RETURN TO MAIN MR/DD WAIVER RENEWAL PAGE

◊ CONTACT US

◊ MISSION

◊ MEMBERSHIP

◊ CALENDAR

◊ POSITIONS
   Talking Points

◊ COMMITTEES

◊ WV MEDICAID

◊ LEGISLATIVE

◊ ELECTIONS

◊ LINKS

◊ JOB MATCH

TALKING POINTS
MR/DD WAIVER RENEWAL APPLICATION
2nd Draft

The Department (DHHR) claims that it "bent over backwards" to accommodate consumer wishes during this renewal process.  The table below demonstrates how warped that assertion really is.

BROAD STROKES
On May 26th, MRU WV hosted a meeting of stakeholders to develop talking points regarding the waiver renewal process.  Here are the things that those participating encourage folks to emphasize at the public forums and in writing:

• DHHR must set the example for "responsibility" by holding providers accountable for the consistent delivery of the services which the interdisciplinary team (IDT) has determined are necessary.  Failure to do so only drives costs higher and renders the program less effective.
   

• DHHR must ensure that "choice" is more than just a word on paper.  Right now, only the providers have any real choice.
   

• DHHR must allow for program growth.  The waiting list simply cannot move at a "reasonable pace" unless allocations are added each year.
   

• DHHR must implement an effective system of quality assurance.  The system represented on the draft application is merely a plan rather than a functioning system, and as such, is quite misleading.
   

• DHHR must ensure aggregate cost effectiveness for providers so that individuals are not treated as commodities.  Currently, providers pick and choose clientele based solely upon the bottom line.  That is not "choice" for anyone but the providers.
   

• DHHR must effectively remove the service coordination conflict of interest.  This can only be accomplished by prohibiting agencies from providing both service coordination and direct services to the same individual.  (See below for a recommended fix.)
   

• DHHR must abandon its proposal to add another layer of bureaucracy to the program.  The IDT is more than capable of determining which services are necessary and appropriate -- WITHOUT additional cost -- if permitted to do its job.  The proposed system moves AWAY from, rather than toward, a person-centered system.
   

• DHHR must be required to reimburse the attorney fees of consumers who prevail in Fair Hearings.  Further, DHHR must adhere to timelines for the conduct of hearings and the delivery of rulings -- and then ensure that the rulings are followed.
   

• DHHR must involve all stakeholders in the development of the program.  Failure to do so demonstrates a complete lack of respect for what various stakeholders can bring to the table.  The Department cannot claim to be developing a person-centered program without the meaningful participation of the end users.
   

• DHHR must ensure the IMPLEMENTATION of Individual Program Plans (IPPs).  There simply is no other way to "ensure" the health & welfare of program participants.  There is nothing in the draft application that ensures anything beyond the development of an IPP -- and just having an IPP, no matter how well constructed, ensures nothing but paperwork.  Additionally, federal regulations require program implementation:  "Each individual must receive a continuous active treatment program consisting of needed interventions and services in sufficient intensity and frequency to support the achievement of IPP objectives." (42 CFR 483.440(d))
   

• Simply using the words "person-centered" is an empty promise.  DHHR must demonstrate an understanding of the concept by changing the way the program is administered.  There is no such thing as person-centered managed care!  A tiered system of services and supports is merely compartmentalized, not individualized.
   

• DHHR must make it clear to providers that individuals are not required to accept 24 hour agency supports in order to remain on the program.  Such policies are at direct odds with the stated intent of the waiver program: to promote independence and decrease reliance on public assistance.  A tiered service delivery system is NOT the way to accomplish this!  DHHR must also address the issue of liability so that providers are not fretting about being held accountable for something that transpires when natural supports (as documented on the IPP) are being relied upon.  Providers should instead be fretting about liability for what transpires when they ARE, or are supposed to be (as documented on the IPP), on the job!
   

• Rather than chasing the 5% fraud inherent to any public assistance program (throwing good money after bad and punishing those who do use the program responsibly in the process), DHHR must shift its focus to the upper end of the program.  Giving more authority to the IDT and allowing individuals to direct their own services and supports will more than offset any losses from those few who "milk the system."
   

• DHHR must make program data readily available to stakeholders in the form of statistical reports comparing the DD-6s (Cost Estimate Worksheets) to the actual billing.  Information regarding which services are being provided and in what amounts would be very helpful in identifying problem areas and would clearly indicate whether or not IPPs were being implemented.

MRU WV urges DHHR to work WITH diverse stakeholders to develop policy and programs that will effectively address the broad points above.  (For additional points, please also refer to the document developed as a result of the May 10, 2005 stakeholder meeting at DHHR.)

The list above is broad, and it is understood that each person will have other specific concerns that are of critical importance.  Please use this list as a guide rather than a canned response to the Department and CMS.
 

• It is IMPORTANT to attend AT LEAST one of the public forums and provide input -- even if that input merely echoes what you've read here or elsewhere.  There is strength in numbers!  Make a point to call at least three other people to encourage their attendance.
   

