Waiver Rate Study

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vaACCSES Comments
Burns & Associates Proposed Rate Study
On behalf of our membership and the Virginians with disabilities that we serve, thank you for the
opportunity to provide comment and recommendations on the proposed provider rate study and
proposed rate structures.
We clearly understand the need for Virginia to develop a sound rate methodology to establish
reimbursement rates based upon costs associated with quality of care and the provision of services. We
clearly understand this with the example of the “exceptional rate” that was passed by the General
Assembly and that has not been implemented as a result of the state’s inability to defend the rate
increase to CMS. We clearly understand the inadequacy of current rates because providers live with this
inadequacy day-to day.
However, rates must match the Commonwealth’s definition and expectation of “Quality of Care” or
“Standards of Care” for individuals to be served. The survey instrument must clearly capture this
standard and be sound. In addition, the survey instrument and instructions must be “user friendly” in
order to capture the information needed.
Finally, and most important, we must not discard current rates that are based on a sound rate
methodology and work well – whether currently being implemented regionally or for a specific service.
We do not want to “throw the baby out with the bath water”.
Recommendations
Individual Supported Employment Rates Need to Be Excluded From Survey
Chapter 879, Statutes of 2008 of the Virginia General Assembly specifically directed the Department of
Medical Assistance Services (DMAS) to align individual supported employment rates provided under the
Medicaid home and community-based waivers to the same rates paid to employment services
organizations (ESOs) by the Department of Aging and Rehabilitative Services (DARS). The change was
implemented July 1, 2008. Language also instructed the state to make this change permanent.
Individual Supported Employment (ISE) rates are mandated by the General Assembly and are
implemented by the state through code and regulation (12VAC30-120-100). They are individualized cost
based rates established between the ESO and DARS and are not part of the regular DMAS fee
schedule. Over Sixty-five (65) ESO specific individualized rates are annually adjusted based upon the
Consumer Price Index (CPI).
The ISE rates were fixed in 2008 by the General Assembly and continue to work well for providers of
individual supported employment. ISE rates have contributed to the ever increasing number of ESOs
that participate in the Medicaid Waiver program, as well as the annual increase in the number of
individuals with disabilities that receive individual supported employment. ISE Individualized rates are
the only rates that will fulfill the General Assembly and the Commonwealth’s Employment First mandate.
Individual Supported Employment in Virginia includes job development, job placement, job coaching, job
stability and job maintenance. The survey, which separates job development from job coaching and
long-term follow along, seeks to change supported employment policy in the Commonwealth of Virginia.
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The ISE individualized rate structure is one of the only Medicaid waiver rates that meet the needs of
providers and individuals with disabilities that it serves. What is mandated by the General Assembly and
works well - must not be tampered with or needs to be fixed.
Fundamental Flaw Exists with Survey
The survey starts by asking the provider to begin their calculation by using their current pay scale for
direct service professionals (DSP) which has been arguably kept low due to inadequate Medicaid
reimbursement since the inception of Virginia’s Medicaid home and community-based waivers. Many
providers must pay wages that are limited by current Medicaid reimbursement. Because the survey asks
providers to begin their calculation by using the current pay scale for DSPs, the survey instrument is
flawed from the initial question. A rate built on an insufficient wage will continue to be insufficient.
Regional Rate Setting Protocols Already Exist
There is an alternative approach, at least for day and employment providers that could replace the need
for the surveys and result in the immediate submission of accurate data on rates charged for day and
employment services. A regional rate setting protocol has established these rates, based on review,
analysis and negotiation.
Currently, the Region II CSBs participate in a regional rate setting protocol, along with DARS and NVTC.
Based on regional negotiations among these public agencies and the numerous providers, rates are
negotiated and published. These provider specific rates are then accepted for purchase of service by
these 5 CSBs, by DARS, by NVTC, and by and local ICFs within Region II.
There are published rates to provide the resulting information that Burns and Associates is seeking to
calculate for day support, pre-vocational and group supported employment services. In the cases of
these day and employment services, no survey is needed since the information is already publicly
available from Region II.
It is acknowledged that this alternative is specific to Region II but Region II represents about 25% of the
State population and about 13% of all active ID Waiver slots. It may be possible to propose some
mathematical calculations and extrapolations to adjust these rates to reflect what day and employment
services cost in other areas of Virginia.
A sampling protocol for other Waiver services (beyond these day and employment services) is strongly
recommended. With regional differences, and varying sizes and administrative capabilities of individual
providers, it is likely that results could be more accurately achieved by strategically managing the survey
completions.
