15% Budget Reduction Exercise

1

• 15 Budget Reduction Exercise
• House Human Services Appropriations Committee
• Florida House of Representatives
• February 10, 2009

Jim DeBeaugrine, Agency Director Charlie Crist,
Governor
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Agency for Persons with Disabilities FY 2009-10
Base Budget by Major Functions(Total Budget
1,044,845,160)
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Funding of Services

• Services provided by the Agency for Persons with
  Disabilities are funded mostly through the
  Medicaid program.
• The Medicaid program provides approximately 56
  federal match to 44 general revenue dollars.
  This funding is in both the Medicaid waiver
  programs and the public and private institutional
  care programs.

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Major Funding Sources

• Medicaid Home and Community Based Waiver
  833,529,770 amount and 31,000 people served.
• State General Revenue and Federal Block Grant
  funds for people in the community the majority of
  whom are currently not enrolled in a waiver
  21,836,771 and 7,100 people served.
• Developmental Disability Centers (DDC) -
  118,227,904 and 1,010 people served.
• Mentally Retarded Defendant Program (MRDP) -
  14,587,933 and 146 people served.

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Schedule VIII-B Reductions and Additional
Options(Based on a 10 Recurring Budget Target)
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Guiding Principles

• Administrative and overhead functions which would
  have least impact to direct services.
• Efficiencies to provide same service levels at
  less cost.
• Avoid reductions to services having direct health
  and safety effect.
• Provide for consumer and family flexibility to
  mitigate the effect of service reductions.
• Avoid further reductions to provider
  reimbursement levels due to previous reductions.
  
• NOTE Options were developed for FY 2009-10.
  Ability to implement reductions to waiver during
  current fiscal year is limited due to need to
  obtain Federal approval and state procurement
  processes.

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Reorganization for Efficiency

• The Agency offered 175 FTE toward the 10 budget
  reduction exercise which were taken during
  special session
• Central Office 15.5 FTE Area Offices 13.5 FTE
  Institutions 146 FTE
• The Agency is currently undergoing a
  reorganization to improve functionality and
  efficiency
• Existing FTEs were shifted under the Chief of
  Staff and given additional responsibilities to
  assist in coordinating performance and service
  delivery system improvements
• Two (2) bureau chief positions were eliminated
• Remaining staff functions were evaluated and
  restructured to maximize efficiency
• Gulf Coast Center is currently scheduled to close
  on June 30, 2010

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Interactive Effects of Reductions

• All aspects of the service delivery system are
  closely intertwined. Therefore, a reduction to
  one service delivery area will result in
  additional reductions to other service delivery
  areas.
• For example, a reduction to Medicaid waiver
  services will significantly impact the waiver
  tiers, cost-plan rebasing, and the
  consumer-directed care (CDC) program. Reducing
  waiver services will significantly impact all
  other programs and aspects of service delivery.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 1 BUDGET REDUCTION IN CENTRAL OFFICE
• Original (707,377) GR
• Balance Not Taken (439,030) GR
• 10 Reduction in General Revenue from Salaries
  and Benefits, Other Personal Services, Expenses
  and Operating Capital Outlay from headquarters
  operations.
• Impact
• Reduction would result in a reduction of staff at
  headquarters which will impact Central Offices
  ability to provide administrative support
  statewide to area offices and developmental
  disability centers.
• Reduction will also affect the agencys ability
  to respond to communications, requests for
  information, legal and technical assistance from
  outside entities, stakeholders, other government
  offices and clients.
• Reduction to General Revenue used as match will
  necessitate a reduction in the Operations and
  Maintenance Trust Fund as the ability to draw
  down federal funding will also be reduced.
• Partially adopted during Special Session