• It is important to ALSO provide written comments to the Department AND send a copy to CMS.  The feds need to see what we're saying to DHHR so that they can see for themselves how we're dismissed, disenfranchised, and disrespected.  (The only reason we even have a 2nd draft application on which to comment is because CMS came down hard on the Department as a result of our feedback!)
  
  Send your written comments via e-mail to:
  Regina Wilson of DHHR -- ReginaWilson@wvdhhr.org,
  Harry Mirach of CMS -- HMirach@cms.hhs.gov,
  and, if you want them shared online, comments@MRUWV.org

SPECIFIC QUESTIONS/CONCERNS
Here are some detailed problems that were identified with the 2nd draft renewal application (see also the DD Council's comments):

• Application page 9 (Appendix B-1):  "Case Managers will be defined as Service Coordination" should read "Case Managers will be defined as Service Coordinators"
   

• Application page 14 (Appendix B-1):  Why is a service level specified for day habilitation?  It is not done for any other service and should be an IDT decision.  In addition, clarification is needed on the requirement for habilitation.  Federal code makes it clear that a habilitative program is required.  However, nothing in federal law specifically requires DAY habilitation be used to meet that requirement.  DHHR has perpetuated the myth that individuals MUST participate in a day habilitation program when in reality, individuals could opt for only residential habilitation.
   

• Application page 17 (Appendix B-1):  Yes, nursing services are available under the state plan for individuals below age 21.  However, what happens when the state plan denies nursing services because they're primarily HABILITATIVE in nature and only require a nurse because the individual has, for example, a g-tube?  (See delegatable nursing recommendation below.)
   

• Application page 19 (Appendix B-1):  If Adult Companion Care requires a "therapeutic goal," then how does it differ from habilitation?  How does a "therapeutic goal" differ from a habilitative goal?  When this service was introduced in 2000, it was touted as "down time" for the individual:  time during which the participant didn't have to jump through any programming hoops.  Why the shift in focus?
  
  Failure to include a true "down time" care service on this program can be construed as a human rights issue, as the individual will have NO leisure time whatsoever unless natural supports are available.  It is the IDT which should determine how much training an individual requires.  There is a point beyond which more training becomes counter-productive (in addition to being just plain cruel).  Just because an individual has a developmental disability and requires support does not mean it is appropriate to require that individual to perform every waking moment.  The program MUST make allowances for supported leisure time.
   

• Application page 22 (Appendix B-1):  The parameters for crisis services are ambiguous and inadequately defined.
   

• Application pages 25-26 (Appendix B-2) lists "N/A" in the certification column for many services for which individual-specific training SHOULD be required, especially if providers will be required to implement treatment plans.
   

• Application pages 25-26 (Appendix B-2):  The word "aide" is used incorrectly in reference to First Aid.  "Aide" is a person.  "Aid" is a service.  (This error occurs throughout the document.)
   

• Application page 35 (Appendix D-2):  The IDT should determine the frequency of psychological evaluations for adult participants.  An annual evaluation should be OPTIONAL, especially for those taking certain medications or with certain diagnoses.
   

• Application page 40 (Appendix E-1):  Neither "Professionals" nor "QMRPs" is possessive.  Lose the apostrophes.
   

• Application page 41 (Appendix E-2):  Why is nursing considered an "exceptional service" on a program for individuals who often have complicated medical issues?
   

• Application pages 44-56 (Appendix G) is incomplete.  Consumers should have the opportunity to comment on the financial components of the application.  On May 11, 2005, a FOIA request was submitted to BMS for a report of waiver expenditures by billing code.  BMS claims it does not have this information.  How can an administration be a responsible steward of public funds if it does not even know how that money is spent?
   

• Attachment 1 (Quality Management Program):  There are two copies included, and they differ.
   

• Attachment 2 (DD-2A):  There are two copies included.
   

• Attachment 12:  There are two documents labeled "Attachment 12."  The "Billing Process" attachment should be labeled "Attachment 13."
   

• Precisely how will the proposed concept of personal needs budgeting cut costs?  The two additional assessment tools planned (ICAP and SIS) carry a per-use cost.  The ICAP has been shown to be unreliable in other states, and the SIS is only normed for individuals with intellectual disabilities over the age of 16.  It is estimated that these additional assessments will cost over $600,000 annually for something that the IDT can/should already do at no additional expense.  Further, the tiered services approach has been proven inefficient and ineffective in other states.
   

• Personal needs budgeting will not change the budgeting process of $6400/month/individual (the average for an ICF/MR).  Thus, the same appropriation will be required.  So, where exactly does the expected savings come in?  If program implementation costs do fall short of budgeted amounts, what happens to that money?
   

• Is HOUSEHOLD income to become a factor in determining financial eligibility?  If so, it will force some families into bankruptcy and tear others apart in an effort to preserve eligibility for Medicaid programs and services.  This might appear to be a cost savings initially, but in the long run it will cost MUCH more -- in dollars AND in lives.
   

