Gauging the Use of HCBS Support Waivers for People with Intellectual and Developmental Disabilities: Profiles of State Supports Waivers

10/01/2006

U.S. Department of Health and Human Services

Gauging the Use of HCBS Support Waivers for People with Intellectual and Developmental Disabilities: Profiles of State Supports Waivers

Gary Smith, Jon Fortune and John Agosta

Human Services Research Institute

October 2006

PDF Version (124 PDF pages)


This report was prepared under contract #HHS-100-03-0025 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the the Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Linda Bergofsky, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Linda.Bergofsky@hhs.gov.

The opinions expressed herein are solely those of the authors and do not reflect the position or policy of any office of the Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services or any other government authority.

Some state profile information in this report was updated in the report "Gauging the Use of HCBS Supports Waivers for People with Intellectual and Developmental Disabilities: Final Project Report" (April 2007). It can be viewed at http://aspe.hhs.gov/daltcp/reports/2007/gaugingfr.htm.

TABLE OF CONTENTS

INTRODUCTION
METHODS USED TO COMPILE THE STATE PROFILES
SUPPORTS WAIVER PROFILES
SUMMARY RESULTS
Supports Waivers Service Coverage
Number of Individuals Participating in Supports Waivers
Trends in Expenditures
Average Participant Expenditures
Diversity in Per-Person Spending
STATE-BY-STATE “SUPPORTS” WAIVER PROFILES
Alabama
Colorado
Connecticut
Florida
Indiana
Louisiana
Missouri
Montana
Nebraska
Ohio
Oklahoma
Oregon
Pennsylvania
South Dakota
Tennessee
Texas
Washington
ACRONYMS
NOTES

INTRODUCTION

Home and community-based waivers authorized under 1915(c) of the Social Security Act allow states to waive certain federal requirements to enable them to provide home and community-based service (HCBS) alternatives to institutional services, particularly those provided in hospitals, skilled nursing facilities, and intermediate care facilities for persons with mental retardation (ICFs/MR). Since the enactment of 1915(c) in 1981, states have used HCBS waivers to serve steadily increasing numbers of people with intellectual and developmental disabilities (I&DD).1 Over 443,000 people with I&DD were served nationally in 2005.

For a variety of reasons, 17 states2 have restructured HCBS waivers under Medicaid for persons with I&DD into distinct “supports” and “comprehensive” programs that operate side-by-side, as a mechanism to rebalance their long-term care systems, enhance family care giving by leveraging state dollars to acquire additional federal Medicaid dollars and reduce the costs of addressing spiraling service demand. In addition, at least two other states (i.e., Delaware, Georgia) are in the final stages of developing “supports” waivers. The number of “supports” waivers in play is steadily rising and by the end of 2006 we anticipate that these 19 states will operate a total of 23 “supports” waivers.

One possible consequence of this restructuring of Medicaid waivers is that services for some people with I&DD are being redesigned to direct demand to less costly in-home services. There is little systematic information available about the types of participants enrolled in these “supports” waivers or whether demand for Medicaid services from this cohort of Medicaid enrollees has been moderated as a result of introducing a variant type of waiver.

Thus, in the absence of a singular approach to providing HCBS waiver services to persons with I&DD, an amalgam of waiver programs has emerged. And, as there is no single definition of an I&DD “supports” waiver (or comprehensive waiver for that matter), each state that operates one has somewhat idiosyncratic enrollment or participant targeting criteria, service mix, caps, and enrollment limits. Moreover, there is no consolidated data set on these waivers. While there was been a process evaluation of Medicaid HCBS waivers for the I&DD population in 2000 (Lakin and Hewitt) and the National Association of State Departments of Developmental Disability Services (NASDDDS) issued a policy advisory on I&DD support waivers as well as an overview of waiver programs in six states, neither entailed a critical policy analysis of the phenomenon. Another reason to look at “supports” waivers in detail is that there are some 480,000 adults with I&DD who are age 60 and over living with family. A recent study by UCLA showed that older adults with I&DD have substantial health needs that influence their ability to integrate into their communities and well being (Hahn & Aronow, 2005). The aging of people with I&DD along with their caregivers may pose additional challenges for states in determining how best to deploy limited Medicaid resources, particularly residential services (Larson, Lakin, et al., 2001; D. Baxley, personal communication, 2005).

According to NASDDDS, a “comprehensive” services waiver program for the I&DD population typically includes the following features:

  • 24-hour in-home supports, when deemed necessary.
  • 24-hour care and supervision in several types of licensed or certified community residential facilities.
  • A dual focus on preventing out-of-home placement, where possible, and furnishing out-of-home residential services, where it is not.
  • Relies on traditional community provider agencies for service delivery and may include consumer-direction.
  • May target participants by age or disability characteristics but usually not by type of community living arrangement.
  • Subject to a global per-participant expenditure cap based on average institutional spending.

In contrast, a variation on the comprehensive I&DD waiver, referred to as a “supports” or “support services” waiver, is geared specifically toward preventing out-of-home placement and offers less than 24-hour in-home supports, and will not offer 24-hour care and supervision in a community residential facility. “Supports” waivers operate under dollar limits on the amount of waiver services that are roughly 20-50% of the per capita costs that states incur in “comprehensive” waivers. By design, “supports” waivers are consumer-driven and, in some cases, consumer-directed. Finally, these “supports” waivers are further distinguished from “comprehensive” waivers because they are designed to encourage the use of non-traditional providers of care, such as family and neighbors.

The current commitment to community living for persons with I&DD stands in stark contrast to service patterns evident when Medicaid was first enacted. The force of increased consumer involvement in care decisions, combined with limited state resources to support large, inefficient institutions eventually led the Health Care Financing Administration (HCFA) (now the Centers for Medicare and Medicaid Services (CMS)) to issue “Interpretive Guidelines” covering the development of community ICFs/MR in 1981. A recent notable milestone in the care of persons with I&DD has been the creation of the Medicaid waiver program in 1981. The option for states to pursue HCBS waivers came out of the Omnibus Budget Reconciliation Act (OBRA) of 1981 (commonly referred to as OBRA 81). Examples of HCBS covered benefits with particular relevance to the I&DD population are 24-hour out-of-home care in community residential facilities (community ICFs/MR), case management, personal care services, habilitation services and respite.

The landscape has been further transformed as a result of the Olmstead v. L.C. Supreme Court ruling in 1999. Olmstead held that states must make diligent efforts to serve individuals in the most integrated setting, although it did not make HCBS an entitlement. There has also been a high volume of lawsuits that challenge wait-listing individuals with I&DD for Medicaid HCBS (Smith, 2004). States have responded to Olmstead (and other litigation) as well as the continued demand for HCBS (as evidenced by growing waiting lists) by implementing alternatives to serving individuals with I&DD that require specialized community services and supports. NASDDDS has concluded that “state policymakers were well aware that offering a full array of supports--including residential services--as the sole alternative to accessing publicly funded supports accentuated demand for intensive, costly services which legislative bodies increasingly were unwilling or unable to fully fund”. The creation of “supports” waivers, with more circumscribed services “packages” and lower overall per-person costs than comprehensive waivers, offered one strategy for serving individuals appropriately while minimizing demand for 24-hour out-of-home residential supports.

In 2002, CMS offered states a way to expedite waiver review and approval through use of the Independence Plus waiver template (both for Section 1115 and 1915(c) waivers). This demonstration initiative is intended to further assist states to offer families with a member who requires long-term supports and services, or individuals who require long-term supports and services, greater opportunities for consumer-direction. However, the level of “consumer direction” that is embedded within the operations of either “supports” or “comprehensive” waivers is not well documented.

In an effort to better understand these “supports” waivers or whether demand for Medicaid services from this cohort of recipients has been moderated as a result of them, the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services undertook this project to:

  • Gather descriptive information on the waivers, both “comprehensive” and “supports”, operated for people with I&DD in 17 states with operational “supports” waivers.
  • Determine how “supports” waivers have emerged as separate and distinct HCBS waivers.
  • Better understand the range of participant characteristics and experiences that distinguish “supports” waivers from other HCBS waiver programs for people with I&DD.
  • More fully appreciate how states view “supports” waivers as a way to address demand for HCBS.

To achieve these goals a series of tasks were fashioned to collect and review data pertaining to state HCBS waiver programs. To begin, we sought to profile the 17 states with “supports” waivers. This outcome will be followed by case studies of a smaller number of selected states. This document provides information pertaining to the first of these steps, offering a profile of the HCBS waivers in operation in each of 17 states.

METHODS USED TO COMPILE THE STATE PROFILES

Several activities were undertaken to collect information from the targeted 17 states related to their HCBS programs. To begin, we developed a computer-based template and an Excel database for sorting and compiling the information we planned to collect from each state. Next, we sought information related to each state’s waiver activity including fiscal years 2000-2006. In some instances, we were able to secure projections through 2008. To collect such information, we:

  • Contacted individual state staff associated with state HCBS waivers to acquire state specific information such as CMS approved or submitted waiver documents, initial or lag CMS 372 annual waiver reports, relevant state documents, state staff projections, and other applicable reports.
  • Reviewed information available electronically through state web sites.
  • Reviewed national data sets available from the Research and Training Center on Community Living Institute on Community Integration/UCEDD at the College of Education and Human Development at the University of Minnesota.
  • Reviewed previous reports on the topic such as finding compiled by NASDDDS.

In those instances where information from different sources did not match, we attempted to reconcile the data sets. In some instances, however, we were left to include estimates in the resulting state profiles. We note any case where we needed to include estimates in each profile as warranted.

SUPPORTS WAIVER PROFILES

The profiles compile extensive information concerning “supports” waivers that are now operated in 17 states. The profiles have been structured to capture uniform information across all the supports waivers in operation in 2006. In particular:

  • A list of the approved waivers in operation: The HCBS waivers in operation for people with I&DD are listed. The waivers are listed by name along with the following information: type (i.e., comprehensive or “supports”), CMS waiver number, the number of participants in 2005, start date and status (e.g., on-going, initial, pending CMS approval). The list includes the comprehensive waiver to which the “supports” waiver is linked. In a few cases, states operate other waivers for people with I&DD that are not listed, but these waivers are not linked directly to comprehensive waivers.

  • Supports Waiver Features: This section offers fundamental descriptive information about each targeted supports waiver, including:

    • The target population (who the waiver serves).

