Texas Council Update Presented by: Erin Lawler, Esq. Director of IDD Services Texas Council of Community Centers January 11, 2018

Major Themes IDD System Redesign PASRR HCBS Settings Regulations IDD Managed Care Pilots Cancelled STAR+PLUS Reprocurement RFP PASRR State Plan Amendment Approved HCBS Settings Regulations Focus on Day Habilitation and Residential Settings HCS/TxHmL Impact of Rate Cuts Lack of Diversion Slots Performance Contract Issues ECC/Hub Funding Sustained Crisis Services

IDD System Redesign Take away: Texas Council is Highly Engaged in Ensuring system Redesign follows incremental, deliberate stages laid out in law.

IDD System Redesign (Senate Bill 7/83rd) IDD Managed Care Pilots Cancelled September 2017: HHSC announced its intention to cease implementation of the IDD Managed Care Pilot June 2017: HHSC announced the following MCOs were awarded contracts for the IDD Pilot in the following counties, contingent on CMS approval: Molina Healthcare of Texas (Bexar, Atascosa, and Dallas) UnitedHealthcare Community Plan of Texas (Harris, Brazoria, Galveston, Ft. Bend, Matagorda, and Wharton)

What will fill the void left by the cancelled Pilots? HHSC proposed using the STAR+PLUS Reprocurement RFP as the vehicle for assessing MCO readiness for the transition of IDD LTSS to managed care. Texas Council and other stakeholders objected to this shift from “if” to “when.”

“The Letter” (October 12, 2017) Texas Council drafted a letter on behalf of a coalition of diverse stakeholders. The coalition urged HHSC to adhere to the requirements of law. The coalition letter and accompanying Appendix outlining the requirements of SB 7, can be found on the Texas Council intranet site.

Managed Care Transition Timeline (select) 2014: STAR+PLUS Medical services for individuals with IDD supported HCS and TxHmL waivers and ICF rolled in to STAR+PLUS 2016: STAR Kids Medical services for children with IDD and some LTSS (MDCP waiver) rolled in to STAR Kids 2020 (potential): LTSS for individuals in TxHmL Waiver to roll in to STAR+PLUS 2021 (potential): LTSS for individuals in HCS, ICF, and other waivers to roll in the STAR+PLUS

Structure of Senate Bill 7: IDD Transition to Managed Care Programs to Improve Service Delivery Models Stage One Transition of Long Term Care Medicaid Recipients to Integrated Managed Care Systems Stage Two

STAGE ONE: PROGRAMS TO IMPROVE SERVICE DELIVERY MODELS Develop and Implement Pilot Programs to Test Managed Care Strategies: Cancelled Deliver Acute Care Services for Individuals with IDD through Managed Care: Implemented Analyze Acute Care Outcomes: Incomplete Implement Attendant and Habilitation Services [Community First Choice]: Implemented

REQUIRED BEFORE POTENTIAL TRANSITION OF TXHML: STAGE TWO: TRANSITION OF LONG-TERM CARE MEDICAID WAIVER RECIPIENTS TO INTEGRATED MANAGED CARE SYSTEM REQUIRED BEFORE POTENTIAL TRANSITION OF TXHML: Evaluate Cost-effectiveness of Potential TxHmL Transition: Status unknown Evaluate Experience of Providing Community First Choice: Status unknown Determine Whether to Provide All or a Portion of TxHmL LTSS through Managed Care: Status unknown Determine Whether the STAR+PLUS Medicaid Managed Care Program Delivery Model or a Different Integrated, Capitated Managed Care Delivery Model is Most Appropriate (based on 1 and 2 above) Status unknown

Stage Two (continued) REQUIRED UPON POTENTIAL TRANSITION OF TXHML: Develop Stakeholder Process re: Implementation of TxHmL Transition: Status unknown Develop TxHmL Transition Plan to Ensure Continuity of Care: Status unknown Develop MCO Contract Requirements: Started

Stage Two (continued) REQUIRED PRIOR TO TRANSITION OF CLASS, DBMD, AND HCS WAIVER PROGRAMS AND ICF-IID PROGRAM Evaluate Cost-effectiveness of Potential Transition of CLASS, DBMD, and HCS Waiver Programs and ICF-IID Program: Status unknown Analyze TxHmL Transition: Status unknown Evaluate MCO Provider Network Experience and Expertise: Children’s Services: Status unknown Evaluate MCO Provider Network Experience and Expertise: Adult Services: Status unknown Determine Whether to Transition Services: Status unknown Determine Whether to Provide All or a Portion of Services in Managed Care: Status unknown Determine Whether the STAR+PLUS Medicaid Managed Care Program Delivery Model or a Different Integrated, Capitated Managed Care Delivery Model is Most Appropriate: Status unknown

