Comments of DisAbility Rights Idaho on 

Medicaid Supported Living Rates for People with Developmental Disabilities.

Rate setting assumptions and base wage rate.

The rates appear to be based on an assumption that the appropriate average wage for all of the levels of support should be $10.47/hr. This is based on the mean wage for personal care aide in the Bureau of Labor Statistics (BLS), Occupation Code 39-9021, Personal Care Aide. We think this assumption is flawed and that it will lead to undesirable consequences. Although direct support staff for all levels of support may share the same job title, the level of difficulty, and the level of responsibility, and the level of skill will generally be very different for example in hourly supported living versus intense support. The tasks involved and the qualifications for direct care staff are markedly different from those of a personal care aide. People who are approved for Intense Supports must have either a serious medical condition or a history of dangerous behavior (IDAPA (b)). The skill level, training needs, and responsibility level for Intense Level direct care staff are markedly higher than for most participants receiving hourly supports. These disparities will likely impede delivery of high quality services, create perverse financial incentives, and may result problems with access to service for some individuals.

  1. Supported Living Direct Care staff have responsibilities beyond those of a personal care aide. While Residential Habilitation- Supported Living (hereafter, SL) includes personal care services, it also includes skill training, and some high levels of supervision and medically related care and monitoring which are not provided by personal care aides (PCA). Teaching independent living skills to people with developmental disabilities requires training and skill beyond those expected of personal care aides. Although there may not be an appropriate BLS category for Supported Living direct care staff, it is clear that the job title selected by Meyers and Stauffer, does not match the skill set for this position. If PCA is used as a basis for salary some premium should be added to account for the higher skill and responsibility level expected in SL.

Recommendation: Set a higher base wage for Supported living direct care staff

  1. Intense Supports will likely involve much higher levels of skill and responsibility than most Hourly Supports. Once an appropriate salary level is determined for basic SL direct care, a higher base rate should be used in Intense Supports. A reading of the standard used for approving intense support level will quickly reveal that the skill and responsibility of providing care and supervision for this population is on a much higher level than standard hourly supports. Idaho is unusual (possibly unique) in having developed a system for SL which serves the most complex participants in the DD System. Idaho has for decades utilized SL to serve the people previously served in the Idaho State School and Hospital/Southwest Idaho Treatment Center (SWITC). While in state custody Idaho spent over $900/day to care for these individuals. The most medically involved participants would qualify for placement in Long Term Acute Care Facilities at a similar or greater daily cost. In either case the individuals involved in their care are paid at much higher rates than PCAs. The work involved for some staff includes risk to personal safety. For others, it requires high levels of responsibility in the face of unpredictable and complex medical conditions. These are not job conditions faced by PCAs or by most hourly SL providers. In early meetings with M&S, and H&W representatives, I provided rationale for why direct care staff in intense supports, although having the same job title, needed a much higher level of training, responsibility, and reliability than in hourly SL. At that time, I was assured that this would be taken into consideration. That does not appear to have been the case. The effect of basing the Intense Supports level rates on the same base pay, will be to create a perverse incentive to avoid accepting people in this level of care.

Recommendation: Set a higher base wage for Intense support staff than for Hourly support staff

  1. High supports is set at exactly one half of the Intense Supports rate which will discourage any individual activities. "High Supports" allows for some of the billable hours for people in that level to be provided in groups of two or three. However, the service, and in particular the new HCBS rules, require that at least some of the hours are available to allow people to engage in individual activities with the help of staff. By setting the rate at half of the 1:1 rate, the department virtually guarantees that the HCBS rules will not be implemented. If two participants ever want to do different things, like attend different churches, the agency needs to have flexibility to staff some 1:1 time for both participants. An arbitrary ½ of the 1:1 rate makes this impossible without significant financial penalty to the provider. This is one more case of the Department creating perverse incentives by expecting providers to honor participant choice, and financially penalizing them each time they do so.

Recommendation: Create a rate that allows providers to provide 1:1 staffing for part of each day to allow for personal choice of participants in compliance with CMS/ HCBS regulations.

Submitted by DisAbility Rights Idaho

James R. Baugh, Executive Director