10
Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 2 BUDGET REDUCTION IN AREA OFFICES
• Original (733,282) GR
• Balance Not Taken (109,190) GR
• 4 Reduction in General Revenue from Salaries and
  Benefits, Other Personal Services, and Expenses
  from area offices operations.
• Impact
• Impact to APD staff that provide support
  coordination, case management, referral and
  outreach services to consumers.
• Staff also involved in program planning, facility
  licensure, placement coordination, program
  development and monitoring, budget management,
  training, inter-agency coordination.
• Other staff provide administration related to the
  Medicaid Waiver Program, and Information
  Technology support. The agency is currently
  managing this 4 reduction.
• Partially adopted during Special Session

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 3 BUDGET REDUCTION IN OPERATIONS AND
  MAINTENANCE
  TRUST FUND
• Original (182,835) Trust
• Balance Not Taken (182,835) Trust
• 10 Reduction in Operations and Maintenance Trust
  Fund, which are state funds match in the
  developmental disabilities centers.
• Impact
• Reduction to Developmental Disabilities Centers
  use of funds in the Operations and Maintenance
  Trust Fund which are unrestricted.
• Affected categories include salaries, expense,
  food service and contracted services.
• This will impact staffing levels and the ability
  to provide active treatment and will reduce
  Federal Medicaid matching funds as well.
• Reduction in ability to draw down federal
  funding.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 4 BUDGET REDUCTION IN SPECIAL
  CATEGORIES
• Original (1,556,131) GR
• Balance Not Taken (1,359,557) GR
• 10 General Revenue reduction in the Individual
  and Family Supports, Room and Board Payments,
  Contracted Services, Home and Community Services
  Administration, Grants and Aids Contracted
  Services, Grants and Aids Contracted
  Professional Services, Prescribed Medicine/Drugs
  and Salary Incentive Payments categories.
• Impact
• Reductions in contracts for services provided to
  consumers on the waiting list services that
  cannot be reimbursed through the waiver such as
  room and board and staff related to Medical Case
  Management, Medical Utilization Review and
  Continued Stay processes. The effect of the
  reduction will be to reduce the number of
  individuals that can be served and to force
  reductions in expenses in the Mentally Retarded
  Defendant Program in order to continue to
  purchase necessary medications.
• Partially adopted during Special Session

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 5 BUDGET REDUCTION IN INDIVIDUAL AND
  FAMILY SUPPORTS SOCIAL SERVICES
  BLOCK GRANT
• Original (1,774,056) Trust
• Balance Not Taken (1,774,056) Trust
• 10 Reduction in Social Services Block Grant
  funding for Individual and Family Supports
• Impact
• Reduction in ongoing services to Individuals on
  the Waiver Waitlist to avoid crisis situations.
• Reduction in temporary, short term or one-time
  services provided to clients who are not enrolled
  in a Home and Community Based Services Waiver.
• NOTE The Agency proposes a fund shift from
  general revenue to the Social Services Block
  Grant. This would utilize the Social Services
  Block Grant dollars freed on the Schedule VIII-B
  and redirect those dollars toward items currently
  funded by general revenue dollars. This is a
  technical fund shift that would allow federal
  trust fund dollars to be spent in lieu of general
  revenue dollars. This would achieve general
  revenue dollar savings.
• Fund Shift (1,774,056) GR (1,774,056) Trust

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 6 BUDGET REDUCTION IN THE
  DEVELOPMENTAL DISABILITIES CENTERS
• Original (2,682,096) GR
• Balance Not Taken (91,651) GR
• 4 General Revenue reduction in Salaries and
  Benefits, Other Personal Services, Expenses,
  Operating Capital Outlay and Food Products for
  Forensic and Long Term components of the
  developmental disabilities centers (DDCs).
• Impact
• Reduction in staff for the forensic and long term
  care components in the DDCs causing a higher
  staff to client ratio. Although the agency is
  currently managing this 4 reduction, there is
  concern that this could eventually jeopardize the
  agencys ability to maintain staffing levels
  necessary for ICF/DD licensure and lead to
  serious safety issues in the forensic programs.
  If the agency were to lose ICF/DD licensure,
  there would be a substantial loss of Federal
  Medicaid funds which would lead to further
  reductions in staffing. This would create serious
  health and safety concerns in the facilities.
• Partially adopted during Special Session