    • Funding limits (the maximum dollar amount of waiver services that may be authorized for a waiver participant).

    • Funding parameters or relevant rules that govern how funds are allocated under the funding limit.

    • Exceptions (if any) to funding limit including how such exceptions are managed.

    • Provisions regarding transition to the comprehensive waiver to illustrate how an individual may move from the supports to the comprehensive waiver.

    • Whether the waiver includes features to promote self-direction. Waivers and state materials were reviewed for indicators to show that the waiver provides for individual budgets, permits participants to direct how these funds are spent, and/or supports participants in employing support workers.

Supports Waiver Services: This section provides information on the services that the supports waiver offers. In consultation with the ASPE Task Order Monitor and consistent with the existing literature and our understanding of how waivers are structured, Health Services Research Institute (HSRI) identified 16 broad service categories to facilitate cross-state/cross-waiver comparisons of the scope of waiver services. State waiver service definitions were reviewed and services were sorted into these predefined categories. These service categories include:

Service Category Services/Activities Associated with Category
Case Management/Service Coordination HCBS waiver intake, assessment, service planning, and on-going monitoring
Supports of Participant Direction (Support Broker) Assistance to individuals/families who self-direct services. Such assistance may include the development of the person-centered plan, managing individual budgets, recruiting workers and accessing generic services and supports
In-Home Services Personal care/assistance, chore services, companion services, homemaker services
Person Directed Goods and Services A service that a state may make available to individuals who self-direct. Coverage permits waiver participants to purchase goods and services that are not specifically covered in a waiver but contribute to meeting the person’s needs for assistance.
Equipment/Supplies Adaptive equipment, augmentative communication devices, personal emergency response systems (PERS)
Vehicle Repair/Modification Modification of a vehicle to accommodate a person with a physical disability
Respite Relief to a person’s primary caregiver
Clinical Services Physical therapy, occupational therapy, behavioral interventions, speech and language services and similar services performed by credentialed professionals
Day Supports Services furnished outside the person’s residence in facility-based settings such as day habilitation centers or in the community to promote community inclusion (e.g., community participation)
Environmental Accessibility Adaptations Home modifications to accommodate physical disabilities (e.g., ramps, bathroom modifications, etc.)
Health Related Typically skilled nursing services
Financial Management Services Services furnished to support individuals who directly hire their own workers and/or manage an individual budget
Supported Employment Services to assist individuals to secure regular community jobs and support their on-going employment
Family and Caregiver Training Services that teach family members/caregivers to perform activities that address one or more dimensions of a person’s disability
Transportation Transportation to community activities and/or other waiver services
Other Services that do not fall into the foregoing categories (e.g., supported living coaching in Florida)

For each profile we show whether or not the waiver offers each service type. If so, the particular service label applied by the state is also shown.

  • Background Information on the Supports Waiver: This section offers background on how and why the supports waiver was developed. This discussion identifies the unique state dynamics that may be in play that served as impetus for implementing a “supports” waiver. Common driving factors include: (a) holding down costs or make systems more cost efficient; (b) addressing increasing service demand (waiting list reduction); (c) developing service options to promote consumer direction; and (d) coming into compliance with CMS Olmstead Letter #4.3

  • Current/Major Issues or Changes Underway: This section offers factors that reportedly may have an impact on a state’s waiver strategy. This could include such issues as: (a) the impact of active court cases regarding waitlists, (b) anticipated outcomes resulting from discussions with CMS staff regarding waiver administrative structure or operations, (c) changes to waivers that states are planning to make, and (d) changes in state budgets that have the potential of altering how a waiver is structured or run.

  • Statistical Profile: This section provides information on comprehensive and “supports” waivers regarding the number of participants served by waiver and associated costs. In most instances, the data depict waiver utilization and expenditures during the period 2000-2006. In some instances, data were only available through 2005; in a few cases, states provided out year projections. Complementing graphics are also presented to illustrate changes over the period.

  • Web-Accessible Resources/Documents Inventory: This section offers information about waivers that is available on the internet or that was collected in print copy.

  • State Contact Information: Information is offered to show the name of a key contact person and his or her address, phone number and email address.

SUMMARY RESULTS

This section compiles selected information from the profiles regarding the “supports” waivers presently in operation.

Number of States Operating “Supports” Waivers. In 2006, 17 states were operating one or more “supports” waivers in tandem with comprehensive HCBS waivers for people with I&DD. In 2006, two additional states (Delaware and Georgia) will submit “supports” waiver applications to CMS. Once these applications are formally submitted, profiles of these waivers will be added. The following table shows the trend in the operation of “supports” waivers since 2000:

STATES OPERATING SUPPORTS WAIVERS
  2000 2001 2002 2003 2004 2005 2006
Cumulative Number of States Operating Supports Waivers 4 7 8 12 13 17 19
States COOK (2)PASD LA (1)MTOR IN ALMOOHNE (1) TXWA (2) CTFLTN DE*GA*NE (2)**LA (2)**
Cumulative Number of Supports Waivers in Operation 5 8 9 13 16 19 23
* Submission planned. ** Pending CMS approval.

As can be seen, there has been steady year-over-year growth in the number of states operating “supports” waivers.

Supports Waiver Target Populations. Of the 21 “supports” waivers presently in operation or slated to go into operation in 2006, three (Louisiana, Oklahoma, and South Dakota) target children with I&DD. Another seven (Colorado, Louisiana, Montana, Nebraska, Oklahoma, and Oregon) target adults with I&DD. The remaining eleven target both children and adults with I&DD.

Funding Limits. “Supports” waivers funding limits range from a low of $5,000 per year to a high of $52,000 per year. Most “supports” waivers operate with a funding limit in the range of $13,000-$20,000 per year. One common mechanism that 15 of the 17 “supports” waiver states use is an annual cap on the total expenditure for a participant.

 STATES USING ANNUAL CAPS WITH THEIR SUPPORTS WAIVERS IN THOUSANDS OF $ 
 AL   CO   CT   FL   IN   LA   MO   MT   NE   OK   OR   PA   TX   TN   WA 
18 35 52 14.2 35.5 15none 20 7.8 20 12.318.5 20 21.2 10 36 6.5 19

Supports Waivers Service Coverage

This table shows the scope of “supports” waiver service coverage by the service categories that HSRI defined. As can be seen from this table, most “supports” waivers cover a common set of services (e.g., respite, in-home supports, day supports). However, there is considerable variation among the states in their coverage of other types of services. Especially noteworthy is that only a few states are explicitly covering supports for self-direction.

SUPPORTS WAIVER SERVICE COVERAGE
Services Category  AL   CO   CT   FL   IN   LA   MO   MT   NE   OH   OK   OR   PA   SD   TN   TX   WA  TotalAcross Waivers 
Case Management/ Service Coordination * * * X X X * * * * * X *   * * * 4
Supports for Participant Direction (Support Broker)     X                 X     X     3
In-Home Services X X X X   X X X X X X X X X X X X 16
Respite X   X X X X X X X X X X X X X X X 16
Day Supports X X X X X X X X X X X X X   X X X 16
Health Related X X     X X   X   X X X X X X X X 13
Supported Employment X X X X X X X X     X X     X X X 13
Transportation X X X X X   X X   X X X X X X   X 14
Person Directed Goods and Services                     X       X     2
Equipment/ Supplies X X X X X X X X X X X X X X X X X 17
Vehicle Repair/ Modification   X X   X X X   X         X X     8
Clinical Service X X X X X   X   X   X X X   X X X 13
Environmental Accessibility Adaptations X X X X   X X X X X X X X X X   X 15
Financial Management Services     **                 X **   X     2
Family and Caregiver Training     X   X X         X X         X 6
Other X X X X X     X   X   X         X 9
Total by State 10 10 12 10 11 10 9 9 7 8 11 14 8 7 13 9 11  
* Service coordination furnished as Targeted Case Management (TCM) coverage or via Medicaid administrative claiming rather than as a waiver service ** Financial management services furnished administratively rather than as a waiver service

Number of Individuals Participating in Supports Waivers

The chart below shows the 2000-2006 trend in waiver enrollment for the 17 states that are presently operating “supports” waivers.4 As shown, total waiver enrollment in these states trended upward across the period, increasing by roughly 66% during this period.

Among these states, enrollment in “comprehensive” waivers grew by roughly 31%. Enrollment in “supports” waivers accounted for 56% of total enrollment growth. By 2006, about 26% of all waiver participants in these states will be enrolled in “supports“ waivers.

STATES WITH COMPREHENSIVE AND SUPPORTS WAIVERS ENROLLMENT TRENDS 2000-2006

Trends in Expenditures

The financial growth of “supports” waivers was proportionally slower than enrollment from 2000 to 2005 as shown in this chart:

The “supports” waivers were able to grow to 9.4% of the total waiver expenditures by 2006 while serving 25.7% of the total waiver participants.

STATES WITH COMPREHENSIVE AND SUPPORTS WAIVER EXPENDITURES TRENDS ($B) 2000-2006*
* Indiana, Montana, Oklahoma, Washington 2005 information was used for 2006 which is not yet available.

Average Participant Expenditures

Not unexpectedly, “supports” waiver costs per participant were 30.2% of the comprehensive waiver costs in 2006. “Supports” waivers average participant cost stayed at an average of 23.8% of the comprehensive waiver costs over the course of the seven years. The overall result of “supports” waivers in the states that had them was to generally allow more people to be served while moderating the increases in the average participant annual expenditures. This is evident in the restraining of the blended average cost per participant in the chart above.

We compared spending on waiver services in the “supports” waiver states with the remaining states and found that the costs were very similar. In 2005, the national average annual waiver participant expenditure was $37,637, compared to $37,084 in the “supports” waiver states, a difference 2.7%. Taken together, the group rank of the “supports” waiver states for average overall waiver participant expenditures for all of their waivers was 24th.

STATES WITH COMPREHENSIVE AND SUPPORTS WAIVER ANNUAL EXPENDITURES PER PARTICIPANT 2000-2006*
* Indiana, Montana, Oklahoma, Washington 2005 information was used for 2006 which is not yet available.