• After the first draft application was posted and reviewed, the DD Council suggested that the Department simply submit an application to renew the existing program and, once it was approved, start a process to build a true self-directed waiver.  That is an acceptable alternative, as is the recommendation to do a demonstration model using individualized budgets and fiscal intermediaries for up to 10% of program participants.

MRU WV RECOMMENDATIONS
Here are some practical suggestions that, if implemented, MRU WV thinks would save money, enhance self-direction, and streamline administration without adversely impacting services:

• Delegatable Nursing
  Using a system similar to that used by the public schools, have the IDT's RN training and monitor direct care staff for the delivery of certain delegatable procedures (i.e., meals & meds via g-tube, etc.).  Even if staff were given a higher pay rate for the extra duties, it would still be cheaper than the $26/hour that is currently expended for an RN or LPN.  Plus, it would be one less person invading the individual's already limited privacy, and it would cut the expense and red tape involved with obtaining prior authorization.
  
  How?  Add a form (DD-13A) like that used by QMRPs to document program training.  Include it as part of the required "individual specific training" with the IDT's nurse being responsible for the training and supervision of certain staff as identified by the IDT.
  
  If the school system can circumvent the Nurse Practices Act to allow trained aides to provide some services, then so can the waiver program.
   

• Annual Medical Evaluation
  The DD-2A is largely useless in terms of eligibility.  It is five pages which could easily be condensed into one (which amounts to a savings of 15,376 pieces of paper annually, not to mention the costs of its completion and handling).  Only the last section is truly substantive in terms of the need for an ICF/MR level of care.  For purposes of eligibility, this form should simply have a statement USING THE LANGUAGE FROM FEDERAL CODE certifying that the individual "but for the provision of [waiver] services" would require the level of care provided in an intermediate care facility for the mentally retarded.  The form should also list the federal definition of an ICF/MR:  "... an institution (or distinct part of an institution) that -- (1) Is primarily for the diagnosis, treatment, or rehabilitation of the mentally retarded or persons with related conditions; and (2) Provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration of health or rehabilitative services to help each individual function at his greatest ability" (instead of a watered down arbitrary definition).

  The IDT and the individual can determine the need for other medical care and/or assessment without bureaucratic involvement.  It's of no concern to DHHR or the "administrative services organization" and is, quite frankly, a serious and unnecessary invasion of privacy.
  
  The DD-2A also affords DHHR an opportunity to collect and maintain up-to-date contact information for waiver participants.  Fields for the participant's address, phone, and e-mail should be added.

  See MRU WV's proposed DD-2A form HERE.
   

• Psychological Evaluation
  The DD-3 is also largely useless in terms of eligibility.  While the evaluation might be of use to the IDT in the development of the program plan, the information it contains is often second-guessed by those at DHHR who have never even met the individuals on whom they pass judgment.  This process could be streamlined by simply documenting the deficits by which eligibility is determined and a statement (as is on the DD-2A) which indicates the level of care that would be required "but for the provision of [waiver] services."
  
  See MRU WV's proposed DD-3 form HERE.
   

• Service Coordination
  To address the conflict of interest issue, MRU WV recommends that the agency providing service coordination be prohibited from providing other direct care services to the same individual.  In addition, to ensure that agencies actually deliver direct care services, each should be required to provide 24 hours of direct care services (habilitation, respite care, adult companion care) for each hour of service coordination billed.  Failure to do so should result in non-payment of any unbalanced service coordination billing.
   

• Independent Contracting
  DHHR should invest in the development of sound policy that eliminates the concerns surrounding labor and taxes for contracted services so that agencies cannot use them as excuses to refuse to provide contracted services if that is what the IDT determines is needed.  Independently contracted direct care services (Respite and Adult Companion care), cost Medicaid $2.50/hour LESS than that provided by agency employees, AND it is the service most individuals CHOOSE because staff receive a higher wage (thereby increasing both quality and consistency).
   

• Annual Nursing Assessments
  Remove the arbitrary "requirement" for an annual nursing assessment which was put into place following an audit, but has never been made a part of the waiver regulations.  This assessment adds no value to the program and costs Medicaid at least $99,944 annually.  Additionally, it is often viewed as an added invasion of the individual's very limited privacy.  The IDT is quite capable of ensuring that nursing needs are identified.  If additional assurances are needed, a section could be added to the IPP.
   

• Active Treatment
  Federal code requires that waiver participants receive "active treatment" which is comprised of assessment, program development AND implementation, documentation, monitoring and change.  It does NOT require specific services (i.e., day habilitation) as we have been led to believe.  The IDT must have the latitude (without bureaucratic interference) to prepare an IPP that is "directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible and the prevention or deceleration of regression or loss of current optimal function status."  42 CFR 483.440
   

~*~  Contributions are NOT (yet) tax deductible.  ~*~

++  PRIVACY STATEMENT  ++

MRU WV will never share its members' personally-identifiable information (name, address, phone, or e-mail address) with any outside person or organization without express consent.

This page last updated Wednesday 22 June 2005