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 7 BUDGET REDUCTION IN WAIVER CATEGORIES
  CONSOLIDATE DURABLE AND CONSUMABLE MEDICAL
  EQUIPMENT PURCHASING TO REALIZE TEN PERCENT (10)
  SAVINGS
• Original (836,460) GR (1,027,725) Trust
• Balance Not Taken (836,460) GR (1,027,725)
  Trust
• 10 savings in purchasing durable and consumable
  medical equipment through statewide and regional
  contracts for competitively procured bulk
  purchasing and the resulting economics of scale.
• Impact
• Savings to the agency and state. Less flexibility
  for consumers. Trust fund figure reflects loss of
  Federal Medicaid matching funds.
• Procurement activity needs to begin immediately
  in order to realize a full 12 months of cost
  savings.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 8 BUDGET REDUCTION IN WAIVER CATEGORIES
  ELIMINATE BEHAVIOR ASSISTANCE SERVICES IN
  STANDARD AND BEHAVIOR FOCUS GROUP HOMES
• Original (1,794,800) GR (2,205,200) Trust
• Balance Not Taken (1,794,800) GR (2,205,200)
  Trust
• Deletes the use of Behavior Assistant services in
  a licensed group home or foster home setting and
  directs the Behavior Analyst to train direct care
  staff funded through Residential Habilitation.
• Impact
• Group and foster home operators would bear more
  responsibility for managing individuals with
  behavior issues. Trust fund figure reflects loss
  of Federal Medicaid matching funds.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 9 BUDGET REDUCTION IN WAIVER CATEGORIES
  REDUCE CONSUMER DIRECTED CARE (CDC) ACCOUNTS
  BY TEN PERCENT (10)
• Original (1,474,691) GR (1,811,895) Trust
• Balance Not Taken (1,474,691) GR (1,811,895)
  Trust
• 10 reduction in accounts for consumer directed
  care (CDC) enrollees.
• Impact
• Some consumers may ask to be enrolled back into
  the traditional waiver program, and the state
  would lose the 8 percent discount it receives
  when individuals enroll in the CDC Program.
  Trust fund figure represents loss of Federal
  Medicaid matching funds.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 10 BUDGET REDUCTION IN WAIVER CATEGORIES
  CONSOLIDATE MEANINGFUL DAY ACTIVITY SERVICES
  AND REDUCE BY EIGHT PERCENT (8)
• Original (9,685,154) GR (11,899,768) Trust
• Balance Not Taken (9,685,154) GR (11,899,768)
  Trust
• Reduces a number of service categories generally
  regarded as meaningful day activities and in-home
  maintenance. Would allow for flexible benefit
  giving families options to mitigate the impact.
• Impact
• This represents an 8 reduction of current
  expenditures for adult day treatment, supported
  employment, supported living, in-home support
  services, companion and respite service. The
  reduction amount is based on the current discount
  applied to cost plans for consumers enrolled in
  the Consumer Directed Care Plus (CDC) program
  which allows greater consumer flexibility.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 11 BUDGET REDUCTION IN WAIVER CATEGORIES
  
• CAP TIER 1 AT 120,000
• Original (5,024,972) GR (6,173,986) Trust
• Balance Not Taken (5,024,972) GR (6,173,986)
  Trust
• Tier 1 waiver is currently the only one of four
  waivers that does not have an expenditure limit.
  This would cap the amount to 120,000.
• Impact
• There are 328 individuals who are currently
  projected to spend more than the 120,000. 142
  consumers would experience at least a 20
  reduction in services and institutional care may
  be necessary for some individuals. Trust fund
  figure represents loss of Federal Medicaid
  matching funds.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.

