From Forbes McIntosh, Government Policy Solutions, WALA Lobbyist
The state’s nonpartisan Legislative Fiscal Bureau on Thursday released its analysis of Gov. Scott Walker’s proposed 2015-17 state budget. The document describes the changes in Walker’s budget for each of the department and budget areas.
The LRB analysis of the proposed changes to Department of Health Services (DHS) Family Care/IRIS programs states:
CHANGES TO FAMILY CARE, IRIS, AND AGING AND DISABILITY RESOURCE CENTERS
Governor: Reduce funding by $14,336,900 (-$6,000,000 GPR and -$8,336,900 FED) in 2016-17 to reflect changes to the Family Care program. This funding reduction reflects the Department of Administration’s estimates of anticipated increases in county contributions during the expansion of the Family Care benefit to additional counties in 2016-17. It does not account for any potential cost savings related to the expansion of managed care, or changes in costs related to any other provisions in this entry.
Under the Family Care program, managed care organizations (MCOs) provide long-term care services to elderly individuals, adults with developmental disabilities, and adults with physical disabilities. The state also offers the fee-for-service, self-directed IRIS (Include, Respect, I Self-Direct) program to provide individuals who qualify for Family Care services with an alternative to managed care. In addition to Family Care and IRIS, individuals in two counties have access to the Program of All-Inclusive Care for the Elderly (PACE), and individuals in 14 counties have access to the Family Care Partnership Program (Partnership), which provide integrated delivery of primary and acute medical care, long-term care, and prescription drug coverage.
The bill contains the following provisions.
Statewide Provision of Services. Require DHS to submit a request for a federal waiver from the U.S. Department of Health and Human Services (HHS) allowing for the administration of the Family Care program statewide by MCOs, unless DHS waives this requirement for a specific MCO. If a federal waiver is approved, require DHS to make the Family Care program available statewide by January 1, 2017, or a date determined by the Department, whichever is later. This provision does not require all eligible individuals to be enrolled by January 1, 2017, and the Department has noted that, assuming a federal waiver is approved, it intends to enroll individuals using the same 36-month enrollment phase-in as is specified under current law.
Require DHS to request a federal waiver allowing for the elimination of the competitive procurement process for MCOs, and, if approved, to contract for the statewide provision of services with any MCO that meets the statutory requirements for providing services.
Remove the statutory requirement that the Department submit proposals for Family Care expansion to the Joint Committee on Finance (JFC) for approval. Allow DHS to eliminate the community integration program (CIP), the community opportunities and recovery program (CORP), and the community options program (COP) after the Family Care program is offered to all eligible residents in a county. Modify current references in the long-term care statutes to improve consistency and reflect current practices.
Under current law, Family Care and IRIS are available in 57 counties, and will be expanded to an additional seven counties in calendar year 2015. The eight counties that will not be participating in Family Care and IRIS at the end of calendar year 2015 are Adams, Dane, Florence, Forest, Oneida, Rock, Taylor, and Vilas. The state currently provides home and community-based long-term care services to individuals in these counties through the “legacy” home and community-based waiver programs, including CIP, COP, and CORP.
Under current law, DHS awards a contract to one MCO to provide services in a geographic service region of the state, based on a competitive, sealed procurement process. If DHS proposes to contract with an entity to administer the Family Care benefit in a new geographic area, it must first submit the proposed contract, an estimated fiscal effect demonstrating that the expansion is cost neutral, documentation that the proposed expansion county consents to the expansion, the county’s Family Care contribution, and the county’s proposal for how it will use any county expenditure savings that result from the Family Care benefit being available in that county, to JFC, and DHS may only enter into the proposed contract if JFC approves the contract.
Self-Directed Services. Eliminate the IRIS (Include, Respect, I Self-Direct) program. Require DHS to allow Family Care enrollees to self-direct services. Remove statutory references to IRIS program services offered to individuals receiving post-secondary education on the grounds of an institution, and replace with references to the self-directed Family Care program. Remove all other statutory references to IRIS.
