1. Texas Council Update Presented to: IDD Directors’ Consortium
September 15, 2016
Presented by: Erin E. Lawler, J.D., M.S.
Director of IDD Services
Texas Council of Community Centers

2. Agenda State Budget Update Sunset / HHS Agency Consolidation
IDD Crisis Initiatives
Community First Choice
HCBS Settings Regulations
Updates and Reminders: PASRR, HCS Sprinkler Reimbursement, IDD Managed Care Pilot, DOL Overtime Regulations, ICF Vacancies, “What Ever Happened To…?”

3. State Budget Update: FY2018-19

4. State Agencies Directed to Reduce Budget Requests
Background. June 2016: Governor, Lt. Governor and Speaker of the House released state agency Legislative Appropriations Request (LAR) instructions for FY biennium.
Reductions. Instructions direct state agencies to reduce base budget requests by 4%.
Exemptions from reductions:
Behavioral health services programs
Child Protective Services (CPS)
Benefits and eligibility for Medicaid programs (base budget request to include case load growth)
Children's Health Insurance Program (CHIP)
Foster care program
Adoption subsidies and permanency care assistance programs
Full policy letter:
Call to action. As the LAR process moves forwards it will be necessary to not only thank legislators for the continued recognition of unmet mental health needs across the state, but to draw their attention to unmet needs for people with intellectual disabilities.

5. Sunset: HHS Agency Consolidation

6. Transfer of Client Services: DADS DARS
Effective September 1, 2016:
· Over 120 programs and 4,100 positions transferred to HHSC
· Client programs and services transferred to the new HHSC Medical and Social Services Division  
· Transitioned employees began using addresses ending
September 1, 2016
Transfer of Client Services:
DADS
DARS
Transfer of Administrative Services
September 1, 2017
Transfer of Facilities
DADS (SSLCS)
DSHS (State Hospitals)
Transfer of Regulatory Operations

7. Gary Jesse, Deputy Executive Commissioner, Medical and Social Services Division
Gary Jessee is leading the Medical and Social Services (MSS) division within the consolidated HHSC
The new Medical and Social Services division combines :
Office of Social Services (SNAP food benefits, TANF cash assistance, community partners)
Medicaid
Community Services department (new)
The new structure comes from recommendations made during the system's Sunset review process.

8. Associate Commissioners for Medical Social Services
Ms. Sonja Gaines
Associate Commissioner for Intellectual and Developmental Disability and Behavioral Health Services
*includes Local IDD Authority Services and PASRR
Ms. Lesley French Associate Commissioner for Health, Developmental, and Independence Services *includes Early Childhood Intervention
Ms. Jami Snyder
Associate Commissioner for Medicaid and CHIP Services
Mr. Wayne Salter
Associate Commissioner for Access and Eligibility Services

9. IDD Crisis Initiatives

10. Background: Crisis Initiatives
June 2015: 84th Texas Legislature allocated approximately $18.6 million to support individuals with IDD and high behavioral and psychiatric needs.
$6 million in FY16
$12 million in FY17
November 2015: DADS released Needs & Capacity Assessment (NCA) with expectation that certain submitted projects across the state (but not all) would be funded.
April 2016: DADS determined it would not use NCA submissions as basis for fund distribution; Texas Council (per direction of ED leadership) worked with DADS to ensure new funds would reach every local service area in the state.
May 2016: DADS released contract amendments:
Attachment Z: Crisis Intervention Specialist (funds intended to support at least on specialist position at each LIDDA)
Attachment Y: Crisis Respite (distributed on a per capita basis and should be used strategically to ensure provision of crisis respite services to residents of each LIDDA's local service area

11. Crisis Initiatives: Recent Updates
Next Steps: Crisis Respite Plan Review. Attachment Y required each LIDDA to submit a FY16 crisis respite plan to DADS within 30 calendars days after full execution of the contract amendment.
Deadline for submission of FY17 plans extended to October 7, 2016.
Members of the Local Authority Workgroup (LAW) recommended Texas Council and LAW members compile and review completed Crisis Respite Plans as submitted to DADS.
Results will be used to identify different approaches across service areas and to develop models for use by LIDDAs.
Reporting. Technological problems with Crisis Intervention Specialist and Crisis Respite Data Report (due September 15, 2016 for Q4 of FY16).