Survey Instrument is Complex, Lacks Consistent Language and Requires Clarity
We recommend that the survey instrument be more “user friendly”, include consistent language and be
as simple to complete as possible. The survey is overwhelming and many smaller providers cannot
afford to employ staff specifically trained in fiscal skills and therefore may not be able to complete the
survey. It also requires many providers to publish what they consider to be proprietary information. This
leads to the concern that any responses received will be skewed based on which providers are able to
complete the survey. Providers that are best equipped to compute the survey will not be a statistically
acceptable sample.
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Clear Definitions and Terms
The survey includes numerous assumptions that all providers understand the terms and what is included
in certain categories. What can be possibly misunderstood – will be misunderstood.
 Clear definitions of terms is strongly recommended. Below are some examples of terms that
need specific definitions to ensure consistent responses by providers since these terms may
be interpreted and expensed differently by different providers based on their business
models.
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The use of the term “typical week” suggests using an “average” which will automatically lower
the data collected.
Is the survey capturing people or FTEs? This needs to be clear and consistent throughout
the survey.
“Fringe benefit” must be clearly defined and be consistently implemented throughout the
survey and survey instructions. It is used as a term in one example while employee related
benefits are used on another. Still, the abbreviation ERE is used on another.
“Paid Holidays” must be clearly defined. (residential staff work 24/7 so holidays are managed
differently than by providers of other services)
“Period of time captured” must be clearly defined and consistent throughout the survey and
survey instructions. “Last year”, “FY13” and “2014” are used throughout the survey. A date
certain or specific period of time needs to be stated and needs to be consistent throughout.
Terminology for ID is sometimes different for DD (i.e. ISP vs POC).
“Annual Turnover” needs clarity. Does this include whether it is a clear separation and/or
promotion? A specific formula is required since providers approach this differently.
“Overtime” needs to be clearly defined. Some providers pay overtime while some use relief
staff. If Overtime is figured into the total wage paid in the survey, the average wage figure will
be inflated but alternatively if Overtime is not included, the average wage will be insufficient to
cover costs. A precise instruction is needed.
Case Management as a function of a provider needs to be clarified.
“Optional Benefits” needs to be clarified. The term “optional” needs clarity especially in light
of ACA employer requirements.
“Corporate office” versus “Administrative Office” overhead and the differences between the
two needs to be clearly defined. This is especially true for small providers working in a single
home. They need clarity since their “overhead” is not based in a corporate office.
Clear and Detailed Instructions
The following topics need to be more clearly described so providers can respond appropriately:
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Each section of the survey should include a notation “See page ______in Instructions”.
In the revenue sections, are we capturing only ID and DD waiver funding or all ID/DD funding that
includes waiver, local and/or private funding? This needs to be clearly indicated in the instructions.
“Non-billable time” must be clearly defined in each instance that it is used in the survey and survey
instructions. For example, providers engaged in day support find their DSPs engaged in very time
consuming activities related to both the use and maintenance of adaptive equipment as well as the
clean-up of changing tables after self-care and food preparation prior to lunch and snacks. These
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activities may not include the participants being present but are critical for health, safety and service
provision.
o Communication with collaterals - DSPs are often discussing clinical issues with other
provider staff, with CSB staff and/or with family collaterals and this communication and
coordination is essential but it does reduce direct “billable time”. There needs to be a basic
explanation of how collateral time may or may not be identified as billable.
o Documentation. Is a fuller term than progress notes since documentation also includes items
such as incident reports and CHRIS entries and not just daily notes.
o Consideration should be given to an additional “miscellaneous” category and allow a nominal
exclusion factor. Providers could continue to identify other interruptions and arguably some of
the example above may apply differently to different providers.
“Paid Days Off” needs to include “Inclement weather” paid days off in Virginia because of snow days,
hurricanes, tropical storms, etc.
“Administrative Costs and %” – is unemployment insurance and workman’s comp included and
where? Administrative Support % - Since many funding sources, such as the federal government,
set the limit to 15% for administrative costs, would it be simpler to enter that as a cap on all surveys
rather than expect providers to calculate it individually?
“Program Support Costs and %” - Instructions should be provided that this category is more inclusive
than just supervisors but should include all other staff who is neither DSP nor administrative, for
example, Quality Assurance staff or those providing specific therapeutic interventions not contained
in other service models.
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“Productivity” section needs clarity. Currently assumes that a DSP can devote all time to
direct care EXCEPT for the listed “interruptions”. These are displayed as “productivity
assumptions” but they are in fact “productivity reduction factors” since they interrupt or
distract from billable time. The instructions must be clear on this and should include more
examples. This is a key factor in deriving an honest cost of service since providers must pay
for their staff to complete these activities but Medicaid may not allow them as billable
activities.
