medical Expenditure Panel Survey (MEPS) average employer portion (Wyoming 2016 MEPS Table II.C.1 minus Table II.C.2) with a six percent inflation factor added to update insurance costs to the midpoint of SFY 2019 (using Quarterly Index Levels in the CMS Prospective Payment System Price Index using Global Insights, Inc. Forecast Assumptions, by Expense Category 1996-2024). Retirement benefits were based on June 2017 BLS data for retirement costs as a percent of salary and wages for private industry health care and social assistance "service" workers. Federally required benefits were calculated using national and state percentages, and additional benefits were based on provider cost report data.

Full Time Equivalent (FTE) Factor: The FTE factor represents costs associated with payroll hours required to cover for staff when they are not available to provide direct services (i.e., vacation days, sick time, training). Approximately 22 days per year were included for the FTE factor based on the average number of paid time off and paid training hours per employee reported in the provider cost and wage surveys.

Productivity Adjustment: The rate model includes service-specific productivity factors to account for non-face-to-face time necessary to deliver services (planning, meetings, recordkeeping, etc.). The Provider Team provided productivity factor recommendations to the Steering Committee based on provider experience, service requirements and a review of the productivity factors used in the SFY 2016 study. The proposed factors were reviewed and changes that were needed were made based on service requirements.

Indirect Care Cost Rate Components

Administration Factor: The administration factor reflects costs associated with operating a provider agency. These costs include: administrative employees’ salaries, office supplies and services, information technology expenses, central corporate office other administration expenses allocated to the local level, licenses/taxes, liability and other insurance, background checks, and non-service related transportation. Provider cost data specific to non-case management service providers was used to calculate an admin factor representing approximately 16 to 18 percent of the rate (varies by service). The community living services host home and special family habilitation home service rate does not include an administrative component.

Program Support Factor: The program support factor reflects the costs that support direct care services, such as non- payroll program support costs, non-payroll facility, vehicle and equipment expenses, maintenance costs, and program supplies. The Program Support Factor was tailored by service to reflect if service provision required facility and/or vehicle costs. Costs related to room and board for participants including facility maintenance, upkeep, and improvement related to community living (residential) program services were excluded from the total costs collected for the rate determination. Additionally, cost outliers from provider costs and wage surveys were excluded and the program support portion of the rate for community living services was capped at the level 4 amount. Program support factors vary by service and range from three percent to approximately 17 percent of the rate. Transportation services are calculated without a program support factor as the program support portion of the rate is provided through the mileage payment adjustment. Transportation Services

Transportation rates were developed using the rate methodology described above that combined direct and indirect cost components, with an add-on payment for mileage at the Federal per-mile business rate of $0.535/mile. Previously, a per- mile rate that did not include staff time was used; the current rate is a tiered per-event rate that includes staff time and a per-mile cost based on the Federal per-mile business rate. The tiers reflect the varying distances that Wyoming providers may need to travel. Tier 1 is based on 5 miles and Tier 2 is based on 10 miles.

Skilled Nursing and assessment; Dietitian; OT; PT; Speech Rates – These services were not included in the updated rate methodology. These rates shall be based on the rates paid through the Medicaid State Plan.

Incentive Factor (or Reduction Factor) – The service rate calculation for Child Habilitation Ages 0-12 includes a $0.75 reduction to the calculated rate to account for time that a child would normally receive services from school or other child care.

Case Management Monthly Rates: These rates were developed using a similar methodology as described above, and adjusted over time using appropriations from the State legislature.

Due to the variable nature of some services, the determination of a standardized reimbursement rate is not possible. Case managers must obtain at least two competitive bids for environmental modification and specialized equipment services. Payment is authorized to the provider with the most cost-effective bid which meets the needs of the participant.

Please see additional information box in Main Section for information on Behavioral Support Services.

For self-directed services, the participant does not utilize the provider-managed rate methodology. Instead, s/he pays staff a wage that covers the needed services and can be paid within his/her IBA. The cost to the participant’s IBA is the wage, which includes employer payroll taxes, state and federal unemployment taxes. The participant may increase the wage to assist with employee medical benefits. The wage minimum is based upon the federal minimum wage and the wage maximum is based upon what the IBA will support.