12. Community First Choice

13. Community First Choice: Recent Highlights
DADS and HHSC solicited stakeholder feedback on the CFC PAS/HAB Assessments used to assess individuals with IDD accessing CFC through Medicaid Managed Care and the HCS and TxHmL waivers.
With assistance from the CFC Workgroup, Texas Council submitted feedback on the assessments on July 28, 2016.
DADS (now HHSC) compiled all stakeholder feedback and is reviewing internally.

14. CFC in IDD Waivers

15. CFC: TxHmL Targeted UR Review
CFC/TxHmL Utilization Review
Round 1
Round 2
Round 3
Type of plans reviewed
Cost of $85,000+
Cost of $68,000+
Cost of $57,884+
Number of plans reviewed 24 61
114
Number of individuals requested appeals 7 1
Cost savings to State as a result of revisions (approximate)
$1,100,000
(annualized cost)
$2,175,000 (annualized cost)
$1,640,000 (annualized cost)
DADS staff provided this information at a stakeholder meeting on August 11, 2016.

16. CFC: TxHmL Cost Per Enrollee
Texas Home Living Cost Per Enrollee
Total Cost
% of total cost spent on CS or CFC PAS/HAB
CS or CFC PAS/HAB Cost
% of enrollees using CS or CFC PAS/HAB
CS or CFC PAS/HAB cost per user
Average service hours per month and week (rate = $22.41/hr)
May 2015
$862.64
28.46%
$245.48
53.48%
$459.04
20.5 hrs/mo
4.6 hrs/wk
May 2016
$1,804.91
65.32%
$1,178.95
71.22%
$1,655.48
73.9 hrs/mo
16.4 hrs/wk
DADS CFO David Cook provided information shaded in blue at the IDD Systems Improvement Workgroup meeting on August 12, 2016.

17. CFC: HCS Cost Per Enrollee
Total Cost
% of total cost spent on SHL or CFC PAS/HAB
SHL or CFC PAS/HAB Cost
% of enrollees using CS or CFC PAS/HAB
SHL or CFC PAS/HAB cost per user
Average service hours per month and week (rate = $22.41/hr)
May 2015
$3,531.47
6.04%
$213.39
13.12%
$1,626.30
72.6 hrs/mth
16.1 hrs/wk
May 2016
$3,636.46
7.80%
$283.57
12.77%
$2,221.36
99.1 hrs/mth
22 hrs/wk
DADS CFO David Cook provided information shaded in blue at the IDD Systems Improvement Workgroup meeting on August 12, 2016.

18. CFC in Managed Care

19. CFC Enrollment Activity Survey: Preliminary Results
3 LIDDA responses still pending
Estimated LIDDA personnel cost per CFC referral:
Average: $526.82
Range: $ $1,282.70

20. CFC: LIDDA Role for STAR Kids Members
Refresher. The STAR Kids Program will be the first Medicaid managed care program for children age 20 and younger with disabilities. STAR Kids Managed Care Organizations (MCOs) will begin serving clients on November 1, 2016.
Participation in the STAR Kids program is required for individuals age 20 and younger, covered by Medicaid, who meet at least one of the following:
Receive Supplemental Security Income (SSI);
Receive services through the MDCP waiver;
Receive services through the YES waiver;
Live in a ICF/IID or nursing facility;
Receive services through a Medicaid Buy-In program; or
Receive services through any of the following DADS IDD waiver programs: CLASS, DBMD, HCS, and TxHmL.