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Schedule VIIIB 10 Recurring Budget Reductions
for FY 09-10

• Issue 12 FURTHER REDUCTION TO WAIVER SERVICES
• Original (23,088,027) GR (28,367,347) Trust
• Balance Not Taken (23,088,027) GR (28,367,347)
  Trust
• This represents an additional reduction of
  expenditures for adult day treatment, supported
  employment, supported living, in-home support
  services, companion and respite service. Flexible
  benefit would be available to consumers and
  families.
• Impact
• May result in increased utilization of
  institutional and other congregate care settings
  at increased cost to the state. Trust fund figure
  represents loss of Federal Medicaid matching
  funds
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.
• NOTE Reducing waiver services will significantly
  impact other programs and aspects of service
  delivery.

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Summary of Remaining Schedule VIIIB Reductions To
Reach 15
22
Additional Reduction Options to Reach 15
Target
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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 1 Increase savings from consolidation of
  durable and consumable medical equipment to 15
• (418,200) GR (513,863) Trust
• This represents an additional 5 reduction of
  expenditures above the amount listed in the
  original Schedule VIII-B exercise due to
  consolidation of purchasing for durable and
  consumable medical equipment.
• Impact
• Less flexibility for consumers. May result in
  increased utilization of institutional and other
  congregate care settings at increased cost to the
  state. Trust fund figure represents loss of
  Federal Medicaid matching funds.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 2 Additional reduction to special
  categories
• (974,640) GR (0) Trust
• This represents an additional 5 reduction above
  the amount listed in the original Schedule VIII-B
  in the areas of Individual and Family Supports,
  Room and Board Payments, Contracted Services,
  Home and Community Services Administration,
  Grants and Aids Contracted Services, Grants and
  Aids Contracted Professional Services,
  Prescribed Medicine/Drugs and Salary Incentive
  Payments categories.
• Impact
• Reductions in contracts for services provided to
  consumers on the waiting list services that
  cannot be reimbursed through the waiver such as
  room and board and staff related to Medical Case
  Management, Medical Utilization Review and
  Continued Stay processes. The effect of the
  reduction will be to reduce the number of
  individuals that can be served and to force
  reductions in expenses in the Mentally Retarded
  Defendant Program in order to continue to
  purchase necessary medications.

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 3 Additional reduction to Social Services
  Block Grant
• (0) GR (887,028) Trust
• This represents an additional 5 reduction of
  expenditures above the amount listed in the
  original Schedule VIII-B to Social Services Block
  Grant funding for Individual and Family Supports
• Impact
• Reduction in ongoing services to Individuals on
  the Waiver Waitlist to avoid crisis situations.
• Reduction in temporary, short term or one-time
  services provided to clients who are not enrolled
  in a Home and Community Based Services Waiver.
• NOTE The Agency proposes a fund shift from
  general revenue to the Social Services Block
  Grant. This would utilize the Social Services
  Block Grant dollars freed on the Schedule VIII-B
  and redirect those dollars toward items currently
  funded by general revenue dollars. This is a
  technical fund shift that would allow federal
  trust fund dollars to be spent in lieu of general
  revenue dollars. This would achieve general
  revenue dollar savings.
• (887,028) GR (887,028) Trust

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 4 Eliminate behavioral therapy assessment
  in waivers
• (200,899) GR (246,855) Trust
• This assessment provides for a determination of
  the medical necessity of behavioral services.
  The Local Behavioral Review Committee and the
  Area Certified Behavioral Analyst can perform
  this function without any cost.
• Impact
• This service that can be managed through the
  Local Review Committee and PSA process.
• The net result of this elimination will be less
  time and process being expended between
  identification of participants with needs for
  behavior services and service initiation.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.
• This is estimated to impact 1,240 APD clients.

