Home and Community-Based Waivers Employment and Day Services

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).

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.

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).

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.

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).

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

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).

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.

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).

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.

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).

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.

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).

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.

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).

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

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).

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.

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).

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)

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).

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.

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).

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.

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).

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.

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).

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.

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).

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.

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).

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

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).

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.

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).

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

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).

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.

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).

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.

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).

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.

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).

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

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).

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

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).

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.

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).

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

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).

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

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).

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).

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).

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.

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).

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.

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).

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.

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).

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.