Primary and Acute Services in Family Care Program. Require DHS to request a waiver from HHS allowing for the inclusion of any primary and acute health services mandated under federal MA law, such as physicians’ services, inpatient hospital services, and skilled nursing home services, that the Department chooses to offer as a benefit under the Family Care program. If approved by HHS, allow DHS to offer the approved services under the Family Care program.
Family Care Open Enrollment. Require DHS to request a waiver from HHS allowing enrollees to change MCOs only during a specified open enrollment period and, if approved, implement this provision.
MCO Contracts and Oversight. Require DHS to request a waiver from HHS to remove statutory requirements for MCOs under Chapter 648 (“Regulation of Care Management Organizations”), which specify the requirements for applying for, issuing, and suspending or revoking an MCO’s permit, the role of the Office of the Commissioner of Insurance (OCI) and the Commissioner in regulating MCOs, reporting duties of MCOs, requirements for responsiveness of MCOs to OCI, the ability of OCI to examine, audit, or otherwise study the operations of an MCO, the responsibility of MCOs for the costs of such examinations and audits, the ability of OCI to refuse to disclose information, including reports, records, and information obtained through reports and during examinations regarding MCOs, the ability of OCI to enforce relevant regulations, processes related to disclosing management changes, protections related to enrollees of MCOs, and processes for insolvency funding of MCOs. Eliminate the transfer from OCI’s general program operations appropriation to the DHS appropriation for oversight of MCOs. Repeal OCI appropriations related to the costs OCI may charge MCOs for employing experts to examine or review transactions, and for other costs related to analysis and financial monitoring of MCOs by OCI under current law. Eliminate the appropriation related to collections of expenses for insolvent or financially hazardous MCOs. Allow OCI to apply statutory regulations related to insurance providers, including provisions related to solvency assessment, accounting and reserves, rate regulation, insurance marketing, and other general public policy provisions applicable to insurers, to MCOs. Permit OCI to promulgate rules regarding licensing MCOs as insurers and regulating the operations of MCOs as necessary. These provisions would be effective July 1, 2018.
Prohibit MCOs from investing risk reserve funds in time deposits, or in bonds or securities issued or guaranteed by the federal government or by a commission, board, or other instrumentality of the federal government.
Eliminate the requirement that, as a term of a contract with an MCO, an MCO must contract for the provision of services covered under the Family Care benefit with any community-based residential facility, residential care apartment complex, nursing home, intermediate care facility for the intellectually disabled, community rehabilitation program, home health agency, provider of day services, or provider of personal care that agrees to accept the reimbursement rate that the MCO pays under contract to similar providers for the same service and that satisfies any applicable quality of care, utilization, or other criteria that the MCO requires of other providers with which it contracts to provide the same service. Eliminate the ability of DHS to prohibit MCOs from including provisions in contracts with Family Care service providers to return any funding for residential services, prevocational services, or supported employment services that exceed the costs of services to MCOs. These provisions would be effective July 1, 2018.
Under current law, MCOs are subject to oversight provisions enforced by OCI, including permitting, reporting, and examination requirements. Additionally, they are subject to certain restrictions on contracts with service providers specified by DHS.
ADRC Service Providers and Services. Permit DHS to contract with entities other than aging and disability resource centers (ADRCs) to perform the duties of ADRCs. Permit DHS to specify in a contract with an ADRC or agency acting as an ADRC that the entity provide any of the following services or functions: (a) information and referral services and other assistance at hours that are convenient for the public; (b) a determination of functional eligibility for Family Care; (c) within the limits of available funding, prevention and intervention services; (d) counseling concerning public and private benefits programs; (e) a determination of financial eligibility and of the maximum amount of cost sharing required for a person who is seeking long- term care services, under standards prescribed by the Department; (f) assistance to a person who is eligible for Family Care with respect to the person’s choice of whether or not to enroll in an MCO and, if so, which available MCO would best meet his or her needs; (g) assistance in enrolling in an MCO; (h) transitional services to families whose children with physical or developmental disabilities are preparing to enter the adult service system; and (i) a determination of eligibility for state supplemental payments, MA benefits related to the receipt of certain Social Security, Medicare, or BadgerCare Plus benefits, or for FoodShare benefits.