21. CFC: LIDDA Role for STAR Kids Members (cont’d)
STAR Kids will cover acute care services for all children enrolled in the program, and long-term services and supports (LTSS) for children in the MDCP waiver.
Children in the following waiver programs will be enrolled in STAR Kids, but continue to receive LTSS through the waivers: YES, HCS, TxHmL, CLASS, and DBMD.
The LIDDA role in STAR Kids CFC will closely resemble the LIDDA role for children previously served in STAR+PLUS or STAR Health. The LIDDA will:
conduct eligibility determinations (DIDs, ID/RCs),
submit eligibility information to DADS/HHSC, and
communicate status updates with STAR Kids MCOs.
STAR Kids MCOs will be responsible for conducting the functional assessment and providing ongoing service coordination.
HHSC will release STAR Kids CFC procedures soon.

22. High Medical Needs

23. High Medical Needs Pilot and Effect of SSLCs Remaining Open
Background: The 84th Legislature appropriated funds for an add-on payment to ICF-IID providers serving individuals with high medical needs (HMN) within 6-months of the individual’s transition from a State Supported Living Center (SSLC).
High Medical Needs Pilot. DADS began this initiative with the “High Medical Needs Pilot” in January 2015.
Participation in the pilot was limited to four ICF providers (24 beds total) in the greater Austin area.
The appropriation funded add-on payments for 150 ICF/IID beds (including those in the pilot) for the biennium. The ICF/IID beds for FY 2016 were expected to be necessary in the event of closure of one or more SSLCs.
Effect of SSLCs Remaining Open. An insufficient number of eligible individuals transitioned from SSLCs for the HMN add-on payment to fully utilize appropriated funds. Effective May 24, 2016, DADS expanded eligibility criteria to include not only individuals transitioning from an SSLC, but also individuals transitioning from a Medicaid-certified Nursing Facility (NF).
Parameters of Current Program. The add-on rate for HMN is only available in Community ICFs with a Medicaid certified capacity of 13 or fewer individuals and is only available to individuals transitioning from SSLCs and NFs who:
have a current Form 8578, Intellectual Disability/Related Condition Assessment (ID/RC), showing the individual receives at least 181 minutes of face-to-face nursing services per week as indicated by a nursing frequency code of “6” on Item 40;
meet the resource utilization group (RUG) value in one of the qualifying categories determined through a medical needs assessment conducted by a DADS registered nurse; and
[SSLC transitions only] have resided in the SSLC for at least six consecutive months.
Looking Ahead. However, in 2017, we will see increased supports for individuals with HMN added to the HCS Waiver Program.  

24. Looking Ahead: HMN Support Coming to HCS
New Services to be added in High Medical Needs Support, High Medical Needs Support Registered Nursing, and High Medical Needs Licensed Vocational Nursing will likely be added as new services to the HCS Waiver Program in 2017.
Available to Individuals with High Needs. These services will provide additional support for eligible individuals who have medical needs that exceed the service specification for existing HCS services and require additional support in order to remain in a community setting.
LON Bump. The same rule amendments will include DADS current practice of increasing a Level of Need (LON) 1, 5, or 8 to the next LON due to an individual’s high medical needs if the individual meets certain criteria, including requiring 181 minutes or more per week of face-to-face nursing services.
Status. Draft rules were considered at HHSC’s Medical Care Advisory Committee on August 11, The proposed rule development schedule includes publication of proposed rules in the Texas Register in October 2016 and a final effective date in January 2017.

25. Home and Community-based Settings (HCBS) Regulations

26. HCBS Regulations: Recent Updates
Texas remains in the assessment phase of its transition into compliance with the Medicaid Home and Community-based Settings (HCBS) requirements.
HHSC submitted a revised draft Statewide Transition Plan (STP) in February 2016; Texas Council provided significant comment on this draft.
CMS provided feedback on Texas’ plan on June 7, The feedback included requests for reorganization of certain content, a broader scope to include state laws and rules beyond Medicaid rules (e.g. housing rules), and more detail on the State’s plans to bring areas identified as out of compliance into compliance.
While other states plan to submit final drafts of Statewide Transition Plans to CMS by September 2016, Texas indicated it will not meet this deadline due to agency transformation.
HHSC anticipates revising the STP again in 2017 based on information gained from assessment surveys.
DADS/HHSC released self-assessment surveys to Medicaid HCBS providers
and participant surveys (surveys to be completed by individuals who are recipients of HCBS services).