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 5 Reduce certified behavioral analyst
  (CBA) rates by 15
• (2,041,504) GR (2,508,496) Trust
• CBA's provide oversight of behavioral therapy and
  direct behavioral services. This is a 15
  reduction in the quarter hour reimbursement of
  this provider group.
• Impact
• This is a reduction which aligns rates for this
  service (certified behavioral analysis) with
  other behavioral services
• Ensures comparable and equitable rates across
  behavioral services
• Could reduce the availability of willing service
  providers

28
Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 6 Eliminate medication review in waiver
• (180,614) GR (221,929) Trust
• This service involves a pharmacy review of
  medications to identify potential drug
  interactions. This informational service is
  generally provided at no cost to pharmacy
  clients. Existing APD area office nurse review
  of medications, in addition to physician and
  pharmacy access through support coordinators,
  makes this service unnecessary. Medication
  review is a component of the Medicaid payment to
  physicians.
• Impact
• Requires greater involvement by consumers, waiver
  support coordinators, and local Medicaid
  pharmacies.
• Reduces duplication of services.
• This is estimated to impact 4,784 APD clients.

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 7 Eliminate specialized mental health
  assessment services in waiver
• (42,635) GR (52,388) Trust
• This service determines the necessity of mental
  health counseling. The service is covered under
  the Medicaid State Plan at local mental health
  centers throughout Florida.
• Impact
• Requires greater involvement by consumers and
  waiver support coordinators.
• Reduces duplication of services.
• This is estimated to impact 303 APD clients.

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 8 Eliminate specialized mental health
  therapy in waiver
• (271,333) GR (333,399) Trust
• Mental health therapy services are covered under
  the Medicaid State Plan at local mental health
  centers throughout Florida.
• Impact
• Requires greater involvement by consumers and
  waiver support coordinators.
• Reduces duplication of services.
• This is estimated to impact 1,000 APD clients.

31
Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 9 Reduce CDC accounts by additional 5
• (737,309) GR (905,966) Trust
• This represents an additional 5 reduction of
  expenditures above the amount listed in the
  original Schedule VIII-B exercise to account for
  consumer directed care (CDC) enrollees.
• Impact
• Some consumers may ask to be enrolled back into
  the traditional waiver program, and the state
  would lose the 8 percent discount it receives
  when individuals enroll in the CDC Program.
  Trust fund figure represents loss of Federal
  Medicaid matching funds.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.
• NOTE This recognizes that other reductions
  (Medicaid waivers) will result directly in
  reduced services to CDC clients.

32
Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 10 Redesign supported living program to
  reduce duplication
• (987,101) GR (1,212,899) Trust
• This model for this program was first implemented
  in the 1980's. Over time, the program has become
  increasingly complex and has grown to include a
  variety of new options and providers. This
  redesign would overhaul the program and is
  designed to reduce duplication of efforts and to
  simplify processes.
• Impact
• Reduces duplication of services.
• Simplifying processes may enhance consumer
  direction and increase consumer satisfaction.

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Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 11 Reduce level of supported employment
  services for recipient with history of employment
  stability
• (921,638) GR (1,132,460) Trust
• Many individuals who have experienced long-term
  success in competitive employment still receive
  job coaching services. The level of these
  services can be lowered while maintaining the
  health, safety and well-being of the recipients.
• Impact
• Reduces services based on assessed employment
  support needs to achieve cost savings.

34
Additional Recurring Budget Reduction Options to
Reach 15 Target

• Issue 12 Additional reduction to waiver
  services
• (18,445,512) GR (22,664,962) Trust
• This represents an additional 23 reduction of
  expenditures above the amount listed in the
  original Schedule VIII-B exercise for adult day
  treatment, supported employment, supported
  living, in-home support services, companion and
  respite service. Flexible benefit would be
  available to consumers and families.
• Impact
• May result in increased utilization of
  institutional and other congregate care settings
  at increased cost to the state. Trust fund figure
  represents loss of Federal Medicaid matching
  funds.
• Federal approval is required through the Agency
  for Health Care Administration. The approval
  process may result in delays.
• NOTE The Agency does not support this reduction
  and believes that potentially devastating results
  may occur. Reducing waiver services will
  significantly impact all other programs and
  aspects of service delivery.

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Summary of Additional Recurring Budget Reduction
Options to Reach 15 Target