Diversity in Per-Person Spending

In the following table the states with “supports” waivers show their diversity:

TABLE OF AVERAGE COMPREHENSIVE, SUPPORT, AND BLENDED ANNUAL COSTS, AND PER-PERSON AVERAGE COST*
 State 2006   Comprehensive Per Participant  Supports Per Participant  Blended Per Participant Supports Waiver % Comp Waiver Per Person
AL $41,433 $8,950 $39,630 21.6%
CO $54,999 $15,983 $36,742 29.1%
CT $72,205 $24,443 $53,647 33.9%
FL $21,837 $14,282 $20,609 65.4%
IN $65,569 $8,520 $42,833 13.0%
LA $49,756 $9,255 $43,901 18.6%
MO $37,208 $4,222 $33,806 11.3%
MT $29,893 $6,252 $27,006 20.9%
NE $50,526 $9,158 $38,881 18.1%
OH $48,141 $22,733 $42,921 47.2%
OK $65,383 $13,167 $52,821 20.1%
OR $55,000 $8,505 $30,304 15.5%
PA $67,574 $12,738 $49,450 18.9%
SD $33,581 $4,015 $26,831 12.0%
TN $60,385 $18,051 $55,311 29.9%
TX $37,480 $8,669 $32,857 23.1%
WA $56,771 $13,581 $33,020 23.9%
Average 2006 $45,168 $13,655 $37,084 30.2%
* Indiana, Montana, Oklahoma, Washington 2005 information was used for 2006 which is not yet available.

STATE-BY-STATE “SUPPORTS” WAIVER PROFILES

ALABAMA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Living at Home Supports 0391 125 04/2003 Initial
Home and Community-Based Services for Persons with Mental Retardation Comprehensive 0190 4,854 08/1981 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children age three and older and adults with mental retardation on the waiting list for community services.
Funding Limit $18,000/year.
Funding Parameters Amount authorized based on individual plan.
Exceptions to Funding Limit Crisis intervention services may be furnished over and above the funding limit.
Transition to Comprehensive Waiver Individuals whose needs cannot be safely met under the supports waiver program and who are in crisis may be admitted to the comprehensive waiver program.
Self-Direction Limited. Community specialist services provided assistance to families and individuals in the development of person-centered plans and on-going assistance, if desired.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Alabama Waiver Services
Case Management/Service Coordination N [Case management provided through TCM coverage]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Residential Habilitation, Personal Care
Respite Y Respite in Home, Respite Out-of-Home
Day Supports Y Day Habilitation, Prevocational Services
Health Related Y Skilled Nursing
Supported Employment Y Supported Employment
Transportation Y Personal Care Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Specialized Medical Equipment and Supplies
Vehicle Repair/Modification N  
Clinical Services Y Physical, Occupational, Speech and Behavior Therapy
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N  
Family and Caregiver Training N  
Other Y Community Specialist, Crisis Intervention

Background Information: Supported Living Services Waiver

The Living at Home (LAH) Waiver was first approved by CMS in 2002 but not implemented until 2003. The waiver was designed to provide low cost services and supports to individuals with mental retardation who live with their families or on their own and as a tool to reduce the state’s waiting list for services. The waiver provides both in-home and day supports as well as other ancillary services. The waiver stresses the use of person-centered planning methods in support of family/participant direction of services. Participants may select a community specialist to assist in the development and implementation of the person-centered plan. When community specialist furnishes on-going support, the frequency of case manager monitoring is reduced. State officials also report that the waiver is playing a role in its systems change initiative to eliminate the practice of “paying for the program” in Alabama (i.e., paying for slots in a particular program run by a private provider, rather than paying for the particular array of services and individual is determined to need). Community specialist services also have been added to the comprehensive waiver. The supports waiver uses a pre-authorized payment system to create a model that funds people, not programs. The state is implementing a new billing and data management system that will make the LAH Waiver much more usable by simplifying service authorization and billing.

The waiver has been slow to ramp up due to the lack of state funding. Recently, however, additional funds have been released to permit the program to be expanded. Alabama has been sued in federal court concerning the wait-listing of individuals for community services. Recently, a tentative settlement agreement was developed by the parties to eliminate the 1,400 person waiting list through a three-year expansion of the LAH Waiver. However, this agreement was nixed by the Attorney General and the lawsuit continues to be litigated. Since openings are available in the comprehensive waiver, the state is able to shift individuals between the waivers as necessary. The state uses a criticality scale to determine placement on the waiting list, so that those with the most critical needs are the first to fill slots in the comprehensive waiver.

Alabama’s longer-standing comprehensive waiver provides a full-range of community services and supports. In recent years, the program has underwritten the costs of community placements from the state’s institutions as part of the settlement of the 33-year Wyatt v. Stickney lawsuit. At present, Alabama operates only one large public facility.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006* 2007*
“Comprehensive” 4,037 4,395 4,764 4,437 4,868 4,854 5,100 5,200
“Supports” 0 0 0 7 84 125 300 584
Total Participants 4,037 4,395 4,764 4,444 4,952 4,979 5,400 5,784
“Supports” Waiver % of Total Participants 0% 0% 0% 0.2% 1.7% 2.5% 5.6% 10.1%
* Approved cap.

Between 2000 and 2005, Alabama’s waiver enrollment increased by 23.3%, principally to support the community placement of individuals from the state’s large public facilities.

ALABAMA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006 2007
“Comprehensive” ($M) $96.4 $98.0 $120.4 $148.7 $188.6 $218.7 $211.3 $221.5
   Per Participant $23,885 $22,299 $25,272 $33,521 $38,732 $45,051 $41,433 $41,433
“Supports” ($M) $0 $0 $0 $0.1 $0.4 $1.0 $2.7 $4.4
   Per Participant $0 $0 $0 $4,153 $4,292 $7,608 $8,950 $7,450
Total Expenditures ($M) $96.4 $98.0 $120.4 $148.8 $189.0 $219.7 $214.0 $225.9
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0.1% 0.2% 0.4% 1.3% 1.9%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 35.4% 11.1% 16.9% 21.6% 18.0%
Blended Cost Per Participant $23,879 $22,298 $25,273 $33,480 $38,480 $44,115 $39,630 $39,056
ALABAMA WAIVER EXPENDITURES ($M)

Between 2000 to 2005, total waiver expenditures more than doubled due principally to the expansion of the comprehensive services waiver.

ALABAMA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Alabama Department of Mental Health and Mental Retardation, Mental Retardation Services Web page describing Alabama Mental Retardation Serviceshttp://mh.state.al.us/services/mr/index.htm
Alabama Medicaid Agency LAH Waiver Fact Sheethttp://medicaid.alabama.gov/documents/3D-1c-3-Fact-Sheet-Living_at_Home_...Original LAH Waiver Applicationhttp://medicaid.alabama.gov/documents/3D-1c-2-CMSWaiverApplication.pdfMental Retardation Waiver Fact Sheethttp://medicaid.alabama.gov/documents/Program-LTC/3D-1d-3-Fact%20Sheet-MR_Waiver_3-22-06.pdf

Document Inventory

  • 2002 LAH Waiver Initial Waiver Application
  • 2005 LAH Waiver 5 Year Renewal Application
  • HCFA 372s: LAH 03-04, 372 LAH 04-05 and Comprehensive 00-01 & 02-03 & 03-04
STATE CONTACT INFORMATION
Name Fordyce Mitchel Director MR Community Service Program
Agency Department of Mental Health and Mental Retardation Mental Retardation Services
Address 100 North Union Street P.O. Box 301410 Montgomery, AL 36130-1410
Telephone   334-242-3719
E-mail Fordyce.mitchel@mh.alabama.gov

COLORADO

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Support Living Services (SLS) Supports 0293 3,568 07/1995 On-going
Home and Community-Based Services for the Developmentally Disabled (HCB-DD) Comprehensive 0007 3,996 10/1983 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Adults age 18 and older with developmental disabilities who do not require comprehensive 24/7 services. Each person must be in control of his or her own living arrangements, which is defined at: (1) a living arrangement which the individual has control over (house, apartment or condo) because he or she owns it or which the individual rents or leases in his or her own name; or (2) the individual lives with his or her family or legal guardian. The individual does not have to be in an eligible SLS Waiver setting to begin the process, however, once SLS Waiver services begin, the person must live in an eligible setting. No more than three persons with developmental disabilities may reside in one residential setting, unless they are all members of the same family. The state employs the 300% of Supplemental Security Income (SSI) special income eligibility standard.
Funding Limit $35,000/year.
Funding Parameters Individual funding amount is determined by Community Centered Board (CCB). Board policies vary with respect to the amounts authorized. Individual funding amounts are restricted by the overall funding available to CCB.
Exceptions to Funding Limit Colorado does not provide for exceptions to the overall funding limit.
Transition to Comprehensive Waiver Entrance to 24-Hour Comprehensive Supports Waiver is limited to available openings. Entrance is prioritized to individuals experiencing crisis and persons aging out of children’s services.
Self-Direction Limited Self-Direction. Some CCBs offer an “agency with choice” option that permits individuals to recruit workers who are then employed by CCB. Participants also receive “supporting living consultation” services that include assistance with decision-making, planning daily activities, and direct assistance to access community resources and/or service providers.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Colorado Waiver Services
Case Management/Service Coordination N [Case management is furnished through TCM coverage]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Personal Care, Specialized Habilitation, Household Activities
Respite N  
Day Supports Y Community Access, Prevocational Services
Health Related Y Vision/Hearing/Dental Services; Personal Care Services Requiring Medical Professionals
Supported Employment Y Supported Employment
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Environmental Engineering*
Vehicle Repair/Modification Y Environmental Engineering*
Clinical Services Y Professional Services [behavioral services, theapeutic services, communication services]
Environmental Accessibility Adaptations Y Environmental Engineering*
Financial Management Services N  
Family and Caregiver Training N  
Other Y Supported Living Consultation; Mentorship activities
* Environmental engineering spans home and vehicles modifications as well as the acquisition of assistive technology and adaptive equipment.

Background Information: Supported Living Services Waiver

Colorado was one of the first states to design and implement a “supports waiver.” In 1991, Colorado was one of eight states selected by the federal HCFA (now CMS) to offer Community Supported Living Arrangements (CSLA) services. When the CSLA authority expired in 1995, Colorado decided to continue furnishing these services through a separate HCBS waiver (SLS Waiver) that would operate side-by-side with the longer-standing HCB-DD Waiver.

