Minutes of the PAD-CO meeting with DDD
with DDD (Sharon Jacksi, Barbara Ramsey, Christine Thomas) on 6/23/09; 11 PAD-CO
members were present.
is a listing of topics and questions that were discussed.
- HCPF had to okay the waivers
and the funding caps and then forwarded the waivers to CMS/
- DDD & HCPF decided not to
change all plans 7/1/09 when the new waivers went into effect. They decided to have a “phase-in”
approach where all new plans, or plans modified, after 7/1/09 would have
to comply with the new waiver caps but when all the other plans came up
for renew later then that is when the new waiver caps would apply.
- DDD stated that they received
“hold harmless” funding in the past for Comprehensive waiver changes and
that they did not get similar funding for the current SLS changes. (They stated that the legislature
did not appropriate the “hold harmless” funds but it was not clear as to
whether DDD and/or HCPF submitted a funding request this legislative session
- To include some funding for
the transition process, they decided to hold back $4 million (from the $40
million appropriated) to cover some of the “phase-in” (they also referred
to this as the “transition”) approach.
- DDD will look at the caps and
rates next fiscal year to figure out where the $4 million will be applied.
How were the funding caps for the SLS levels developed and by whom?
- DDD looked at the State appropriation
of $40 million (the State legislature sets the appropriation amount for
SLS funding), then they looked at all SIS ratings and this showed
a “curve” (I think they implied it was a bell curve).
Then they analyzed all funding caps and how they affected the appropriation.
Next they looked at the utilization rates and analyzed individual rates
(e.g., respite services) and how many units were used. DDD
staff stated that they put in as many day hab units into this evaluation
as was possible.
- DDD stated that some people
are actually getting increases to their caps.
- Sharon Jacksi (DDD) said that
they found out within the last two weeks that some CCBs had created “artificial
caps” for their clients. Some
limited SLS plans to $13,000 and under and another CCB had limited their
plans to less than $9,000. (This
data was not known when DDD and HCPF gathered and analyzed data to come
up with the new funding caps and levels.
So, the outcomes were based on flawed data.)
- There was a “rates” committee
that had representatives from CCBs, DDD, HCPF, and providers.
- PAD-CO asked why geographical
rates were not included in the final rates.
DDD stated that HCPF (long term benefits unit) determined that the
State cannot allow for geographical cost-of-living allowances (so rates
in Aspen are the same as rates paid in lower cost-of-living cities
in the State).
- DDD said that personal care
rates are higher in SLS than under Medicaid and EBD.
- PAD-CO raised the issue of transportation
rates and that transportation needs varies by location and by the individual. For example, individuals in the
rural areas have further to travel than individuals in metro areas and para-transit
is more expensive than other types of transportation.
- PAD-CO raised the issue of providers
quitting because of the reduced rates.
- PAD-CO said that some rates
substantially increased and asked why the rates weren’t just caps. The answer
was that the State wanted uniformity in rates.
- PAD-CO gave an example of higher
rates: a person who is at a level 6 SIS and attending day hab, the provider
rate (for that level) went substantially higher.
This higher rate causes the person’s plan dollars to be utilized
faster (thereby reducing the services provided).
DDD said that since the day hab provider could provide services at
a lower rate then we may be able to negotiate “free services” from the day
hab provider because they were now getting a higher rate.
(Comment: What the DDD
doesn’t realize is that providers average out the rates they receive from
the population they serve so as to cover their operating expenses.
So, the people whose plans pay a higher rate are basically subsidizing
other people’s whose plans pay at a lower rate.)
Question: Can providers direct bill to Medicaid?
- DDD said that there is a lag
time in getting providers paid.
- DDD is working this year to
develop a process to allow individual and smaller providers to register
as a Medicaid provider.
Will there ever be a
requirement for Independent Contractors (ICs) to
get a Medicaid Number and meet similar rules required of PASAs?
RESPONSE: All waiver providers must meet Medicaid qualifications whether
the provider is delivering services as an individual, an agency or through an
Organized Health Care Delivery System (OHCDS.) The only OHCDSs delivering
services for people with developmental disabilities in Colorado
are the CCBs. DDD is working to create system changes necessary to enroll
all providers, however the system is not in place yet and we don't anticpate
it will be in place until the end of next year.
- Renee brought up an excellent
point about utilization rates, which is that due to circumstances beyond
parents’ controls (e.g., providers not showing up), parents were not able
to utilize all the “allotted” funding and now our family member’s plans
- DDD said that the average underutilization
was estimated at 10% (the comparison was made between the IP Plans and what
was actually paid).
- PAD-CO explained that the utilization
rates do not represent the need but the SIS represents the need. PAD-CO asked if we could get copies
of this analysis.
- PAD-CO explained that PAD-CO
had created a letter that explained the SIS evaluation process and that
DDD had agreed to use this letter and that it would go out to all parents
prior to the actual SIS evaluation meeting.
PAD-CO members stated that they never received a copy of the letter
– either before or after the SIS evaluation.
- PAD-CO explained that the SIS
process is counter-intuitive to the way parents have been taught to describe
their family member(s). Through
the school years, parents were taught to focus on the positive aspects of
their family member and to describe the things that were accomplished. The SIS process is the opposite
and parents needed to focus on all the things that their family members
could not do. Without realizing
this “opposite” evaluation methodology, parents approached the SIS assessment
with “here are the things that my family member can do.”