Stage Two (continued) REQUIRED UPON TRANSITION OF CLASS, DBMD, AND HCS WAIVER PROGRAMS AND ICF-IID PROGRAM Develop Stakeholder Process re: Implementation of CLASS, DBMD, HCS, and ICF-IID Transition: Status unknown Develop Transition Plan to Ensure Continuity of Care: Status unknown Establish Process for Voluntary Enrollment: Status unknown Develop MCO Contract Requirements: Started

Current Status HHSC formulating an official response to “The Letter” (possibly to be presented to IDD SRAC, January 25, 2018) STAR+PLUS Reprocurement RFP is open for responses Special thanks to Sheri Talbot for assisting Texas Council with reviewing RFP and submitting IDD specific content Texas Council and other stakeholders submitted “The Letter 2.0” this week, registering continued objection to use of RFP as vehicle to assess MCO readiness IDD SRAC Annual report: 2017 report published online September 2017 at: https://hhs.texas.gov/sites/default/files//documents/laws-regulations/reports-presentations/2017/long-term/implementation-acute-care-ltss-redesign-sept-2017.pdf

Key Date: STAR+PLUS Reprocurement RFP March 6, 2018: MCO proposals are due October 2018 (estimate): HHSC will announce contract awards January 1, 2020: Selected MCOs will begin serving members under the new contracts

IDD Comprehensive Assessment Pilot Individuals in Lakes Regional and Tarrant County service areas, along with Denton and Mexia SSLCs, assessed using InterRAI IDD Assessment Instrument during summer 2017. LifePath Systems and Metrocare Services recently invited to participate. HHSC indicated results of assessments may be available by December 2017 (delayed)

PASRR Take away: Medicaid rates for Habilitation Coordination and other PASRR Specialized Services are Coming, but May be a Year or More Away.

PASRR: State Plan Amendment Approved HHSC received CMS approval through an approved Medicaid State Plan Amendment (SPA) to create two new Medicaid services. The services are: Habilitation Coordination (case management currently performed in Nursing Facilities for PASRR individuals outside of the 180-day window of transition), and PASRR Specialized Services (employment assistance, supported employment, independent living skills training, day habilitation, and behavioral support). These services are currently performed by LIDDAs and funded by General Revenue. Timeline: SPA effective December 1, 2017, but implementation of rates may take 12-18 months.

PASRR Specialized Services: Provider Qualifications Habilitation Coordination: Local IDD Authority as exclusive provider. HHSC received a 1915(b)(4) [Social Security Act] Selective Contracting Waiver, which allows the state to waive Freedom of Choice requirements, allowing the Local IDD Authority to be the exclusive provider of Habilitation Coordination services. A provider of habilitation coordination must be employed by the LIDDA, have a bachelor’s or advanced degree with a major in a social, behavioral, or human service field, and must have at least one year of experience working directly with individuals with IDD. Other PASRR Specialized Services: Open to other provider types. Providers of the following services will be eligible to provide PASRR Specialized Services: HCS TxHmL Community Living Assistance and Support Services (CLASS), and Deaf Blind Multiple Disabilities (DBMD)

Service Current Rate (General Revenue) Proposed Medicaid Rate $ Change % Change Supported Employment (per hour) $33.10 $29.15 -$3.95 -12% Employment Assistance (per hour) $29.66 -$3.44 -10% Independent Living Skills Training (per hour) $22.41 $17.73 -$4.68 -21% Behavioral Support (per hour) $79.53 $86.87 +$7.34 +9% Habilitation Coordination $182.80 $208.23 +25.43 +14% Day Habilitation (daily) $44.76 $41.83 -$2.93 -7%

Home and Community-based Services (HCBS) Settings Regulations Take Away: HHSC Continues to work Toward a final Statewide Transition Plan, including Remediation Strategies for Programs Currently Out of Compliance.

HCS and TxHmL HCBS Regulations: Background What. Federal regulations require home and community-based services to meet certain requirements in order to continue to draw down federal Medicaid funding. Requirements apply to: • 1915(c) HCBS Waivers [HCS, TxHmL] • 1915(i) State Plan HCBS Services [Adult Mental Health] • 1915(k) [Community First Choice] • STAR+PLUS HCBS Waiver. How. Regulations enhance the quality of HCBS and provide additional protections to individuals that receive services under these Medicaid authorities. Timeline: Requirements around Person Centered Planning were effective March 2014. States originally had five years to bring existing programs into compliance with settings requirements (March 2019), but the timeline for compliance was recently extended by three years to March 2022. Revised Statewide Transition Plan. HHSC plans to submit a revised Statewide Transition Plan (STP) to CMS in 2018. The revised STP will include plans to remediate program areas found to be out of compliance with the rule.