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“Employer Development” costs need to be captured with Group Supported Employment. This
includes, but is not limited to, identifying employer opportunities and working with employers to
develop enclave and work crew opportunities within their business structure. The front end costs of
this service are extremely tough, time consuming and thus, costly.
“Vehicle Costs” needs to be expanded and clearly defined. The cost associated with a regular
vehicle or regular van is very different from a para-transit van. Also, does this include staff classroom
training and “on the road” training costs, maintenance costs, insurance, vehicle related safety
supplies, GPS supplies and fees, e-record database systems and training OR is this captured under
Staff development is a preferred term rather than training and providers acknowledge that staff
development is required by regulations. Staff development which includes “Training Costs” needs to
be expanded and clearly defined. Costs associated with all training needs to be clarified and
captured including training in Human Rights, incident reporting, medical administration, CPR/First
Aid, and professional certification training, as well as required DSP waiver training.
“Attendance” should be standardized for day providers with an example such as “52 weeks times 5
days is 260 days then minus 10 holidays and minus 4 weather closings and minus one staff training
days results in 245 days” that the program is open for business. Then that number is further reduced
by a utilization factor, which is driven by the actual attendance of the recipients. Providers have
historical data and these data should correlate to the service models since, for example, more
medically fragile individuals in day support would traditionally have lower attendance than those
individuals who work regularly in individual supported employment. This factor in the equation is very
critical in rate derivation.
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Group Size is another key factor in actually deriving the rate - especially with the distinctions among
tiers. Staffing ratios need to account for smaller ratios including 1:2 or 1:1 to implement appropriate
Standards of Care for some with extraordinary medical and behavioral needs.
Mileage – This should include clear examples to providers on examples of operating expenses for
purchased vehicles (such as maintenance, insurance and fuel) and an option to enter leasing costs
rather than purchase price if applicable.
Facility expenses—Supplies should be entered here.
Employer requirements may need augmentation with some examples for providers.
SIS
Since the SIS scores will be used to determine tiers and these tiers will subsequently be applied to
determine reimbursement rates, it is necessary to provide additional information on how the SIS scores
will be calculated along with a discussion on defining tiers. As an example, DBHDS has publicly stated
that the SIS will function as “one of the tools”. DBHDS needs to provide clarity on which tools are being
proposed and how the descent of tier rankings will occur based on scores. This is critical background
information if providers are expected to propose staffing support ratios for each tier in their rate
calculation since they will need instructions as to the definitions of the tiers. In order to achieve
consistency among respondents, this information on the tiers must be provided along with survey
instructions.
Other
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Personal Assistance & Respite – These services are not unique services under the ID/DD waivers.
Serious consideration should be given to including these services in the survey since they are linked
to Personal Care rates under other waivers. Since both services can also be provided in a
congregate setting how should providers separate the costs for space, time, equipment & personnel?
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Sponsored Residential - It is unlikely that providers of sponsored residential will be able to
complete the survey as constructed. Compensation derives mostly from the Medicaid waiver
reimbursement rate for the number of hours authorized by the individual’s plan for support,
minus a small percentage retained by the licensed agency in order to cover the costs of
technical and clinical support and supervision. “Host home” providers are independent
contractors, rather than employees of the licensed Sponsored Residential agency that
sponsors them. Each signs a contract with the licensed agency for the services to be
rendered. Each signs an additional service agreement that is, in effect, a three-party
agreement between the “host home”, the licensed agency and the individual to be served.
The responsibilities of a “host home” are similar to those of both a group home manager and
a direct support provider.
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Group Home Detail – How should providers reflect individual differences which are part of a person
centered plan? For example, one of four individuals has a job for 6 hours a week, 5 days per week,
one works 3 days per week, and the remaining residents choose to have no organized day program
but enjoy volunteering some days and relaxing at home on others. How do providers calculate these
hours or differentials within one cell?
The Congregate Residential Model - should reflect an attendance modifier for any day activities and
would, of course, vary according to the level of disability of each resident. There should not be the
assumption that a residential site would be homogeneous for all residents and that, for example, all
residents work 90% of the time.
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The survey and example lack the opportunity to display the owner’s “contributions” or “in-kind” value
in an environment where the owner does not draw a wage.
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If the survey template is distributed with numbers already inserted as placeholders or
examples, these existing numbers may confuse providers who may interpret these numbers
as fixed in the formulas. When templates are used, no numerical information should be
entered into the cells and directions must be clear on exactly which numbers each
respondent should enter.
For more information please contact:
Karen Tefelski  Executive Director  [email protected]  (703) 200-7660
Dave Wilber  President  vaACCSES and COO  VersAbility Resources
[email protected]  (757) 896-8450
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