Public Notice

Rate determination methods and rates are reviewed and approved by the SMA. In addition to the public process described above, DHCF solicits public comments by means of a public notice when changes in methods and standards for establishing payment rates under the Waiver are proposed. Notice is published in accordance with federal requirements at 42 CFR 447.205, which prescribes the content and publication criteria for the notice. Whenever rates change, DHCF makes listings of all covered services and corresponding rates available to clients and their families and service providers. Information on payment rates are available to participants during team meetings. Rates are posted on DHCFs website and are available upon request.

DHCF monitors provider enrollment data on a quarterly basis. Provider enrollment is monitored on a regional basis to assess the provider network adequacy in all areas of Wyoming. Fluctuations in the provider network precipitates further analysis to determine the cause, which would include provider payment rates.

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Medicaid Overview

Medicaid Overview for American Samoa Waiver# {None}

The Medicaid program in American Samoa differs from Medicaid programs operating in each of the 50 states and the District of Columbia. Some of the key differences are:

American Samoa became a territory in 1900 and its Medicaid program was established in 1983. It is a 100% fee-for-service delivery system with one hospital servicing the territory. There are no deductibles or co-payments under the American Samoa Medicaid program however there are some fees charged by the hospital located in American Samoa. The territory does not administer a Medicare Part D Plan, instead the Medicaid program receives an additional grant through the Enhanced Allotment Plan (EAP) which must be utilized solely for the distribution of Part D medications to dual-eligibles.

American Samoa operates its Medicaid program under a broad waiver granted under the authority of Section 1902(j) of the Social Security Act. This provision allows the Secretary to waive or modify any requirement of Title XIX, in regards to American Samoa’s Medicaid program, with the exception of three: the territory must adhere to the cap set under Section 1108 of the Act; the territory must adhere to the statutory Federal Medical Assistance Percentage (FMAP); Federal medical assistance payments may only be made for amounts expended for care and services described in a numbered paragraph of section 1905(a).

Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $181,307,628 in Medicaid funding to American Samoa.

Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in American Samoa, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing American Samoa’s FMAP to 57.2%.

Demonstrations and Waivers

Demonstrations and Waivers for American Samoa Waiver# {None}

Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(a) and 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.

Currently, American Samoa has no demonstration projects or waivers.

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Medicaid Overview

Medicaid Overview for Guam Waiver# {None}

The Medicaid program in Guam differs from Medicaid programs operating in each of the 50 states and the District of Columbia. Some of the key differences are:

Guam became a territory in 1950 and its Medicaid program was established in 1975. It is a 100% fee-for-service delivery system with one hospital currently servicing the territory. There are no deductibles or co-payments under the Guam Medicaid program. Guam’s Medicaid program does not administer a Medicare Part D Plan; the Medicaid program receives an additional grant through the Enhanced Allotment Plan (EAP) which must be utilized solely for the distribution of Part D medications to dual-eligibles.

Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $268,343,113 in Medicaid funding to Guam.

Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in Guam, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing Guam’s FMAP to 57.2%.

Medicaid-Marketplace Overview

Guam was awarded $24,436,001 million for its Medicaid program in lieu of establishing a health marketplace. Guam must exhaust its Affordable Care Act (Section 2005) allotment prior to using these funds.

Demonstrations and Waivers

Demonstrations and Waivers for Guam Waiver# {None}

Demonstrations and Waivers

Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(a) and 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.

Currently, Guam has no demonstrations or waivers.

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Medicaid Overview

Medicaid Overview for Northern Mariana Islands Waiver# {None}

The Medicaid program in the Commonwealth of the Northern Mariana Islands (CNMI) differs from Medicaid programs operating in each of the 50 states and the District of Columbia. Some of the key differences are:

CNMI became a territory in 1978 and its Medicaid program was established in 1979. It is a 100% fee-for-service delivery system with one hospital servicing the territory. There are no deductibles or co-payments under the CNMI Medicaid program and the territory does not administer a Medicare Part D Plan. Instead, the Medicaid program receives an additional grant through the Enhanced Allotment Plan (EAP) which must be utilized solely for the distribution of Part D medications to dual-eligibles.