27. HCBS Participant Surveys
DADS/HHSC contracted with the Public Policy Research Institute (PPRI) at Texas A&M University to conduct HCBS participant face-to- face surveys with randomly selected 1915(c) waiver program participants, including HCS and TxHmL participants.
The purpose of the surveys is to evaluate the experiences of program participants to assist DADS in identifying ways to improve quality in waiver programs.
PPRI staff will need LIDDA cooperation and assistance in obtaining pre-survey and contact information for participants to be interviewed.
See DADS IL-1633 (August 29, 2016) for further detail. The IL includes a request for LIDDAs to share information about the surveys with employees and subcontractors, including day habilitation and sheltered workshop providers.

28. PASRR Nursing Facility Service Coordination
Attachment C allocation entitled “Nursing Facility PASRR Service Coordination” covers TCM performed in NFs for individuals with IDD outside of the 180-day period before an individual’s transition to community; TCM outside of 180-day period is no longer a Medicaid benefit and thus is not billable to TMHP.
LIDDAs received a straight allocation (no requests for reimbursement); DADS will perform reconciliation at the end of FY2016 if necessary.
LIDDA staff will continue Type A and B encounters.

29. Provider Reimbursement for Installation of Sprinkler Systems in 4-bed HCS Group Homes
DADS processed all reimbursement requests from March 1, 2016 round and funds remain available.
Second round of reimbursement requests will commence in September 2016.
Providers may be reimbursed up to 50% of installation costs, not to exceed $10,000 per home, for installations made after September 1, 2012.

30. IDD Managed Care Pilot: Status
HHSC released draft Request for Proposals (RFP) on May 2, 2016
Stakeholders provided input on draft RFP in May 2016
Implementation deadline for pilot: September 1, 2017
Some MCOs have expressed interest in responding to the RFP (once released); MCOs may reach out to you to discuss collaboration

31. DOL Overtime Regulations: Next Steps
HHSC’s Rate Analysis Department (RAD) recently released a survey to determine impact of the recent DOL rule change.
Survey was designed to capture additional allowable cost associated with employees whose salary falls between $455 and $915 weekly and who were previously overtime pay exempt.

32. DADS/HHCS ICF Vacancy Workgroup: Call to Action
Make sure people are able to take advantage of available resources
resources are there and not being fully used
many providers (and others) believe people are not fully informed of this service.
See LA Broadcast Message 1140: Language to Use on LIDDA Websites regarding ICF/IID for website blurb. Due date: October 31, 2016.

33. What ever happened to…? ABLE Act (SB 1664)
rules adopted;
RFP for program administrator to follow in early October (miles to go before individuals will be able to open ABLE accounts in Texas)
HCS/TxHmL Administrative Penalties (SB 1385)
draft rules shared with stakeholders through a DADS Provider Alert released on July 11, 2016;
formal rulemaking process to follow
Medicaid Therapy Rate Cuts
Texas Supreme Court temporarily blocked HHSC’s planned rate reductions for Medicaid home health services for certain children with disabilities.
The Supreme Court ruled on a procedural issue, not the substance of the case.
 The Supreme Court held that a temporary injunction issued by a Travis County district court preventing the rate cuts from taking effect remains binding until the Texas Third Court of Appeals reverses the district court’s decision or the Supreme Court grants further review.

34. Summary
Major initiatives to improve long-terms services and supports for people with IDD in Texas continue.
Congratulate yourselves for your hard work in the face of change (and much more change to come)!
Questions: