Tier Waiver Implementation Update

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• Tier Waiver Implementation Update
• SENATE HEALTH HUMAN SERVICES APPROPRIATIONS
  COMMITTEE
• February 5, 2009

Charlie Crist, Governor Jim DeBeaugrine, Agency
Director
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How Many Individuals Are On the Waitlist for
Waiver Services?

• As a result of limited funding amounts available
  through Medicaid and General Revenue dollars for
  waiver services, many eligible individuals are
  waiting to receive services.
• Currently, more than 18,000 individuals are on
  the waitlist for waiver services.
• Prior to the tier waivers, the agency was
  required to fund all services determined to be
  medically necessary through the Developmental
  Disabilities Waiver. Expenditures per person
  grew unpredictably and disproportionately to
  available budget funding, leading to challenges
  in the service delivery system.
• This led to a projected agency budget deficit
  exceeding 150 million going into the 2007
  Legislative Session.
• Through a combination of increased funding and
  implementation of SB 1124, the agency reduced the
  budget deficit to 12 million for FY 2007-08.
• The agency is actively working to manage and
  reduce the waitlist. A prerequisite to
  addressing the waitlist and serving more
  Floridians is to stabilize the service delivery
  system. This is being accomplished through the
  implementation of the tier waiver system and the
  rebasing of service cost plans. The agency
  continues to work toward addressing consumer
  concerns and improving service delivery.

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Tier Waiver Implementation

• In 2007, the Florida Legislature passed
  legislation requiring a four-tiered waiver system
  for individuals receiving Medicaid Waiver
  services from the Agency through the
  Developmental Disabilities Waiver, also known as
  the Home and Community Based Waiver (HCBS), the
  Family and Supported Living Waiver (FSL), or the
  Consumer Directed Care Plus (CDC) Program.
• Implementation of 2007-64, L.O.F. (SB 1124), led
  to the four (4) current tier waivers, by
  transforming the Developmental Disabilities
  Waiver into the Tier One waiver, adding Tier Two
  and Tier Three waivers, and transforming the FSL
  Waiver into the Tier Four waiver. Three of the
  waiver programs have a cap on how much may be
  spent.
• Not all persons who were enrolled on the
  Developmental Disabilities Waiver were assigned
  to Tier One, and not all persons enrolled on the
  FSL were assigned to Tier Four.
• Assignment to a tier is based on identified need
  and statutory eligibility criteria provided in s.
  393.0661(3), Florida Statutes.

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Tier 1 Waiver No spending cap

• Formerly the Developmental Disabilities /Home and
  Community Based Waiver
• The individual has intensive medical or adaptive
  needs that are essential for avoiding
  institutionalization, and the individuals needs
  cannot be met in tiers 2, 3, or 4
• The individual has behavioral problems that are
  exceptional in intensity, duration, or frequency
  and present a substantial risk of harm to
  themselves or others, and the individuals needs
  cannot be met in tiers 2, 3, or 4
• This tier offers 28 services

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Tier 2 Waiver A new waiver capped at 55,000 a
year

• Individuals living in a family home are
  statutorily prohibited from assignment to this
  tier.
• Eligible individuals must live in one of two
  different settings
• A licensed residential facility individual must
  be authorized for moderate level of care or above
  or minimal level of care or above for behavior
  focus.
• Supported living (individuals in their own homes)
  individual must be authorized to receive more
  than six hours per day of in-home support
  services.
• This tier offers 28 services

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Tier 3 Waiver A new waiver capped at 35,000 a
year

• Individuals in a licensed residential placement
  who are not eligible for tiers 1 or 2
• Individuals who are 21 years of age or older and
  living in their family home, who need certain
  therapeutic and medical services such as speech,
  physical, and occupational therapy that were
  covered under the Early Periodic Screening
  Diagnoses Treatment Program (EPSDT) before they
  were 21
• Individuals 22 years of age or older authorized
  to receive services from a behavior analyst
  and/or a behavior assistant
• Individuals under the age of 22 years of age
  authorized to receive combined services from a
  behavior analyst and/or a behavior assistant for
  more than 60 hours a month and are not eligible
  for tiers 1 or 2
• This tier offers 28 services

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Tier 4 Waiver Capped at 14,792 a year

• Formerly the Family and Supported Living Waiver
• Individuals who are not eligible for assignment
  to tiers 1, 2, or 3
• Individuals who were receiving services as of
  October 15, 2008 through the Family and Supported
  Living Waiver unless there is a significant
  change in condition or circumstance
• Generally includes individuals who are under 21
  years of age who reside in their own home or the
  family home
• Generally includes individuals who are dependent
  children who reside in residential facilities
  licensed by the Department of Children and
  Families
• This tier offers 13 services
• An increase in the number of services available
  to clients in this tier is not allowed until July
  1, 2009

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Tier Impact

• Fiscal Year 08-09 Annualized Impact
• Tier 2 Cap at 55,000,Tier 3 Cap at 35,000 and
  Tier 4 Cap at 14,792

This assumes full implementation of December 1,
2008. It would have been a savings projection of
71,791,300 had it been in effect for 12 months.
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Tier Impact

• Fiscal Year 09-10 Impact
• Tier 2 Cap at 55,000,Tier 3 Cap at 35,000 and
  Tier 4 Cap at 14,792

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Current Challenges

• Tier implementation as of December 14, 2008
• Delayed due to legal challenges The Advocacy
  Center and other challengers have appealed to the
  First District Court of Appeal.
• Rule challenge was resolved in August and the
  Rule was final in October 2008.
• 5,400 people chose to challenge their tier
  placement, many of whom were not adversely
  impacted. People who filed within 10 days of
  notice of assignment of a tier automatically
  continue services at the pre-tier level until
  case resolved.
• 700 Granted Hearings at the Division of
  Administrative Hearings (DOAH).
• 60 have been forwarded to DOAH so far.

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Tier Impact

• Summary of the APD Clients Who Filed for Tier
  Hearings Within 10 days as of December 14, 2008

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What Is Cost Plan Rebasing?

• The 2008 Legislature passed legislation that
  requires adjustment of Medicaid waiver cost
  plans. This new law, Section 393.0661(6), F.S.
  (2008), requires the Agency to rebase cost plans
  for individuals receiving Medicaid waiver
  services to the amount of an individuals service
  expenditures for the period July 1, 2007 through
  June 30, 2008, plus 5.
• To rebase means adjusting the individuals
  current cost plan to the total amount that he or
  she actually spent for services during the last
  fiscal year (FY 2007-08), plus 5 additional
  funding.
• The statute prescribes a methodology to be used
  to estimate annual equivalent expenditure amounts
  for certain individuals.

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Recent Budget/Service Reductions to APD Waiver
Programs

• Impact of SB 1124 - 75 Million
• Cost plan rebasing - 20 Million
• Budget reductions during 2007 special session
  4.3 million
• Budget reductions during 2008 regular session
  55.9 million
• 9.4 million provided to partially replace 54
  million non-recurring appropriation from FY
  2007-08
• Budget reductions during 2009 special session
  7.3 million
• Total Reduction 207.1 million

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Other Challenges

• Implementing cost plan rebasing
• 6,650 individuals affected
• Delayed due to data issued with fiscal agent
• Completing assessments on remaining enrolled
  consumers
• As of 2-2-09 there were 22,915 QSI Assessments
  completed
• Continuing phase-down of the Gulf Coast Center
  scheduled for closure June 30, 2010.
• Census is now 88