Arkansas Health Care Reform Task Force – ID/DD Wait List Exploring Options for Addressing the Wait List for the DDS Alternative Community Services (ACS) Waiver Program for the Intellectually Disabled and Developmentally Delayed March 2016

Executive Summary TSG reports what a new waiver benefit would look like for the 2,640 people on the ID/DD wait list Top-5 benefits except Supportive Living

Agenda Review historical spending for Waiver program Report results of a survey of households on the wait list Model the effect of alternative capped a range of alternative waiver programs Recommend path forward

Waiver Background Improve the quality of services through Home and Community Based Waiver Services provided under a 1915 waiver for a limited number of individuals as an alternative to ICF/ID placement Serving targeted populations: mental illness, and intellectual, developmental or physical disabilities with an age of onset before age 22 Participation capped at 3,9881, with turnover, served 4,127 different individuals in SFY2015 Wait list of 2,640 1 - http://humanservices.arkansas.gov/ddds/waiverDocs/ACSWaiverGuidebook.pdf

Services Supportive Living – enable beneficiaries to live in their own homes, with their family, or in an alternative residence Respite Services – short-term benefits for beneficiaries unable to care for themselves due to absence of non-paid caregivers Supportive Employment – enable beneficiaries who need intensive ongoing support to perform in a competitive work setting Adaptive Equipment – equipment to increase, maintain or improve functional capabilities to perform daily life tasks Vehicle Modifications – adaptations to an automobile or van to accommodate the special needs of the beneficiary Environmental Modifications – modifications made to or at the beneficiary’s home

Services (cont.) Specialized Medical Supplies – items necessary for life support not otherwise available under Medicaid Supplemental Support Service – enable community living, in response to crisis, emergency or life threatening situations Case Management Services – assistance in gaining access to needed services, in or out of the Waiver Consultation Services – clinical and therapeutic services Crisis Intervention Services – in the beneficiary’s home or other local community site by a mobile intervention team Community Transition Services – set-up expenses for beneficiaries who are transitioning from an institution

SFY2015 Services by Claim Amount Claims data from SFY2015 federal Expenditures Report 96% of Waiver Spending is for Supportive Living 20% of beneficiaries spend less than $20,000 – 80% less than $70,000

Spending by Service Type Total Waiver Claims Amount Unique Beneficiary Count Average for Those Claiming Benefit Percent Supportive Living 196,404,211 4,013 48,979 95.9% Case Management Services 5,550,856 4,094 1,357 2.7% Supportive Employment 668,300 103 6,617 0.3% Specialized Medical Supplies 642,407 925 696 Consultation Services 453,751 733 621 0.2% Adaptive Equipment -ACS 392,835 155 2,568 Respite Services 380,605 153 2,521 Environmental Modifications 238,010 52 4,760 0.1% Supplemental Support Service 16,462 17 1,097 0.0% Adaptive Equipment - PERS Monthly Fee 13,733 31 474 Adaptive Equipment - PERS Installation 479 6 120 Total 204,761,648 4,124 49,675 100.0% Claims data from SFY2015

Supportive Living Averages $49,000 Claims data from SFY2015

Cost of Services Other Than Supportive Living Claims data from SFY2015

Services other than Supportive Living Rarely Total More than $6,000 A program capped at $6,000 would meet 96% of needs other than Living Support Claims data from SFY2015

A Program Capped at as Little as $6,000 would Cover Most Historic Claims -- Except Supportive Living Claims data from SFY2015

Agenda Review current spending for Waiver program Report results of a survey of households on the wait list Model the effect of alternative capped a range of alternative waiver programs Recommend path forward

Survey Method Survey invitation sent by US mail to 2,640 individuals on the wait list Asked to rank the top 5 most important benefits from the list Respondents responded by using a web survey Asked for comments at the end of the survey Offered the opportunity to respond anonymously or provide detailed contact information Respondents spent an average of 8 minutes responding (long for a web-based survey). This suggests they took it seriously

Responses Covered the State 440 responses in 10 days—17% response rate 81% provided addresses All but one provided a comment Responses represented the entire state Note: 81% of responses provided name and address, only these are graphed

How the Services were Ranked

Services by Rank Red: Supportive Living Yellow: Respite Care Lt. Green: Case Management Lt. Blue: Supportive Employment Dark Blue: Environmental Mods

Summary Findings from Survey Supportive Living is #1, but not as strongly favored as the 97% of current Waiver participants that claim for Supportive Living Respite and Case Management are clear #2&3 for those on the wait list Responses are widely dispersed—strongly supporting the notion of self-determination of services Response rate, and number, size and tone of comments all suggest that the wait list is a very unhappy group, looking to the legislature for quick relief Respondents would rather have some benefits even if it is less that the whole Waiver program Respondents seek more self-direction The selection process should be faster, clearer and more transparent

Agenda Review current spending for Waiver program Report results of a survey of households on the wait list Model the effect of alternative capped a range of alternative waiver programs Recommend path forward

What if… TSG has modeled a waiver like those in Indiana, Tennessee and Kentucky. It would… Provide a benefit capped at an amount much smaller that the average of claims for those already on the Waiver Allow recipients substantial latitude to spend up to the cap on any of the services. Both models assume that for most beneficiaries, the capped amount would not be sufficient to fun a meaningful part of Supportive Living This model considered simply for the purpose of understanding what might result from such a capped benefit

TSG Developed the Model Based On Assumptions: Services usage based on survey responses Services cost based on historic Waiver claims Assuming the program would allow beneficiaries to claim services up to the cap Excluding Supportive Housing from the value assessment, as we know it averages $50,000, beyond other state caps Seeking to find out: What services would beneficiaries likely spend the capped amount on? How far would the capped benefit go towards “buying” all of their 5 highest ranked services? How much would the two scenarios cost in total, assuming 2,640 people came off the wait list into the new waiver program

Self-Directed Benefit Simulation 86% 72% 72% of top-5 needs (other than Supportive Living) met by a cap of $12,000 86% by a benefit capped at $15,000 The #4 & #5-ranked services are often the more expensive ones

Agenda Review current spending for Waiver program Report results of a survey of households on the wait list Model the effect of alternative capped a range of alternative waiver programs: Next Task Force Update Recommend path forward

Full Cost of Capped Waiver for 2,640 on the ID/DD Wait List Capped at $12,000 Capped at $15,000 Beneficiaries capped benefit: all services $31,680 MM $39,600 MM Arkansas State Match Cost $9,504 MM $11,880 MM