In the late 1990s, Colorado engaged in the Systems Change Project. An outcome of this project was to revamp both waivers to divide state payments for waiver services between comprehensive and supports services. The project also envisioned the state’s focusing on the expansion of the SLS Waiver as a means of reducing or containing the waiting list for community services. Systems Change featured positioning the state’s network of CCBs as “managed services organizations” (MSOs) and altering the flow of funding from a “fee for service” model to a quasi-capitated model. CCBs are non-profit organizations that function as the single point of entry to community services for specified service areas. CCBs perform intake and case management as well as contract with service providers. CCBs also furnish various types of waiver services. Under Systems Change, SLS Waiver payments were restructured to a “per member per month” model and CCBs were expected to achieve performance minimums for participant enrollment within the overall state funding allocation. CCBs were given latitude in authorizing individual funding levels.5

The SLS Waiver was designed to furnish a comparably modest amount of supports to individuals who do not require 24/7 services and live with their families or in other living arrangements. Based on experience with the predecessor CSLA program, state officials believed that furnishing less than comprehensive supports would reduce pressures for costly out-of-home residential services. During the late 1990s, Colorado restricted growth in Comprehensive Waiver services was held largely to accommodating youth aging out of state-funded residential services. This constrained state funding environment was offset somewhat by counties adopting mill levies earmarked for developmental disabilities services.

The operation of the SLS Waiver has varied by CCB. While all CCBs receive the same per-participant payment ($16,445/participant/year in 2006), CCBs vary in their practices concerning the amount of services authorized for each participant. Some CCBs authorize a uniform amount while others vary the amount authorized based on individual needs. The program’s $35,000 funding limit is rarely authorized. CCBs also vary with respect to the types of services and supports that are authorized and the degree of participant/family flexibility in service selection. Issues have arisen concerning whether the program’s funding limit creates conflicts between the individual and family with respect to daytime activities, such as community participation and community employment.

State officials report that the SLS Waiver framework has created an atmosphere in which families are more prepared to think in terms of what services and supports they can provide for the individual and what they need the state to provide rather than focusing on what the state alone can provide. The SLS Waiver also allows Colorado to offer some services to individuals who are on the waiting list of out-of-home placements but not in enough of a crisis situation to be immediately placed in the comprehensive waiver. The overall impact of the SLS Waiver is that more individuals now receive services and more individuals are able to access these services without out-of-home placements. This has also had the effect of reducing per-participant costs of services system-wide. Informants also describe the waiver program as a precursor to self-directed services because it allows individuals and families more flexibility in arranging services and choosing providers. While there have been discussions within Colorado concerning implementing full-featured self-direction, the discussions have not resulted in modifications to the SLS Waiver.

In January 2006, there were 1,118 people waiting for Comprehensive Waiver services and 2,171 people waiting for SLS Waiver services. Colorado has had a persistent waiting list for community services for many years. Some individuals wait-listed for HCB-DD Waiver services are persons who participate in the SLS Waiver program.

Major Issue(s):

CMS has recently challenged Colorado’s practices in operating its HCBS waiver programs for people with developmental disabilities. In particular, CMS has raised serious questions whether the latitude afforded CCBs in administering waiver services results in inconsistent treatment of program participants CCB-to-CCB. CMS has instructed Colorado to revamp its payments for waiver services. This likely will result in major structural changes in the operation of Colorado’s waivers.

In addition, in 2001, Colorado was sued in federal court concerning the waiting list. The aim of this lawsuit is to force the state to expand community residential services by expanding the use of small ICFs/MR. This litigation is not resolved.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006 2007
“Comprehensive” 3,466 3,648 3,785 3,963 3,996 3,996 4,151 4,232
“Supports” 2,959 2,975 2,978 2,978 3,116 3,568 3,652 3,661
Total Participants 6,425 6,623 6,763 6,941 7,112 7,564 7,803 7,893
“Supports” Waiver % of Total Participants 46.1% 44.9% 44.0% 42.9% 43.8% 47.2% 46.8% 46.4%

Between 2000 and 2007, total Colorado waiver enrollment will have increased by 22.8%. Enrollment in each waiver increased at about the same pace. Since 2000, the proportion of SLS Waiver participants to total Colorado waiver participants has remained roughly the same.

COLORADO WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006 2007
“Comprehensive” ($M) $158.8 $172.7 $185.0 $191.1 $188.7 $184.6 $228.3 $251.9
   Per Participant $45,804 $47,333 $48,870 $48,224 $47,228 $46,206 $54,999 $59,534
“Supports” ($M) $32.0 $34.4 $34.5 $41.2 $42.8 $50.0 $58.4 $60.0
   Per Participant $10,800 $11,559 $11,574 $13,851 $13,736 $14,013 $15,983 $16,383
Total Expenditures ($M) $190.8 $207.1 $219.5 $232.6 $231.5 $241.8 $286.7 $311.9
“Supports” Waiver % of Total Expenditures 16.8% 16.6% 15.7% 17.7% 18.5% 20.7% 20.4% 19.2%
Cost Per Participant: % Supports to Comprehensive 23.6% 24.4% 23.7% 28.7% 29.1% 30.1% 29.6% 27.5%
Blended Cost Per Participant $29,696 $31,270 $32,456 $32,531 $32,551 $31,967 $36,742 $39,516
COLORADO WAIVER EXPENDITURES ($M)

Between 2000 and 2007, total Colorado waiver expenditures will have increased by 63.5%. Expenditures leveled off between 2002 and 2005 due to state budget shortfalls. Additional funds were appropriated for 2006 and 2007. The proportion of dollars allocated to SLS Waiver services has ranged between 16-21%. Since 2003, the relationship between SLS and Comprehensive Services waiver per-participant costs has remained relatively steady at 28-29%.

COLORADO EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Start Here: A Resource Guide, Colorado Division for Developmental Disabilities, 2003 Provides an overview of Colorado community serviceshttp://cdhs.state.co.us/ohr/dds/StartHere-AResourceGuide.pdf
Home and Community-Based Services Medicaid Waivers Six page description of waivers for Colorado citizenshttp://chcpf.state.co.us/HCPF/MedicaidEligibility/mefcc.asp

Document Inventory

  • Individual Choice Statement Both Waivers, Colorado HCPF HCBS Medicaid Waivers
  • Services for People With Disabilities 2006 Legislative Briefing, 372 Lag and Initial for Comprehensive and Support Waivers 2002-2004
  • Comprehensive and Support Waiver 2004-2009 renewal applications, and amended 2004-2009 renewal applications
STATE CONTACT INFORMATION
Name Jay Kauffman
Agency Department of Human Services Division for Developmental Disabilities
Address 3824 West Princeton Circle Denver, CO 80236
Telephone   303-866-7455
E-mail Jay.Kauffman@state.co.us

CONNECTICUT

WAIVERS
Waiver Title Type CMS Waiver # Participants (2006) Start Date Status
Individual and Family Support (IFS) Waiver Supports 0426.1P 3,060 02/2005 Initial
Comprehensive Support Waiver Comprehensive 0437 4,289 10/2005 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children age three and older and adults with mental retardation and other developmental disabilities (MR/DD) who do not required paid 24-hour care or supervision as a result of the natural or informal supports in place, or as a result of the individual’s level of supervision needs.
Funding Limit $52,000/year.
Funding Parameters There are limits on three groups of waiver services:
  • Home and Community Supports (Personal Support, Adult Companion Services; Supported Living; Individual Support Habilitation; Respite; and PERS): $22,000.
  • Day and Vocational Supports (Supported Employment; Group Day Support; and Individual Day Support): $20,000.
  • Ancillary Supports (Transportation; Specialized Medical Equipment; Interpreter Services; and Consultative Services): $4,000.

Exceptions to these limits may be approved. Home and vehicle modifications and Family and Individual Consultation and Support (FICS) are subject to limits specified in the waiver.

Exceptions to Funding Limit None. Persons who require additional services and supports are transitioned to Comprehensive Support Waiver.
Transition to Comprehensive Waiver Persons who require more intensive services may be transitioned to Comprehensive Support Waiver.
Self-Direction Full Featured. Waiver earned CMS Independence Plus designation. Individuals may opt to exercise both budget and employer authority. Employer authority also includes an agency with choice option. Waiver provides for both support broker (FICS) and financial management services.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Connecticut Waiver Services
Case Management/Service Coordination N [TCM services are furnished by Department of Mental Retardation case managers]
Supports of Participant Direction (Support Broker) Y FICS
In-Home Services Y Personal Support, Individual Support Habilitation, Adult Companion, Supported Living
Respite Y Respite
Day Supports Y Group Day Service, Individualized Day Support
Health Related N  
Supported Employment Y Supported Employment
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Adaptive Aids; Personal Emergency Response; Specialized Medical Equipment and Supplies
Vehicle Repair/Modification Y Vehicle Modifications
Clinical Services Y Consultative Service
Environmental Accessibility Adaptations Y Environmental Adaptations
Financial Management Services N [Funded administratively]
Family and Caregiver Training Y Family Training
Other Y Interpreter Services

Background Information: Supported Living Services Waiver

In 2005, Connecticut reconfigured its HCBS waiver for individuals with mental retardation. This reconfiguration involved splitting the waiver into two new waivers: the Comprehensive Support Waiver and the IFS Waiver. In addition, the reconfiguration also included incorporating self-direction features into both waivers.

In part, the reconfiguration also was driven by the settlement agreement that was arrived at in the Arc of Connecticut v. O'Meara waiting list lawsuit. In the settlement agreement, the state agreed to expand the availability of comprehensive services over a five-year period and take other steps to revamp how waiver services are operated, including assuring that all necessary services are furnished to waiver participants in accordance with CMS Olmstead Letter #4. Dividing the existing waiver into comprehensive and supports waivers was designed to ensure compliance with Olmstead Letter #4.

Once both waivers were approved by CMS, Connecticut assigned waiver participants to one of the two new waivers based on living arrangement and service plan costs. Persons served in licensed community residences or who had service plans in excess of $52,000 were assigned to the Comprehensive Support Waiver. Other individuals were assigned to the IFS Waiver. In addition, Connecticut is stepping up waiver enrollments to include individuals who receive state-funded services but can qualify for Medicaid. Waiting list reduction entails offering waiver services to persons in the emergency and Priority 1 waiting list category (services required within one year). Individuals are offered services in the waiver that will meet their needs.

Both waivers include self-direction features. Connecticut had offered self-direction options under the previous waiver. The new waivers provide for more robust self-direction opportunities. About 800 individuals and families are currently taking advantage of these opportunities under both waivers.