Under current law, individuals have access to ADRCs, which serve as a gateway for individuals who need, or expect to need, long-term care services through programs such as Family Care, IRIS, PACE, and Partnership. ADRCs are responsible for the provision of all of the services outlined above, and must provide all of their services at no cost to recipients. As of August, 2014, there were 41 ADRCs operating in Wisconsin, including 28 single county ADRCs and 13 multi-county/tribe regional ADRCs, serving all 72 counties and 11 tribes.
Currently, the contract between an ADRC and DHS assigns responsibilities to each ADRC and allows the ADRC to be reimbursed for its costs in carrying out these required functions.
Counties are not expected to contribute to the cost of operating ADRCs. State funding to support ADRCs is allocated based on the estimated size of the population served in each area and estimates of the amount of time required to carry out the ADRC functions. If actual costs exceed this limit, the ADRC is responsible for those costs. Because ADRCs provide services to, and respond to, inquiries from individuals and their families regardless of MA eligibility, federal cost sharing for their operation is limited to the amount that can be documented as supporting services for MA-eligible individuals. DHS estimates that approximately 65 percent of ADRC expenditures were eligible for federal MA administrative matching funds between July 1, 2014, and October 29, 2014, meaning that approximately 32.5 percent of ADRC expenditures are currently paid by federal matching funds.
Elimination of Long-Term Care Districts, Advisory Committees, and ADRC Governing Boards. Require long-term care districts existing on June 30, 2015, to be dissolved before June 30, 2017, or before a date established by DHS, whichever is later. Prohibit any new long-term care districts from being created after June 30, 2015. Remove all statutory language regarding and references to long-term care districts, effective July 1, 2018.
Under current law, a long-term care district is a local unit of government created with the purpose of operating an MCO, an ADRC, the Partnership program, or PACE. A long-term care district is overseen by a long-term care district board, and has jurisdiction within the county or counties that created it, or the geographic area of the reservation of the tribe or band that created the district. There are currently seven long-term care districts, four of which are Family Care MCOs, one of which operates an ADRC, and two of which have no contract with DHS.
Repeal regional long-term care advisory committees. Remove all statutory references to regional long-term care advisory committees. Under current law, regional long-term care advisory committees are responsible for: (a) evaluating the performance of MCOs in the committee’s region with respect to responsiveness to service recipients, number of choices available to recipients, and other issues affecting recipients, and making recommendations based on these evaluations; (b) evaluating the performance of ADRCs and making recommendations regarding their performance; (c) monitoring grievances and appeals made to MCOs; (d) reviewing utilization of long-term care services in the committee’s region; (e) monitoring enrollments and dis-enrollments in MCOs operating in the committee’s region; (f) identifying gaps in availability of services, living arrangements, and community resources and developing strategies to build capacity to provide those services; (g) performing long-range planning related to long-term care policy for individuals served by ADRCs; and (h) reporting to DHS annually regarding achievements and problems related to the provision of long-term care services in that region.
Eliminate ADRC governing boards. Remove all statutory references to ADRC governing boards. Under current law, ADRCs have a governing board that is responsible for determining the structure, policies, and procedures of, as well as overseeing the operations of, the ADRC. In addition, the governing board is responsible for gathering information regarding the ADRC’s activities, including identifying gaps in services and reporting findings to the regional long-term care advisory committee. Further, the governing board is responsible for recommending strategies for building local capacity, identifying new sources of community resources and funding, appointing members to the long-term care advisory committee, reviewing interagency agreements between ADRCs and MCOs, reviewing the number and types of grievances and appeals related to long-term care in the area served by the ADRC, and recommending system changes as appropriate.
Contingency Provision. Require that, if any of the waiver requests specified above are not approved, the Department continue to administer the Family Care benefit in accordance with current statutory requirements.
Other budget provisions affecting long-term care programs to note include:
- Children’s Community Options Program
- Independent assessment requirement for personal care services
- Transfer independent living grants from Department of Workforce Development
- Dementia care specialists
- Promissory notes counted as assets for Medicaid recipients
- Fund children’s long-term care services and other programs benefiting children with excess school-based services revenue.
Click here to read the full document.
Click here to read the DHS budget provisions.