My last blog was posted in the middle of the Idaho legislative session and chronicled the terrible effects H221 would have on Medicaid services for people with disabilities. I am pleased to report that H221 was held in committee and did not pass. Unfortunately, it was replaced H260 which dropped some of the worst parts of the first bill, but still has enough harmful features to qualify as a disaster. H260 passed easily, was signed by the Governor and is now law.
Fortunately, H260 does not include the elimination of developmental therapy for some adults. It does not include the section forcing people with developmental disabilities over the age of 45 to switch to the nursing home based waiver. But, it still has a lot of sections that will degrade services for people with disabilities and threaten the welfare of many.
Some of the changes made by H260:
1. Change adult developmental disability (DD) services budgets to tiered budget levels “similar to children’s services”. This could result in large reductions in the amount of services for many adults. The Department expects this change to reduce adult DD services by $2,000,000 per year in state funds or $6,667,000 in total funds. The tiers will likely be based mostly on scores obtained on the Scales of Independent Behavior –Revised (SIB-R). Although the SIB-R claims to yield a score for level of support needed, the assessment instrument only asks about the person’s level of skills, not their individual needs. There is probably a statistical correlation between these two levels, individual circumstances can result in huge differences in the cost of needed services between two people with the same score. Grouping people into tiers will result in some people getting less than they need and some getting more than they need. Even if this works out on average, individual people could be harmed by the system. In any case, the only way that budget tiers can save $6.6 million, is by cutting a lot of peoples’ basic supports.
2. Prohibits a person from receiving both psycho social rehabilitation (PSR) and developmental Services, even if they have both a developmental disability and a mental health diagnosis and qualify for both services. Although both services involve “skill training” they are not the same. The people providing the services have radically different training and qualifications, the types of issues addressed are different and the linkage to the rest of the service system is different. Some of the 600 people who have both conditions will face serious consequences by having to choose only one service.
3. Requires Health and Welfare (H&W) to develop a “blended rate” for developmental disability services. Medicaid currently pays a higher rate for individual compared to group DD therapy. This will result in the same rate for both types of supports. . This means that it will twice as profitable to do therapy for two people at the same time and three times as profitable for three people. In fact it will probably be cost prohibitive to provide individual therapy. This will be a powerful incentive to DDAs to make all of their services group services. Unfortunately group services may not be appropriate in many cases and integration will be more difficult.
4. Repealed all automatic Medicaid rate adjustments in Idaho Code. This includes the rate formula for personal assistance services (PAS). The rates were previously based on a formula tied to the average wages paid to nursing assistants in nursing homes. This formula has saved PAS from the stagnant rates that have plagued other services like DD therapy. Under H260, all rate increases have to go through a specific legislative authorization and appropriation process.
5. Limited physical, occupational and speech to the Medicare caps, except for children who can prove that they have a medical necessity for more.
6. Adult dental services will be limited to adult coverage shall be limited to medically necessary oral surgery and palliative services.
7. Mandates the Department to impose co-pays on some services, not yet identified.
8. Mandates the use of managed care “approaches that provide case management for high-risk, high-cost disabled adults and children that reduce costs and improve health outcomes, including mandatory enrollment in special needs plans. Managed care contracts to pay for behavioral health benefits as described in executive order number 2011-01 and in any implementing legislation. At a minimum, the system should include independent, standardized, statewide assessment and evidence-based benefits provided by businesses that meet national accreditation standards. The elimination of duplicative practices that result in unnecessary utilization and costs. Contracts based on gain sharing, risk-sharing or a capitated basis” (sic).
9. Eliminates all payments for “collateral contact”.
10. Eliminates service coordination for people getting PAS waiver services.
11. Cuts the amount of time reimbursed for assessments and evaluations from 12 hours to 4 hours.
12. Changes Certification criteria for Certified Family Homes and add licensing fees
All of these changes deserve an entire blog post to themselves and I will be addressing some of them in future posts. People concerned for the welfare of people with disabilities in Idaho should get detailed information on programs that are likely to affect them and be watching for publication of new rules for public comments. Watch this site for future posts.