Going forward, Connecticut is revamping how it determines provider waiver rates to improve funding portability by standardizing rates. This will facilitate participants exercising free choice of providers. Previously, Connecticut employed master contracts with providers that made it difficult for individuals to select a different provider. In the past, rates were determined through negotiation with provider agencies and varied considerably. In addition, Connecticut has developed a new individual budgeting tool that, when implemented, will replace the more current method of capping groups of services within each waiver.

Major Issue(s):

In April 2006, Connecticut’s waiver waiting list stood at 782 individuals. The waiting list is kept by urgency or need so individuals selected for the waiver are assigned to the two waivers based on service need. Under the settlement agreement, the state has made progress in reducing the waiting list.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006*
“Comprehensive” 5,076 5,508 5,972 5,825 6,356 6,583 4,289
“Supports” 0 0 0 0 0 0 3,060
Total Participants 5,076 5,508 5,972 6,825 6,356 6,583 7,349
“Supports” Waiver % of Total Participants 0% 0% 0% 0% 0% 0% 41.6%
* Approved application.

Between 2000 and 2005, waiver enrollment increased by 19.5%. The decline in comprehensive waiver enrollment in 2006 reflects the transfer of individuals to the IFS Waiver.

CONNECTICUT WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M) $345.0 $350.1 $386.5 $393.8 $410.7 $421.3 $309.7
   Per Participant $67,965 $63,563 $64,726 $67,607 $64,614 $64,000 $72,205
“Supports” ($M) N/A N/A N/A N/A N/A N/A $74.8
   Per Participant N/A N/A N/A N/A N/A N/A $24,443
Total Expenditures ($M) $345.0 $350.1 $386.5 $393.8 $410.7 $421.3 $384.5
“Supports” Waiver % of Total Expenditures N/A N/A N/A N/A N/A N/A 19.5%
Cost Per Participant: % Supports to Comprehensive N/A N/A N/A N/A N/A N/A 33.9%
Blended Cost Per Participant $67,965 $63,563 $64,726 $67,605 $64,614 $64,000 $52,320
CONNECTICUT WAIVER EXPENDITURES ($M)

Between 2000 and 2005, total Connecticut waiver expenditures increased by 22.1%. In 2006, comprehensive waiver spending is dropping due to the transfer of participants to the IFS Waiver. The net effect of the implementation of the IFS Waiver is reduced overall per-participant waiver expenditures.

CONNECTICUT EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Connecticut Department of Mental Health HCBS Waivers Home for Connecticut mental retardation waivershttp://dmr.state.ct.us/HCBS/index.htm
Individual and Family Fact Sheet About Connecticut HCBS Waivers Web page contains two page IFS Waiver fact sheethttp://dmr.state.ct.us/publications/centralofc/fact_sheets/ ifs_hcbswaiver.pdf
Guidebook for Connecticut Consumers and Their Families Web page provides a 56 page guidebook for individuals and families concerning Connecticut’s waivershttp://dmr.state.ct.us/HCBS/HCBS_Guidebook.pdf
Consolidated Waiver Operations Manual for Both Connecticut Waivers Web page offering of 95 page waiver operations manual for the support and comprehensive waivershttp://dmr.state.ct.us/HCBS/Consolidated_HCBS_Manual _10_05_.pdf
Frequently Asked Questions for Waiver Providers Web page providing 14 pages of frequently asked questions concerning wavier serviceshttp://dmr.state.ct.us/HCBS/HCBS_Provider_FAQs.pdf

Document Inventory

  • IFS Waiver Applications
  • HCFA 372 reports: 2001-2004.
STATE CONTACT INFORMATION
Name Laura Nuss Director of Strategic Leadership
Agency Department of Mental Health
Address 460 Capitol Avenue Hartford, CT 06106
Telephone   860-418-6001
E-mail laura.nuss@po.state.ct.us

FLORIDA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Family and Supported Living (FSL) Waiver Supports 294 2,650 10/2005 Initial
Developmental Services HCBS Waiver Comprehensive 010b 23,353 07/1995 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children and adults with developmental disabilities who are on the waiver waiting list. Adults must be legally competent or have a legal guardian that helps them with their living situation. Adults also must be able to direct their own supports (or have family members who are willing to assist) in all but limited areas.
Funding Limit $14,282/year.
Funding Parameters Each service has a dollar cap that may not be exceeded without prior authorization. These caps are:
Adult Day Training Behavioral Services Consumable Medical Supplies Environmental Accessibility Adaptations In-Home Supports PERS Respite Care Support Coordination Supported Employment Supported Living Coaching Transportation $1,000$4,500$800$2,000  $5,000  $300$1,000$1,781$2,500$3,500$1,000
Exceptions to Funding Limit None.
Transition to Comprehensive Waiver Supports waiver participants maintain their position on the comprehensive waiver wait-list for potential future opportunities.
Self-Direction No. Waiver, however, has participant/family-driven features.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Florida Waiver Services
Case Management/Service Coordination Y Support Coordination
Supports of Participant Direction (Support Broker) N  
In-Home Services Y In-Home Support
Respite Y Respite
Day Supports Y Adult Day Training
Health Related N  
Supported Employment Y Supported Employment
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Consumable Medical Supplies; PERS
Vehicle Repair/Modification N  
Clinical Services Y Behavioral Services
Environmental Accessibility Adaptations Y Environmental Adaptations
Financial Management Services N  
Family and Caregiver Training N  
Other Y Supported Living Coaching

Background Information: FSL Waiver

The FSL Waiver was developed as part of Florida's multi-year strategy to reduce the waiting list for home and community services. Florida's efforts along these lines began in 1999 when the state settled the Prado-Steiman litigation and committed to serve all eligible individuals who were on the waiting list as of June 1999. As a result, the number of individuals receiving HCBS grew from 13,800 in 1999 to over 24,000 in 2004. Florida Governor Jeb Bush was instrumental in securing additional developmental disabilities funding during this period and continues to support year-over funding increases for developmental services. Despite tripling funding for developmental services and substantial expansion of the HCBS waiver, a "post-Prado" waiting list emerged that, at one point, reached about 15,000 individuals. The FSL Waiver was added in large part as a tool to support individuals and families who are on the comprehensive waiver waiting list by offering them a more limited package of in-home and other supports.

The FSL Waiver operates under a fixed dollar limit and offers basic services designed to support individuals who live with their families or who can live independently in the community with modest assistance. In July 2005, the program was expanded to include children as well as adults and the coverage of behavioral services was added. Florida triages waiver enrollment to direct individuals/families who do not require 24/7 services to the FSL Waiver.

The FSL Waiver has two relatively unique features. FSL Waiver participants receive support coordination services through independent support coordination agencies. After the first six months of enrollment, an individual/family may elect to reduce the intensity of support coordination in order to maximize the dollars available to purchase other services and supports. Second, the waiver includes the coverage of "supported living coaching," a service designed to provide adults with a personal agent who assists them in meeting the challenges of everyday life. Supported living coaching has been covered in Florida's comprehensive waiver for more than a decade and has been integral in supporting individuals in regular community living arrangements.

Major Issue(s):

Florida continues to aggressively expand services and supports for people with developmental disabilities. In July 2005, the waiting list stood at 14,629 people. New FY 2005-2006 funding is enabling services to be further expanded to reach at least another 7,000 individuals and additional funding is likely to be secured to further expand services in FY 2006-2007 for another 3,000 individuals.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” 21,126 24,910 25,921 24,301 24,079 23,353 26,422
“Supports” 0 0 0 0 0 2,650 6,181
Total Participants 21,126 24,910 25,921 24,301 24,079 26,003 38,747
“Supports” Waiver % of Total Participants 0% 0% 0% 0% 0% 10.2% 19.0%

The year-over-year growth in waiver participants between 2005 and 2006 reflects a substantial increase in funding approved by the Florida legislature.

FLORIDA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M) $251.8 $419.1 $487.5 $554.4 %598.5 $615.4 $695.0
   Per Participant $11,921 $16,183 $19,171 $22,677 $26,377 $28,433 $26,303
“Supports” ($M) 0 0 0 0 0 $5.6 $88.3
   Per Participant 0 0 0 0 0 $2,105 $14,282
Total Expenditures ($M) $251.8 $403.1 $496.9 $551.1 $635.1 $669.6 $783.3
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0% 0% 0.8% 11.3%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 0% 0% 7.4% 54.3%
Blended Cost Per Participant $11,921 $16,183 $19,171 $22,677 $26,377 $25,751 $24,025
FLORIDA WAIVER EXPENDITURES ($M)

Florida experienced a 165.9% rise in overall waiver funding from 2000 to 2005. In 2006, the "supports" waiver and to a lesser degree the "comprehensive" waiver grew another 17.0% while the people enrolled grew 31.2% in 2006. (2006 estimated from waiver documents, organizational materials and newspaper accounts.)

FLORIDA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Agency for Persons with Disabilities Web page provides an overview of Florida’s waivers for DDhttp://apd.myflorida.com/2005-sc-handout-programs.htm#family-waiver
Consumer Guide for Family and Supported Living Waiver 2004 Web site with Consumer Guide for FSL Waiver a seven page documenthttp://apd.myflorida.com/clients/docs/fsl_waiver.pdf

Document Inventory

  • 2003 HCBS Waiver Document
  • 2004 FSL Waiver Document
  • November 2005 SPD presentation to Florida Legislature
  • FSL Waiver Services Directory
  • Florida Medicaid 2005 Developmental Disabilities Waiver Services Coverage and Limitations Handbook
  • Consumer Guide for the Family and Supported Living Waiver
  • Individual Cost Guidelines for Children and Adults
STATE CONTACT INFORMATION
Name Linda Mabile Senior Management Analyst
Agency Agency for Persons with Disabilities Community Development
Address 4030 Esplanade Way, Suite 380 Tallahassee, FL 32399-0950
Telephone   850-414-9132
E-mail Linda_Mabile@dcf.state.fl.us