CNMI operates its Medicaid program under a broad waiver granted under the authority of Section 1902(j) of the Social Security Act. This provision allows the Secretary to waive or modify any requirement of Title XIX, in regards to CNMI’s Medicaid program, with the exception of three: the territory must adhere to the cap set under Section 1108 of the Act; the territory must adhere to the statutory Federal Medical Assistance Percentage (FMAP); Federal medical assistance payments may only be made for amounts expended for care and services described in a numbered paragraph of section 1905(a).

Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $100,139,704 in Medicaid funding to CNMI.

Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in CNMI, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing CNMI’s FMAP to 57.2%.

Demonstrations and Waivers

Demonstrations and Waivers for Northern Mariana Islands Waiver# {None}

Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(a) and 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.

Currently, CNMI has no demonstration projects or waivers.

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Medicaid Overview

Medicaid Overview for Puerto Rico Waiver# {None}

The Medicaid program in Puerto Rico differs from Medicaid programs operating in each of the 50 states and the District of Columbia in three important ways.

The Puerto Rico Medicaid delivery system is a subset of the larger public government healthcare delivery system for most of the island’s population. The Puerto Rico Department of Health is the single state agency, and they have a cooperative agreement with the Puerto Rico Health Insurance Administration (PRHIA) also known as Administracion de Seguros Salud de Puerto Rico (ASES) which implements and administers island-wide health insurance system. Approximately half of Puerto Rico's 3.5 million residents have low incomes and depend upon the public health system for their medical care.

Through Section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, Section 2005 of the Affordable Care Act provided an additional $5.4 billion in Medicaid funding to Puerto Rico.

Unlike the 50 states and the District of Columbia, where the federal government will match all Medicaid expenditures at the appropriate federal matching assistance percentage (FMAP) rate for that state, in Puerto Rico, the FMAP is applied until the Medicaid ceiling funds and the Affordable Care Act available funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing Puerto Rico’s FMAP to 57.2%.

Demonstrations and Waivers

Demonstrations and Waivers for Puerto Rico Waiver# {None}

Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(a) and 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.

Puerto Rico elected to offer a waiver-based section 1915(a) program. It is a mandatory managed care program which requires no waiver authority because Puerto Rico is statutorily exempt from Freedom of Choice requirements.

Waiver Name:
{None}
Effective Date:
{None}
Expiration Date:
{None}

Medicaid Overview

Medicaid Overview for US Virgin Islands Waiver# {None}

The Medicaid program in the United States Virgin Islands differs from Medicaid programs operating in each of the 50 states and the District of Columbia in three important ways.

The United States Virgin Islands Medicaid delivery system is a subset of the larger public government healthcare delivery system for most of the island’s population. The United States Virgin Islands Department of Human Services is the single state agency.

Through section 1108 of the Social Security Act (SSA), each territory is provided base funding to serve their Medicaid populations. For the period of July 1, 2011 through September 30, 2019, section 2005 of the Affordable Care Act provided an additional $273.8 million in Medicaid funding to the United States Virgin Islands.

For the 50 states and the District of Columbia, the federal government will match all Medicaid expenditures at the federal matching assistance percentage (FMAP) rate based on the state’s per capita income. For the United States Virgin Islands, all Medicaid expenditures are matched until the Medicaid base funds and the Affordable Care Act funds are exhausted. The statutory FMAP local matching rate increased from 50%/ 50% to 55% federal /45% local, effective July 1, 2011. From January 1, 2014 to December 31, 2015 there is a temporary 2.2% FMAP increase for all Medicaid enrollees, bringing The United States Virgin Islands’ FMAP to 57.2%.

Demonstrations and Waivers

Demonstrations and Waivers for US Virgin Islands Waiver# {None}

Demonstration and waivers are vehicles states can use to test new or existing ways to deliver and pay for healthcare services in Medicaid and CHIP. The primary types of waivers and demonstration projects include section 1115 demonstrations, section 1915(a) and 1915(b) managed care waivers, and section 1915(c) home and community-based services waivers. More information about waivers is available on the Waivers page.

There are no waivers operational in The United States Virgin Islands