The Medicaid Waiver began to be a topic of discussion after I had been at my post for about six months. Seemingly out of the blue (from my prospective) there was a flurry of trainings, memos, and requirements that meant changing a lot of our job descriptions, programming, and systems. Prior to this time, the biggest discussion topic for providers was the 317 Plan, which paved the way for community based services and the closure of institutional settings.
One of the most interesting changes was the institution of Targeted Case Management. Under the waiver that was submitted, provider agencies with qualified staff (QMRP) were authorized to be case managers for people transitioning to the waiver. The authorization process, budgeting, and coordination of services was very complicated and time consuming, but it was also a reimbursable service. Additionally, Health Care Coordination and Transportation were to be added for agencies with qualified staff. Providers were encouraged to begin the process and convert as many individuals to the waiver as possible. A memo from the state in early October, 2001, confirmed that the waiver was approved with the new services.
As most agencies used QMRP-D (designee) individuals in social services, this would require some reorganization and potentially hiring staff who met the TCM certification requirements. A reimbursement rate increase of 9% for staff training, wages, and benefits was anticipated after negotiations with the state- an increase desperately needed to fund the increases in staffing and administrative burden that came with the new waiver.
In November of 2001, a memo from the director of the Fiscal Division filled in some blanks. First, it clarified that, in addition to the regular Medicaid hurdles, eligibility would be determined by a Developmental Disabilities Profile (DDP) of which IQ score was one of many factors. The DDP minimum score to show eligibility was set at 35. While agencies were asked to collect all of the necessary data, including DDP, the official eligibility determination could only be made by the Office of Medicaid Policy. Once found eligible, the Fiscal Division would review the proposed budget and make the final approval decision. Case managers were warned that any budget cannot cost more than ICF/MR. The memo encouraged cost-effectiveness, and suggested reminding families that savings here would open up waiver slots for other people in need. This was the first mention of a waiting list that I have been able to find relating to the DD waiver.
On December 18, 2001, two communications were sent to providers from FSSA. The first announced a 4.5% increase in reimbursement, and the other created a TCM-D (designee) position, acknowledging that there were not enough qualified QMRPs to handle the workload assigned to targeted case managers. The former, sent by the Secretary of the FSSA, noted that the original increase had indeed been set at 9%, but due to budget constraints, he had to make some sacrifices. An additional sacrifice noted in the memo was that he had to limit out-of-state travel.
These announcements resulted in another change in job description and structure. While somewhat frustrating, it was a great relief to have enough case management support available to meet the challenges ahead.
And what challenges there were! Service definitions now required 15 minute units of service, and the documentation of each one. Prevocational services were introduced, as well as necessity that the consumer must earn less than 50% of minimum wage to be served in the program. Consumers that did not meet this requirement were to be served under sheltered work. Each needed to be recorded and billed separately.
Additional clarification followed between February 2002 and April 2002. Health Care Coordination was determined to NOT be a service from which everyone could benefit. Instead, factors were identified that were to justify the need for service. Prevocational Services were clarified to require that the 50% factor was not an average, and that providers must measure productivity for every consumer, for every job, for every hour. For a busy setting, this is over 1000 separate calculations per day on top of the 15 minute documentation. More administrative support was needed to assure compliance. Service rate changes, and rounding rules were announced in late April.
The Indiana Administration was having problems of its own at this time. FSSA was depending upon the conversion to the waiver to do two things- increase community based alternatives, and to cut costs significantly. The problem was, many people did not want to move to the waiver even as they were told how much more service they could expect. The other problem was that the number of people who met the eligibility requirements and were approved for waiver were not nearly as many as anticipated.
In February of 2002, the eligibility score on the DDP was lowered from 35 to 28. Anyone who scored 28 through 34 were automatically put on the waiver, bypassing the Office of Medicaid Policy approval. In March, OMPP approval was removed entirely. Non-waiver authorization was shifted to the Bureau of Developmental Disabilities Services (BDDS) and case managers were given the authority to approve waivers on their own. The eligibility issue resolved, all that remained was to motivate individuals to choose the waiver over traditional funding.
Part III will continue the story…