INDIANA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Support Services Waiver Supports 387 3,548 04/2002 On-going
Developmental Disabilities Comprehensive 378 5,400 09/1992 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children and adults with developmental disabilities
Funding Limit $13,500/year.
Funding Parameters Case Management, Person-Centered Planning Facilitation and Transportation are funded outside the funding cap. There is an annual limit of $2,000 on respite care.
Exceptions to Funding Limit Limited.
Transition to Comprehensive Waiver As openings/funding available.
Self-Direction No.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Indiana Waiver Services
Case Management/Service Coordination Y Case Management and Initial and Outgoing Person-Centered Planning
Supports of Participant Direction (Support Broker) N  
In-Home Services N  
Respite Y Respite Care
Day Supports Y Community Habilitation Participation, Day Habilitiation Service, Pre-vocational Service, Adult Day Services
Health Related Y Health Care Coordination, Enhanced Dental Service
Supported Employment Y Supported Employment Follow-along
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y PERS, Specialized Medical Equipment/Supplies
Vehicle Repair/Modification Y Vehicle Modifications
Clinical Services Y Occupational Therapy, Physical Therapy, Speech/Language Therapy, Recreational Therapy, Music Therapy, Nutritional Therapy, Psychological Therapy, Behavior Management
Environmental Accessibility Adaptations N  
Financial Management Services N  
Family and Caregiver Training Y Family and Caregiver Training
Other Y Interpretive Service, Crisis Intervention

Background Information: Supported Living Services Waiver

The Indiana Support Services Waiver was launched in 2002. Its purpose is to provide Medicaid-funded services and supports for children and adults with developmental disabilities who reside in the family home or who do not require 24/7 services. The creation of this waiver was one outgrowth of the state's 317 Plan that aimed to expand and reform community services for people with developmental disabilities. The 317 Plan was developed by a task force made up of consumers, advocates and state officials and received gubernatorial support. The 317 Plan included several steps to refinance day and other services in order to leverage additional federal Medicaid dollars to reduce the state's spiraling waiting list for community services. System reforms included adopting person-centered planning methods and placing greater stress on supporting individuals in integrated community settings and reducing the state's over reliance on congregate care facilities.

The Support Services Waiver was designed to principally underwrite the costs of day time services, although the waiver offers some additional services supports. The Supports Services Waiver differs from a more typical supports waiver principally by not offering in-home and family-support services. Indiana does not offer personal care services through its Medicaid state plan. Since 2002, the Support Services Waiver has grown to serve about 3,500 individuals. Per capita costs are running at approximately one-half the funding limit (taking into account services funded outside the limit). Going forward, the program may be expanded again to refinance other state-funded services and supports.

The longer-standing comprehensive Developmental Disabilities (DD) Waiver principally (but not exclusively) underwrites services and supports for individuals who require community residential services. In addition to residential services, the DD Waiver offers a more robust array of services than the supports waiver. Between 2001 and 2004, the number of individuals participating in the DD Waiver almost doubled, in part to capture additional federal Medicaid funds but also to underwrite the community placement of individuals from the state's developmental centers. Indiana closed Muscatatuck Developmental Center and has targeted closure of Fort Wayne Developmental Center (its last state institution) in June 2007. Indiana also has a relatively large private ICF/MR sector that currently serves about 3,800 individuals, most of whom reside in smaller group homes.

Major Issue(s):

Despite the implementation of the Support Services Waiver and the rapid expansion of DD Waiver, Indiana continues to experience a major upsurge in demand for community developmental disabilities services and supports. In April 2006, about 14,800 unduplicated persons were waiting for waiver services. In order to meet this demand, the state would have to more than double the number of individuals who receive waiver services. There is especially high demand for comprehensive waiver services, including by individuals who participate in the Support Services Waiver but are seeking residential and other supports. This high unmet demand in the face of the rapid increase in the number of waiver participants over the past several years is explained in part by the fact that waiver growth has been the result of substantial refinancing of services for individuals who were already receiving services in order to overcome shortfalls in state funding rather than expanding the number of people receiving services.

Indiana also has experienced rapid escalation in DD Waiver per-participant costs. As a consequence, the state is implementing new cost controls. If these cost containment measures are successful, funds may be freed up to address the waiting list.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002* 2003* 2004* 2005* 2006**
“Comprehensive” 2,081 2,646 3,567 4,665 5,303 5,400 5,304
“Supports” 0 0 449 2,997 3,658 3,548 4,591
Total Participants 2,081 2,646 4,016 7,662 8,961 8,948 8,818
“Supports” Waiver % of Total Participants 0% 0% 11.2% 39.1% 40.8% 39.7% 39.9%
* Based on Indiana Family and Social Services Administration periodic reports. ** Estimate based on YTD experience.

Between 2000 and 2006, Indiana waiver enrollment has more than quadrupled. The addition of the Supports Services Waiver accounts for about 64% of the growth between 2002 and 2006.

INDIANA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002* 2003* 2004* 2005* 2006**
“Comprehensive” ($M) $73.0 $107.4 $198.6 $246.4 $329.4 $338.9 $347.8
   Per Participant $35,101 $40,601 $55,685 $52,825 $62,112 $62,763 $65,569
“Supports” ($M) 0 0 $0.4 $10.9 $26.3 $27.9 $29.9
   Per Participant 0 0 $900 $3,623 $7,203 $7,866 $8,520
Total Expenditures ($M) $73.0 $107.4 $199.0 $257.3 $355.7 $366.8 $377.7
“Supports” Waiver % of Total Expenditures 0% 0% 0.2% 4.2% 7.4% 7.6% 7.9%
Cost Per Participant: % Supports to Comprehensive 0% 0% 1.6% 6.9% 11.6% 12.5% 13.0%
Blended Cost Per Participant $35,079 $40,590 $49,552 $33,581 $39,694 $40,992 $42,833
* Based on Indiana Family and Social Services Administration periodic reports. ** Estimate based on YTD experience.
INDIANA WAIVER EXPENDITURES ($M)

Between 2000 and 2006, the total Indiana waiver expenditures nearly quintupled, in part due to participant growth and in part due to rapidly escalating DD Waiver per capita costs. A relatively small share of the increase in spending is attributable to the implementation of the Supports Services Waiver. In 2006, per-participant supports waiver costs were running at 13% of comprehensive waiver costs.

INDIANA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Indiana Family and Social Services Administration, People With Disabilities, Division of Disability, Aging and Rehabilitative Services Web page provides links to People With Disabilities information, including developmental disabilities serviceshttp://state.in.us/fssa/servicedisabl/
Indiana’s Community-Based Medicaid Waivers Web page provides side-by-side comparisons of Indiana’s HCBS waivershttp://in.gov/fssa/statistics/pdf/fssamedwaiverhart 20050930.pdf
Arc of Indiana Useful guide to Medicaid and Medicaid waivers in Indianahttp://arcind.org/guide_to_medicaid_and_medicaid_w.htm Background information on the 317 Planhttp://arcind.org/campaign.htm

Document Inventory

  • 2005 Support Service Waiver Renewal Application
  • Developmental Disabilities Provider and Case Management Standards
STATE CONTACT INFORMATION
Name Lynn Jump
Agency Indiana Family and Social Services Administration People With Disabilities Division of Disability, Aging and Rehabilitation Services Bureau of Developmental Disabilities Services
Address P.O. Box 7083 Indianapolis, IN 46207-7083
Telephone   317-234-2764
E-mail Lynn.Jump@fssa.in.gov

LOUISIANA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
New Opportunities Waiver (NOW) Comprehensive 401 4,620 07/1992 On-going
Children’s Choice Supports 381 785 02/2001 On-going
Supports Waiver Supports N/A 0 07/2006 Initial
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children’s Choice: Children with developmental disabilities, birth through age 18 who live with their families. Supports Waiver: Adults with developmental disabilities, age 18 and older.
Funding Limit Children’s Choice: $15,000/year. Supports Waiver: No set limit.
Funding Parameters Both Waivers: Amount authorized based on individual plan. Supports Waiver has limits on specific services.
Exceptions to Funding Limit Children’s Choice: Exceptions to funding limit may be authorized in crisis situations on a time limited basis. Supports Waiver: Exceptions to service funding limits may be authorized in order to assure participant health and welfare.
Transition to Comprehensive Waiver Children’s Choice: Children who “age out” (reach their 19th birthday) will transfer with their slot to an appropriate MR/DD waiver as long as they remain eligible for waiver services. Supports Waiver: Transfer to NOW as slots are available.
Self-Direction Children’s Choice: Limited. Families have flexibility in selection of services within the funding limitation. Agency with choice option available. Supports Waiver: No formal mechanisms.
CHILDREN’S CHOICE WAIVER SERVICES
Support/Service Category Y/N Louisiana Waiver Services
Case Management/Service Coordination Y Case Management
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Family Support
Respite Y Center-Based Respite
Day Supports N  
Health Related N  
Supported Employment N  
Transportation N  
Person Directed Goods and Services N  
Equipment/Supplies Y Diapers
Vehicle Repair/Modification Y Environmental Accessibility Adaptations
Clinical Services N  
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N  
Family and Caregiver Training Y Family Training
Other N  
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Louisiana Waiver Services
Case Management/Service Coordination N [Case management through TCM]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Personal Care Attendant
Respite Y Respite
Day Supports Y Group Employment, Day Habilitation and Training, Facility Based Work
Health Related Y Individual Goods and Services (dental and vision)
Supported Employment Y Supported Employment
Transportation N  
Person Directed Goods and Services N  
Equipment/Supplies Y PERS
Vehicle Repair/Modification N  
Clinical Services N  
Environmental Accessibility Adaptations N  
Financial Management Services N  
Family and Caregiver Training N  
Other N  

Background Information: Supports Waiver and Children’s Choice Waiver

Children's Choice

The Children's Choice Waiver was developed in lieu of Louisiana's implementing the Katie Beckett Medicaid eligibility option due to cost concerns. The Children's Choice waiver is designed to provide a limited array of services and supports to children who meet ICF/MR level of care and live with their families and afford access to Medicaid State Plan benefits for a capped number of children. As initially implemented, the program operated under a $7,400/child annual funding limit. The limit was subsequently increased to $15,000 as a result of the efforts of advocacy groups. On average, Children's Choice waiver participants receive about $12,500/year in Medicaid state plan services in addition to waiver services. As a consequence, the average amount expended on a Children's Choice participant in 2005 was $21,710. The provision of family support services accounted for about 76% of waiver expenditures in 2005

NOW also serves children. However, there are 7-8 year wait times for entrance to NOW. A family may elect to accept Children's Choice enrollment or continue to wait for a NOW opening. When a family that has been wait-listed for NOW accepts enrollment in the Children's Choice waiver, the child is placed on inactive status on the NOW waiting list. While demand for NOW enrollment remains high, families have expressed satisfaction with the services and supports offered through Children's Choice.

