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Changes to the Indiana state Medicaid waiver program

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Joined: 21 Oct 2005
Posts: 35

PostPosted: Fri Oct 21, 2005 8:37 pm    Post subject: Changes to the Indiana state Medicaid waiver program Reply with quote

On August 12, 2005, Governor Mitch Daniels announced changes to the state Medicaid waiver program that he said were projected to result in $14 million in annual savings, a dramatic reduction in bureaucracy and paperwork, and would allow more individuals to be served.

The major change announced was that annual contracts would be created for the developmental disability, support services, and autism waivers, based on historical usage. Gone was the requirement for tracking services in 15 minute increments, the major source of paperwork reduction in the plan.

Though an overview of the changes was given in the press release, details were sketchy. FSSA pledged to mail letters to providers on Sept. 15 announcing the billing changes, and stated that the plan would go into effect on Nov. 1 for the developmental disability and autism waivers, with support services to follow shortly afterward or perhaps at the same time.

At the time of the announcement, no indication was given as to when case managers or families would receive notice of the changes.

Please read the entire text of this landmark announcement here:
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Joined: 21 Oct 2005
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PostPosted: Sun Oct 23, 2005 4:29 pm    Post subject: Sept. 15 Provider Letter Reply with quote

On September 15, providers received a 27-page document detailing sweeping changes to the state's Medicaid Waiver program, starting with the Developmental Disabilities, Support Services, and Autism waivers.

The cover letter from DDARS Director Peter Bisbecos stated again that the changes would go into effect on Nov. 1, and that providers would receive a document via email on Sept. 26 that would detail rate changes for each individual. Also mentioned were planned opportunities for providers, families, and individuals served to get their questions answered.

Please find attached a copy of the "Annual Plan Provider Information Packet 20050915" in PDF format. Open it with the free Acrobat Reader, available from Adobe's website (http://www.adobe.com/products/acrobat/readermain.html).

Annual Plan revisions for providers

 Filename:  Annual_Plan_Provider_Information_Packet_20050915.pdf
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PostPosted: Sun Oct 23, 2005 11:17 pm    Post subject: Annual Plan Letter to Families Reply with quote

Following the notice to providers, a letter went out from DDARS to individuals and families served by the Developmental Disability, Support Services, and Autism waivers. The memo, dated September 22, described upcoming changes to the waiver system as a "simplification" of a "broken" system.

The memo assured families that the modifications to the programs were "designed to be administrative in nature and should not result in a reduction in service for you or your family member." In addition to a reduction in bureaucratic red tape and costs, the memo stated that proposed changes would allow "flexibility" for people on the program, a reduced workload for case managers, and would allow more people to get on the waiver program. It also mentioned that participants would be locked into a provider at the time of enrollment and would only be allowed to change upon annual plan renewal or under "exceptional circumstances".

The memo listed the upcoming Family Forum meetings to be held around the state from October 3-14. (The last one was "TBA" in the memo--it was actually held on Oct. 17).

A copy of this document (09-22-05_Annual Plan Letter to Families) is attached, in PDF format. You may open it with the free Acrobat Reader software mentioned in a prior post.

09-22-05_Annual Plan Letter to Families.pdf
Notice to families of proposed changes, and dates of upcoming meetings

 Filename:  09-22-05_Annual Plan Letter to Families.pdf
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Last edited by WaiverWatch on Mon Oct 24, 2005 11:26 am; edited 1 time in total
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PostPosted: Mon Oct 24, 2005 1:48 am    Post subject: Family Forum meetings Reply with quote

Representatives from the state held a series of Family Forums around the state in October to explain the changes in the waiver program.

The format of the forum was a PowerPoint slideshow presentation entitled, "DDRS Annual Plan, Individuals and Families--Plain Talk: Real Answers to Your Questions", followed by a Q&A session.

WaiverWatch talked to parents who attended some of the forums. The first one, held in Indianapolis, was videotaped by the ARC of Indiana. A letter from DDARS stated that this videotape would be made available by mid-October on the ARC website, but as of 10/23 the ARC site says that they are trying to have it on their site (and on DVD) by the end of the month.