- PAD-CO stated that parents must
be adequately trained on SIS and on all other types of resources (e.g.,
State Plan, EBD, home care allowance).
- Barbara Ramsey (DDD) stated
that they were going to set up family forums to address this need.
- PAD-CO asked if there was a
way that parents could request another SIS assessment because they were
not properly informed/trained and DDD said there is a SIS dispute process.
- Sharon Jacksi agreed that communications
could be better.
Question: Do you know how many individuals
are losing services and funding?
Jacksi said that DDD has breakdowns by level (she called them “winners” and
“losers”) and will share this information when it is available.
said there are approximately 100 people at level E across the State and these
individuals are funded above the $35,000 cap.
PAD-CO questioned whether these people would be grandfathered under the
new SLS waiver and DDD said that SLS was not meant to meet all needs, and that
these folks might be changed to the comprehensive waiver.
Why did all of this have to change?
- DDD explained that CMS had conducted
an audit of comprehensive services and the audit finding was that Colorado
was out of compliance.
- Based on the audit findings,
the DDD adapted the findings to all the waiver renewal requests.
- The rates used to be set by
the CCBs because the State contracted with the CCBs using the “block grant”
method (meaning they gave each CCB total dollar amount and allowed the CCBs
to determine a lot of the details, like provider rates).
Because of the audit, the CMS/DDD wanted uniformity across programs
and decided to set provider rates at the State level and not at the CCB
level. (Carrie asked a great
question: Do the provider rates
under the waivers match the provider rates under the State Plan.
The answer from DDD was “no.”)
- The audit also required the
State to have a uniform assessment process and the State budgeting process
requires budget neutrality (meaning the Division cannot exceed their appropriated
Why did the DDD combine certain levels?
- Sharon Jacksi (DDD) stated that
they will be re-looking at this.
She also said that she will send out the PowerPoint presentation
(if we want it) as this lays out how the levels were determined.
(She mentioned several times in the meeting that most of this information
is on their website.)
- Sharon said that levels 3 and
4 were close to having the same needs and the “rates group” did not realize
how costs affected services.
- If DDD wants to change the combining
of levels, they need to amend the waiver and DDD stated that this “should
not take long” (they said it shouldn’t take a year to get this through).
- DDD said they copied Day Hab
comprehensive rates over to SLS and DDD did not fully realize
the impact to these changes.
Why not include self-determination in the SLS waiver?
- DDD stated that they want to
expand to all areas of the waivers but that will take time.
- CDASS is for medical assistance/attendant
support (which includes health care, home maintenance and ????).
- DDD does not have legislation
to expand CDASS. to other portions of the SLS program.
- DDD’s next highest priority
is CDASS after the waivers are in place (apparently, CMS has asked for a
couple of clarifications on the waivers and DDD is hopeful that they will
be fully approved by 7/1/09 when the current waivers expire).
- CDASS will require the development
of technical assistance documents, defined rates, training, etc.
- DDD wants CDASS to mirror HCPF
and be flexible.
- PAD-CO asked if CDASS funding
would be separate from the individual’s SLS plan and the DDD said “no”,
that there wasn’t any more money available.
- DDD said that some CDASS services
are available through the State Plan.
Supports. Is DDD looking to add this as a component?
said “yes” and that there are questions on the community risk and they will
add a specific section to the SLS for evaluating behavioral needs.
asked how many people did not get the services by their CCBs.
- DDD said they don’t know but
that wasn’t the issue, DDD needed to standardize provider rates.
- DDD said their contracts with
the CCBs stated that the average per client had to be $13,000.
- DDD said that the intent was
to have a managed care system where people get what they needed. These changes make the system a
“quasi-managed care” system.
- DDD said they had to go to a
“fee-for-service” model and this was a way to redistribute the funds and
asked how we can implement needed changes to these new waivers, rates, and caps.
- DDD stated that they can’t make
changes but can amend the waivers.
- They can change “bands” of services
in the waivers, like transportation.
asked if the DDD would be receiving any stimulus funds for the waivers and the
answer was “no.”
asked if there would be any new SLS slots because it seems as if there will
be more funds available due to the reduced funding to families.
The answer was “no, there won’t be any new SLS slots.”
asked about wait lists and DDD explained that these are handled by the counties
but DDD is considering making it one state-wide list.
– DDD determines the rates for these services and these services do not replace
the SLS case manager and the funding does
not come out of
an individual’s SLS plan and funding.
Denver asked DDD to conduct a study of
the CCB system.
- DDD is looking to put together
a task force.
- In the next couple of months,
DDD will have a renewed effort to evaluate (but not the conflict-of-interest
issue) led by Tim Hall (he is the new Deputy Executive Director over the
Vets and Disability Affairs.
hearing the great input from PAD-CO, Sharon Jacksi was surprised at what is
actually occurring and said that parents should let DDD know what’s going on. She said that under the FAQ page, there
is an e-mail address where questions/inquiries/and issues should be sent.
asked if a parent got an FAQ, could they take that to the CCB without retaliation. Sharon Jacksi stated that they want
to know about all instances of retaliation.
they would provide the written rate analysis to PAD-CO (the PowerPoint Presentation)
and Judy Brown was the work leader on this effort.
Jacksi agreed to have more meetings to continue discussions and agreed to get
us the “winners” and “losers” list.
Sharon asked the group to come up with
a 2-page document that would identify themes or topics (e.g., respite). This would help DDD organize and respond
to questions and issues.
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