Supports Waiver

The Supports Waiver was originally intended to enable Louisiana to leverage additional federal Medicaid dollars and apply those dollars to reducing the state's 13,000 person waiting list. In particular, the waiver design provided for refinancing state-funded adult vocational services and capturing the additional federal funds for application toward waiting list reduction. The Supports Waiver also was intended to create a viable alternative to NOW, which has experienced rapidly escalating costs since it was restructured in 2003.

In the aftermath of Hurricane Katrina, the state was forced to reduce the scope of the Supports Waiver to solely refinancing services for the current 1,800 recipients of state-funded vocational services and cannot deploy the additional federal dollars toward waiting list reduction. Despite this set back, shifting individuals to the Supports Waiver is expected to have positive outcomes in the form of giving individuals greater choices about their type of day support activity, including expanded community employment options. In addition, many of these individuals will now be able to access Medicaid state plan services. CMS is expected to approve the Supports Waiver for implementation on July 1, 2006.

Major Issue(s):

Louisiana continues to struggle with an especially large 13,000 person waiting list. In addition, Hurricane Katrina has negatively affected the state budget and, consequently, the capacity to expand services.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006* 2007*
“Comprehensive” NOW 3,629 4,008 4,007 4,222 4,437 4,620 4,742 4,800
Children’s Choice 0 0 225 587 762 785 800 800
“Supports” 0 0 0 0 0 0 0 2,088
Total Participants 3,629 4,008 4,232 4,809 5,199 5,405 5,542 7,688
“Supports” Waiver % of Total Participants 0% 0% 5.3% 12.2% 14.7% 14.5% 14.4% 37.6%
* Estimates.

As can be seen, the number of Louisiana waiver participants has more than doubled since 2000. Nearly all of this growth is attributable to the implementation of the Children's Choice waiver in 2002 and the addition of the Supports Waiver in 2007.

LOUISIANA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006* 2007*
“Comprehensive” ($M) (NOW) $95.4 $121.1 $142.9 $153.6 $204.8 $229.9 $235.9 $238.8
   Per Participant $26,281 $30,226 $35,674 $36,389 $46,170 $49,756 $49,756 $49,756
Children’s Choice 0 0 $0.9 $3.8 $5.2 $7.3 $7.4 $7.4
   Per Participant 0 0 $4,000 $6,500 $6,841 $9,255 $9,255 $9,225
“Supports” ($M) 0 0 0 0 0 0 0 $36.0
   Per Participant 0 0 0 0 0 0 0 $17,243
Total Expenditures ($M) $95.4 $121.1 $143.8 $157.4 $210.1 $237.2 $243.3 $282.2
“Supports” Waiver % of Total Expenditures 0% 0% 0.6% 2.4% 2.5% 3.1% 3.0% 15.4%
Cost Per Participant: % Supports to Comprehensive 0% 0% 11.2% 17.9% 14.8% 18.6% 18.6% 30.2%
Blended Cost Per Participant $26,281 $30,226 $33,979 $32,730 $40,392 $43,885 $43,901 $36,707
* Estimate. 2007 Supports Waiver expenditures based on waiver application.
LOUISIANA WAIVER EXPENDITURES ($M)

Between 2000 and 2007, total Louisiana waiver expenditures will have nearly tripled. Post-2004, the NOW comprehensive waiver experienced a substantial increase in per-participant costs. The 2007 addition of the Supports Waiver will have a material effect in reducing overall per-person costs.

LOUISIANA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Office for Citizens with Developmental Disabilities Web page provides People With Disability informationhttp://dhh.state.la.us/offices/?ID=77
NOW Comprehensive Waiver Web page on NOW comprehensive waiverhttp://dhh.louisiana.gov/offices/page.asp?ID=92&From Search=1&Detail=4042
Children’s Choice Waiver Web page for Children’s Choice Waiverhttp://dhh.louisiana.gov/offices/page.asp?ID=92&Detail=4122

Document Inventory

  • Fact Sheet on Louisiana's HCBS Waiver--NOW
  • Louisiana Children's Choice Waiver Fact Sheet, 2006 Application for the Support Waiver
  • CMS 372 Reports
STATE CONTACT INFORMATION
Name Bonnie Callahan Executive Director
Agency Office for Citizens with Developmental Disabilities Louisiana Department of Health and Hospitals
Address 1201 Capital Access Road Baton Rouge, LA 70821
Telephone   225-219-0200
E-mail bcallaha@dhh.la.gov

MISSOURI

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
MR/DD Community Support Waiver (CSW) Supports 0404 808 07/2003 On-going
MR/DD Comprehensive Waiver Comprehensive 0178 7,553 07/1988 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children and adults with developmental disabilities. The supports waiver does not include residential services while the comprehensive waiver does.
Funding Limit $20,000/year.
Funding Parameters Specific services are subject to cost limits.
Exceptions to Funding Limit None.
Transition to Comprehensive Waiver Individuals may transition to the MR/DD Comprehensive Waiver based on need and slot availability.
Self-Direction Limited. Participants/families may elect to serve as the employer of record for personal assistance works. The same option is available in the comprehensive waiver. A fiscal intermediary is used to process payroll for participant-employed workers. Pending waiver renewal application provides for the addition of limited budget authority.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Missouri Waiver Services
Case Management/Service Coordination N [TCM. State employees serve as service coordinators.]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Personal Assistant Individual, Personal Assistant Agency, Personal Assistant Medical/Behavioral, Personal Assistant Group
Respite Y In-Home Respite Day, In-Home Respite Hour, In-Home Respite Group, Out-of-Home Respite
Day Supports Y On-Site Day Habilitation Group, On-Site Day Habilitation Individual, Off-Site Day Habilitation Group, Off-Site Day Habilitation Individual, Community Specialist
Health Related N  
Supported Employment Y Support Employment--Individual and Group
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Specialized Medical Equipment & Supplies
Vehicle Repair/Modification Y Environmental Accessibility Adaptations
Clinical Services Y Behavioral Therapy, Physical Therapy, Occupational Therapy, Speech Therapy, Crisis Intervention Prof, Crisis Intervention Tech, Communications Skills Instructor, Counseling
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N [Funded administratively as noted in service category table]
Family and Caregiver Training N  
Other N  

Background Information: Community Support Waiver

Missouri operates three 1915(c) HCBS Medicaid Waiver programs for individuals with MR/DD: the Comprehensive Waiver; Missouri Children with Developmental Disabilities Waiver (MOCDD or Sarah Jian Lopez Waiver); and CSW. The MOCDD Waiver is a model waiver enables children with developmental disabilities who are not otherwise eligible for Medicaid to access Medicaid State plan services.

The Comprehensive Waiver supports children and adults with developmental disabilities in the family home and community living arrangements (principally Individualized Supported Living settings for up to three individuals). There is limited utilization of ICF/MR services in Missouri apart from the state-operated Habilitation Centers (Missouri's large public institutions). In Missouri, counties may establish "SB 40 Boards," funded by local mill levies. Some SB 40 Boards provide matching funds for waiver services.

The CSW began in July 2003 and is being renewed in 2006. The renewal provides for the expansion of CSW to 1,089 people by 2008. CSW was launched to serve as a lower-cost alternative to the comprehensive waiver and as a vehicle to reduce the waiting list. CSW also built on Missouri's experience in operating state-funded family-centered services. The CSW services match comprehensive waiver services except that CSW does not offer residential services. In addition, CSW is subject to a $20,000/year cost limit. The MR/DD Comprehensive Waiver is also being renewed this year.

Missouri was one of the first states to install the “employer authority” in its HCBS waivers. Individuals and families are supported in serving as the common law employers of personal assistance workers. The state employs the Organized Health Care Delivery System model to facilitate consumer direction of workers, including engaging a fiscal intermediary to perform payroll functions. Missouri is piloting a more robust approach to participant direction through an Independence Plus Pilot Program facilitated by a CMS Real Choice Systems Change grant.

Major Issues/Current Situation:

In December 2005, there were 441 persons waiting for Comprehensive Waiver residential services and another 3,246 persons waiting for CSW. For FY 2005-2006, the Missouri Legislature provided funding to reduce the waiting list by 370 persons, split evenly between both waivers. Progress has been made in reducing the residential services waiting list but the CSW waiting list grew by 16% (450 individuals) between December 2004 and December 2005.

A major current focus in Missouri is reducing the number of individuals served at the state's Habilitation Centers by approximately 25%.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” 7,827 8,122 7,999 7,568 7,444 7,553 7,782
“Supports” 0 0 0 0 478 808 897
Total Participants 7,827 8,122 7,999 7,568 7,922 8,361 8,679
“Supports” Waiver % of Total Participants 0% 0% 0% 0% 6.0% 9.7% 10.3%

During the period 2000-2006, total waiver enrollment in Missouri increased by 10.9%. In recent years, CSW has been the principal source of increased waiver enrollment.

MISSOURI WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M) $199.9 $217.4 $238.1 $268.5 $272.3 $275.4 $289.6
   Per Participant $25,544 $26,762 $29,770 $35,475 $36,585 $36,466 $37,208
“Supports” ($M) $0 $0 $0 $0 $1.6 $4.3 $3.8
   Per Participant $0 $0 $0 $0 $3,299 $5,360 $4,222
Total Expenditures ($M) $199.9 $217.4 $238.1 $268.5 $273.9 $279.8 $293.3
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0% 0.6% 1.5% 1.3%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 0% 31.5% 50.8% 33.7%
Blended Cost Per Participant $225,540 $26,767 $29,766 $35,478 $34,575 $33,453 $33,806
MISSOURI WAIVER EXPENDITURES ($M)

Between 2000-2006, Missouri's total HCBS waiver expenditures grew by 48.7%. Expenditure growth slowed appreciably in 2004-2004 due to state budget shortfalls.