According to reports from around the state, one of the most contentious forums was held in Evansville on October 5. Attendees tell WaiverWatch that the slideshow mentioned above was followed by a brief intermission while representatives sorted through index cards of questions written by people in attendance. After the break, selected questions were to be answered. Program leaders could only answer a fraction of the questions posed, however, admitting that those who had the answers were not in attendance. This was said to have caused an uproar, as many families struggled with difficult schedules to make a meeting that was called on very short notice--a meeting where it was announced that drastic changes in the waiver were to be implemented in less than a month, but little information was available.

Eyewitnesses report that one parent confronted the presenters and demanded that her question be answered, then walked out when it was not addressed. Several parents, individuals on the waiver, and case managers then stood up and made their own concerns known to the crowd.

Among the issues raised at that meeting were the perception that these changes were being implemented too quickly and without family involvement, that services were actually being cut for many (since the annual rate was based on an arbitrary "snapshot" of historical usage and not on current needs), that monies were being given to providers regardless of whether or not services were provided, that case management was being cut more drastically than the figures indicated, that accountability was severely reduced along with the paperwork, and much more.

As of 10/23, very little information about the changes has been made available at the FSSA site (it states that the last update was on Tuesday, February 22, 2005). Since the handout from the Family Forum cannot be found there, we are providing a facsimile prepared by a parent who attended one of the meetings (thanks, IndParent!). It is available in both Microsoft Powerpoint (PPT) and Adobe Acrobat (PDF) formats.

DDRS Annual Plan - Individuals and Families.PDF
A facsimile of the presentation given at the October 2005 Family Forums (PDF format)

 Filename:  DDRS Annual Plan - Individuals and Families.PDF
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DDRS Annual Plan - Individuals and Families.ppt
A facsimile of the presentation given at the October 2005 Family Forums (PowerPoint format)

 Filename:  DDRS Annual Plan - Individuals and Families.ppt
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PostPosted: Mon Oct 24, 2005 8:59 pm    Post subject: Concerns from case managers Reply with quote

This letter was sent out by one of the case management agencies to its clients and families. The name of the agency has been removed from the letter.

Oct. 6, 2005

Dear clients, families, guardians, and advocates:

By now most of you have probably heard rumors or facts about the changes that will occur to the Medicaid Waiver programs for the developmentally disabled on Nov. 1, 2005. Your case managers at this case management company have recently received several letters, notices, and bulletins from the state as well as attending a state meeting for case managers a few days ago. We are writing you because we have serious concerns about the state's plan to change these waivers and we want to pass on both the information about the changes and our concerns to you, our valued clients.

Enclosed you will find a letter that all clients were to receive 45 days before the changes were to be implemented. We don't believe that the state actually sent any of these letters out to waiver recipients personally, so we are enclosing them. You will notice that the letter refers to waiver "changes." What we want you to know is that ALL of these "changes" to the waiver represent CUTS in the program. There is not one proposal made by the state that will increase any reimbursement rate or service to your loved one. The cuts will amount to 14 million dollars to the services of current waiver clients. The state is implementing these cuts by changing and reducing the way that they reimburse providers for the care of your loved one. We believe that the way the state is planning to do this will increase the chances of harm and neglect to all clients and decrease their options for a meaningful quality of life.

The present system currently demands accountability. Providers have to prove that they provided services at a given time, and they have to document on each day what they did for the client and how the client was getting along. However, the current system was set up to operate in an inefficient manner. Everyone agrees that changes need to be made. But the proposed changes defy logic. Now, instead of paying providers for the time they actually spend caring for your loved one, the state is going to give providers a "lump sum" annually (called the annual contract) to take care of each person. The provider will bill the state monthly and receive 1/12 of the annual contract each month. The provider will get paid whether or not their staff showed up for all shifts that month. There will be no financial penalty for no-shows. In fact, the provider will even get paid for the days the clients go home with their families for the holidays. We at your case management company feel that this system of reimbursement provides no incentive for providers to "get it right" with staffing and services. It directly contradicts the work ethic we have in Indiana to provide an honest day's work for an honest day's pay.

The flip side to this method of payment is that the state will also expect a provider agency to supply extra care for free if a client should get into a behavioral or health crisis. The annual contract is set, and there are very few situations under which it can be renegotiated. The state has said to providers that they can make money off some of the lower-need clients by under-serving them (according to their contracts) and this would offset any loses they would have on providing extra services to clients in crisis. Again, we feel this is a crazy way to run a business–pitting the high and low needs of different clients against each other in order to "break even" financially.