HCS and TxHmL HCBS Regulations: Recent Updates HHSC convened a time-limited series of workgroup meetings focused on remediation strategies for day habilitation sites and HCS residential services Local IDD Authorities were represented in these meetings by: Kevin Barker (Texana Center), John Delaney (Lakes Regional) Susan Garnett (MHMR Tarrant), Jennifer Farrar (Betty Hardwick Center), Erin Lawler (Texas Council), Sandra Taylor (Community Healthcore) Remediation strategies are still in draft form with more opportunities for stakeholder input Kate Layman (HHSC) will join us today to provide more detail

HCS and TxHmL Take Away: Rate Cuts and Lack of Diversion Slots Continue to Put Pressure on Provider and Authority Functions; Texas Council Will Request Your Assistance Documenting Impacts.

HCS/TxHmL: Rate Cuts Effective August 1, 2017, reimbursement rates for the following services are reduced from $22.41/hr to $17.73/hr: HCS Supported Home Living and Supported Home Living Transportation HCS Community First Choice TxHmL Community Support Services and Community Support Services Transportation TxHmL Community First Choice Consistent with legislative direction, the above rate cuts do not apply to Consumer-Directed Services. See HHSC Information Letter No. 17-16 for additional details. Discussion: What kinds of conversations are occurring locally about future of HCS/TxHmL?

HCS Promoting Independence and Interest List Slots The 85th Texas Legislature significantly reduced funding for HCS Promoting Independence slots and did not fund HCS and TxHmL Interest List reduction for the FY18-19 biennium. Enrollment staff should review HHSC’s HCS Enrollment Plan for the FY18-19 biennium, as shared on the July 2017 LIDDA Webinar (COMNet). Texas Council recommended agency-driven, statewide, consistent messaging to individuals/families on the IDD Waiver Interest Lists HHSC responded with HHSC IDD Broadcast message 1224 (sent October 5, 2017) which included standard language

Documenting Impacts: HCS/TxHmL Rate Cut Expect a survey from Texas Council this quarter asking about the impact of the August 1, 2017 HCS/TxHmL rate cuts Questions will probably cover: Contract terminations (public and private) Operational changes in response to rate cuts (capping programs, restructuring service delivery)

Documenting Impacts: Unmet Need LAW project designed to capture unmet need in IDD services Glenn Pitchford (Permian Basin) will discuss and demonstrate a draft data collection tool

Performance Contract Issues Take Away: ECC/Hub funding Sustained for another year; IDD Crisis Services Processes Being Refreshed.

ECC and Hub Funding Sustained CMS notified HHSC that Enhanced Community Coordination (ECC) and Transition Support Teams (TST, also known as the “hubs”) are fully funded through December 2018, an additional year beyond what was previously approved. HHSC requests that all Local IDD Authorities continue normal operations regarding ECC and TST through December 2018, as funds are approved through CMS until this time.

IDD Crisis Services Crisis respite plan updates: The HHS IDD Services Performance Contracts unit requested crisis respite plans from all Local IDD Authorities to include updates, additions, and changes, along with copies of reports that illustrate the out of home crisis respite locations’ compliance with applicable licensure and/or certification requirements. Information is due to HHSC by January 15, 2018. Crisis Intervention Specialist and Crisis Respite data collection to be revised: The HHS IDD Services Performance Contracts unit intends to revise the quarterly Crisis Intervention Specialist and Crisis Respite data collection tool. Texas Council gathered feedback from the Local Authority Workgroup and Crisis Intervention Specialist learning collaborative to assist HHSC’s efforts to improve data collection.

What Ever Happened To…?

DOL: Overtime Rules Background: In 2016, changes to U.S. Department of Labor overtime rules scheduled to go into effect December 1, 2016 would have extended overtime eligibility to an estimated 4 million American workers by increasing the salary threshold under which employees qualify for overtime pay to $47,476 a year. In late 2016, a federal judge temporarily barred the rules from going into effect; on August 31, 2017, the same judge permanently blocked the rules. The U.S. Department of Labor is not likely to appeal this decision. Current Status: For now, the 2004 salary threshold of $23,660 remains in place. Unless specifically exempted, covered employees must receive overtime pay for hours worked in excess of 40 in a workweek at a rate not less than time and one-half their regular rates of pay. Going Forward: Changes to federal overtime rules may still be coming. Current U.S. Secretary of Labor Alexander Acosta indicated on several occassions that an adjustment to the salary threshold for overtime is warranted, though not as significant an adjusment as the 2016 rules would have required. Experts suggest a notice of proposed rulemaking may be forthcoming in the first quarter of 2018.

ABLE Achieving a Better Life Experience (ABLE) (tax-advantaged savings accounts for certain people with disabilities) accounts are coming to Texas in 2018! Representatives from The Arc of Texas will present on ABLE accounts and other long-term planning tools tomorrow.

Determinations of Intellectual Disability (DIDs) Update from Dr. Maria Quintero-Conk

Conclusion Questions? Contact: elawler@txcouncil.com; 512.541.8667