In addition, the state is planning to reduce payment to the providers for clients who have over 9 hours a day in services. This will most directly affect the clients in supported living (those who don't live with family members and therefore need round-the-clock care). Oddly, and again defying logic, the more care a client needs (that is, the higher his daily cost of services), the more the state is going to cut reimbursement to the provider for that client.

Besides the cuts to direct-care providers, case management and behavior management services are also being cut. Clients with behavior managers can expect cuts of 8-10%, even though the client has the same needs now as last year. Case management for clients on the DD and Autism waivers is being cut 35% across the board. Case management services for those on the Support Services Waiver is being cut by 70%. This basically means that case mangers will get paid for less than two hours a month for working for clients on the SS Waiver. We at your case management company have two concerns about the cuts in case management–they are too drastic and they are discriminatory towards the clients on the SS Waiver. We feel these cuts represent a "cookie cutter" approach to case management (giving all clients the same amount of case management regardless of individual need) instead of the person-centered, individualistic approach to case management (and indeed ALL services) that the waiver regulations demand.

The second big change will be to paperwork and documentation. Everyone agrees that this is a mess now, and needs to be changed. But the proposed changes are so drastic that they are going to significantly decrease the accountability of the provider in their care for your loved one. Currently, each shift working with a client has to document what they did on their shift and what the client did throughout the day. They have to do this in order to prove that they actually cared for the client that day (for billing purposes) and to track health and safety issues on a daily basis. However, the state is going to change the paperwork requirement from the provider to one piece of paper a month. This one document will supposedly tell everything they did and everything that happened to the client during the month. But it is to be only one page long. Your case managers feel that this cut in documentation and accountability is too drastic and will result in the loss of important information needed to track health and safety issues, substantiate incidents, and validate whether the client was meeting the goals that their guardians wanted accomplished.

The third big change to the system is going to place dramatic limitations on the rights of clients and guardians to change and choose their providers. Currently, clients and guardians have the right to change providers and case managers at any time if they become dissatisfied with the quality of care being delivered. Starting Nov. 1, you will only be allowed to change providers or case managers once per year, at the time the annual contract comes due (this will be the same annual date you've always had). If you become dissatisfied with a provider for things like rudeness, laziness, lack of staff, and no-shows, and want to change, you will not be allowed to. Meanwhile, the provider will keep getting paid for substandard care. Only in extreme cases of neglect and abuse will a client be able to switch providers. We at your case management company feel that this is a huge restriction on client rights. The flip side to this is that your provider still will retain the right to give their clients 60 days notice at any time they want to quit serving the client.

Our final concern is that John Dickerson, director of the ARC of Indiana, the largest and most influential advocacy organization for people with disabilities, is fulling backing these state changes. Many families are now up in arms against the ARC and Mr. Dickerson, who states that these changes will "reform a broken system." Our reply to him would be: you don't reform a broken system by breaking it more.

The state of Minnesota tried to implement similar cuts with their Medicaid Waivers and some clients and the ARC of Minnesota sued successfully to stop it. So maybe there is hope for Indiana.

We at your case management company want to encourage all interested and concerned parties to contact their state legislators, the governor, top officials at the FSSA (Family and Social Services Administration), the ARC of Indiana, Protection and Advocacy, and the Office of Civil Rights with concerns about these changes. Also write editorials to your newspapers and the Indianapolis newspapers. These changes WILL go into effect on Nov.1. However, they also have to be approved by the federal government which oversees our state waivers. So the CMS (Center for Medicare and Medicaid Services) would be another place you could contact with your concerns.


your case management team
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Joined: 22 Oct 2005
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PostPosted: Mon Oct 24, 2005 9:26 pm    Post subject: Reply with quote


Thanks for posting this letter. It's a great summary of the concerns a number of us share. Very interesting info about Minnesota's success in fighting cuts. Indeed, there is hope!

I would encourage everyone to write to Leslie Campbell at CMS. You can find her contact info in the Action! section in the post "Write to CMS!"

I know that Protection and Advocacy and ICLU have also expressed interest in what's going on. Hope everyone will contact these organizations, too.
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