MISSOURI EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Missouri Department of Health, Division of Mental Retardation and Developmental Disabilities Web page describes waiver services in Missourihttp://dmh.mo.gov/mrdd/progs/waiver/factsheet.htm
Fact Sheet About Missouri’s Three Waivers Web page provides information about Missouri’s three HCBS waivershttp://www.dmh.mo.gov/mrdd/progs/waiver/factsheet.htm
Independence Plus Pilot Web site that contains information about Missouri’s Independence Plus Pilothttp://www.ihd.umkc.edu/independenceplus/Index.htm

Document Inventory

  • 2003 CSW application
  • Comp and Support Waiver HCFA 372s for 2003, 2004 & 2005
  • 2005 Amendment to Support Waiver
  • DMR/DD updated expenditure and waiver participant count 2000-2008
STATE CONTACT INFORMATION
Name Kay Green
Agency Division of Mental Retardation & Developmental Disabilities Department of Mental Health
Address P.O. Box 687 Jefferson City, MO 65101
Telephone   573-751-8213
E-mail kay.green@dmh.mo.gov

MONTANA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Community Supports Waiver Supports 0371 262 09/2001 On-going
HCBS Waiver for I&DD Comprehensive 0208 1,882 12/1981 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Individuals 18 years or older who meet the Montana state definition of developmental disability according to MCA 53-20-202(3).
Funding Limit $7,800/year.
Funding Parameters All participants are eligible for base funding of $7,800/year.
Exceptions to Funding Limit Cap can be exceeded under three conditions: (1) Short-term crisis (less than one year) (usually means hiring additional staffing); (2) Private duty nursing needs; and (3) Exceptional transportation needs (in practice, Montana has never exceeded the cost cap for exceptional transportation needs).
Transition to Comprehensive Waiver Individuals may transition to comprehensive waiver based on need and slot availability.
Self-Direction Limited. Waiver participants have state or contracted case managers who employ a person-centered planning process to help participate and/or family identify support needs. Participants have flexibility in choosing providers and negotiating service costs.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Montana Waiver Services
Case Management/Service Coordination N [Case Management is furnished through target case management coverage.]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Homemaker, Personal Care, Adult Companion, Residential Habilitation
Respite Y Respite
Day Supports Y Prevocational and Day Habilitation
Health Related Y Private Duty Nursing and Health/Safety/Maintenance
Supported Employment Y Supported Employment
Transportation Y Transportation (rides) and Transportation (client driving related expenses)
Person Directed Goods and Services N  
Equipment/Supplies Y Specialized Medical Equipment and Supplies
Vehicle Repair/Modification N  
Clinical Services N  
Environmental Accessibility Adaptations Y Environmental Modifications
Financial Management Services N  
Family and Caregiver Training N  
Other Y Education (course work) and Social, Leisure, Recreation

Background Information: Community Supports Waiver

The CSW began in 1999 as a distinct waiver service “package” that was nested within Montana's comprehensive waiver. The package was added as a response to the growing waiting list for services. Many wait-listed individuals lived with their natural families or wanted to live on their own but needed help. Financial resources were limited, so the waiver community supports package was designed to meet the “essential needs of persons in the effort to achieve and maintain successful placements in a variety of settings” and rely heavily on natural supports. The dollar-capped package emphasized maximum flexibility and efficiency in meeting participant needs. Services were designed to be portable--funds would follow an individual if the person selected a different service provider or moved to a new community. Case managers were asked to support individuals and families in identifying needed services and supports.

The addition of the community supports “package” to the comprehensive waiver was approved in October 1999 based on an understanding between the state and HCFA (CMS). After the issuance of Olmstead Letter #4, Montana was informed that, in order to continue to offer the package, the state would have to shift community supports to a new waiver. Montana then submitted and CMS approved the CSW in 2001. The original 1999 funding limit of $7,800 per participant was carried forward to the new waiver and remains in effect.

Montana's Comprehensive Waiver includes a children's services component that blends in-home and out-of-home services for children with developmental disabilities. It also covers adult residential and daytime services and supported living services for adults.

Major Issue(s):

In 2005, there were 1,372 Montanans waiting for services with an average wait time of 36 months. There were 292 people waiting for the CSW and 1,080 waiting for the comprehensive waiver.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005
“Comprehensive” 1,206 1,348 1,490 1,533 1,758 1,882
“Supports” 0 0 251 244 267 262
Total Participants 1,206 1,343 1,741 1,777 2,025 2,144
“Supports” Waiver % of Total Participants 0% 0% 14.4% 13.7% 13.2% 12.2%

In 2000 and 2001, community support services were provided through the Comprehensive Waiver. Between 2000 and 2005, the number of waiver participants increased by 77.8%. Since 2002 there has been little change in the number of supports waiver participants.

MONTANA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000* 2001* 2002 2003 2004 2005
“Comprehensive” ($M) $33.6 $36.9 $41.9 $58.5 $53.9 $56.3
   Per Participant $27,829 $27,466 $28,105 $38,138 $30,632 $29,893
“Supports” ($M) $0 $0 $0.1 $1.4 $1.3 $1.6
   Per Participant $0 $0 $515 $5,676 $4,712 $6,252
Total Expenditures ($M) $33.6 $36.9 $42.0 $59.9 $55.1 $57.9
“Supports” Waiver % of Total Expenditures 0% 0% 0.3% 2.3% 2.3% 2.8%
Cost Per Participant: % Supports to Comprehensive 0% 0% 1.8% 14.9% 15.4% 20.9%
Blended Cost Per Participant $27,861 $27,374 $24,124 $33,708 $27,259 $27,006
* Community Support included in Comprehensive Waiver Expenditures.
MONTANA WAIVER EXPENDITURES ($M)

Between 2000 and 2005, Montana waiver expenditures increased by 72.3%. Only a small share of waiver funding is earmarked for the CSW. In 2005, expenditures per support waiver participant were 20.9% of comprehensive waiver expenditures. Comprehensive Waiver per-participant costs are significantly below levels observed in other comprehensive waivers, in part due to the low-cost child component.

MONTANA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Montana Department of Public Health and Human Services, Disability Services Division, Developmental Disability Program Who, What, How, Where? A list of web information related to Montana Developmental Disability Programhttp://www.dphhs.mt.gov/dsd/ddp/index.shtml
Home and Community-Based Waiver for Individuals with Developmental Disabilities “The Big Waiver” MT 0208.90 Waiverhttp://www.dphhs.mt.gov/dsd/mt020890waiver/index.shtml

Document Inventory

  • HCFA 372 Reports
  • 2005 Comp Waiver Renewal, 2003 Support Waiver Renewal
  • 2001 Support Waiver Application
STATE CONTACT INFORMATION
Name Perry Jones
Agency Montana Department of Public Health and Human Services Disability Services Division Developmental Disability Program
Address P.O. Box 4210 Helena, MT 59604-4210
Telephone   406-444-2590
E-mail pjones@mt.gov

NEBRASKA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Home and Community-Based Day Services Waiver for Adults with Developmental Disabilities Supports 0394 664 03/2003* On-going
Community Supports Program (CSP) HCBS Waiver for Adults with Developmental Disabilities Supports N/A 0 07/2006 Submitted April 2006
HCBS Residential Waiver for Adults with Developmental Disabilities Comprehensive 0395 141 03/2003* On-going
Comprehensive HCBS Waiver for Adults with Developmental Disabilities Comprehensive 0396 2,137 03/2003* On-going
* Replaced single comprehensive waiver for adults that began in 1987.
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Home and Community-Based Day Services Waiver: Targets adults with developmental disabilities age 21 and older. CSP Waiver: Also targets adults.
Funding Limit Home and Community-Based Day Services Waiver: No specific limit. CSP Waiver: $20,000/year.
Funding Parameters Home and Community-Based Day Services Waiver: Funding level based on objective assessment. CSP Waiver: The annual cap per person is $20,000 or his/her objectively assessed funding amount, whichever is less, except for individuals who need assistive technology, home modifications, or vehicle modifications. An additional $5,000 is available annually for the combined services.
Exceptions to Funding Limit No.
Transition to Comprehensive Waiver Based on slot availability.
Self-Direction Home and Community-Based Day Services Waiver: No. CSP Waiver: Employer option but not budget authority.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Nebraska Waiver Services
Case Management/Service Coordination N [TCM coverage]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Community Living
Respite Y Respite Care, Respite In Home
Day Supports Y Day Supports
Health Related N  
Supported Employment N  
Transportation N  
Person Directed Goods and Services N  
Equipment/Supplies Y Assistive Technology, Emergency Response System
Vehicle Repair/Modification Y Vehicles Modification
Clinical Services N  
Environmental Accessibility Adaptations Y Home Modification
Financial Management Services N  
Family and Caregiver Training N  
Other N  
[Day Service Waiver for Adult DD Only]
Respite Y Respite
Day Supports Y Day Habilitation
Clinical Services Y Team Behavioral Consultation

Background Information: Supports Waiver

Nebraska has three waivers for adults with developmental disabilities. There is also a relatively small HCBS waiver for children with developmental disabilities. In 2003, Nebraska replaced its single comprehensive waiver with three waivers. Two of the replacement waivers include the coverage of 24/7 residential services. The third waiver does not include residential services. The third waiver was designed to accommodate Nebraska's long-standing policy of offering at least daytime services to youth with developmental disabilities after they leave the special education system. Previously, these individuals were enrolled in the single comprehensive waiver but not afforded access to residential services. The redesign of the previous comprehensive waiver brought Nebraska into compliance with the provisions of CMS Olmstead Letter #4.

In April 2006, Nebraska developed and submitted a new CSP HCBS Waiver to CMS with a proposed July 1, 2006 effective date. The new waiver would serve 100 people in 2007 and scale up to 250 people by 2009. The CSP Waiver is designed to offer alternatives to the traditional model of services currently available through the Nebraska Health and Human Services (HHS) Developmental Disabilities System. The traditional model provides for services consisting of day and residential habilitation and respite, provided only by agencies certified as specialized providers of developmental disabilities services. The CSP Waiver would provide for a broader array of services and permit purchasing services from other community (independent or agency) providers. The aim is to give individuals and families more control over the type of services that they receive and the selection of the providers of those services, as well as allowing individuals to purchase services other than habilitative training. The CSP Waiver incorporates self-direction features.

The underlying philosophy of the CSP Waiver is to build upon the individual and family strengths and to strengthen and support informal and formal services already in place. The CSP utilizes a self-directed philosophy, designed to provide choice when determining the services and supports that are needed to maximize the independence of the person with a developmental disability. The individual has the right and responsibility to participate to the greatest extent possible in the development and implementation of his or her plan. The CSP is a funding stream that may be utilized either alone or in conjunction with other non-developmental disability funded services and supports, as appropriate for the individual. Individual funding is prior authorized by state staff at the local service area level and is based on the application of an objective assessment process.

Major Issue(s):

Like other states, Nebraska reported a longstanding state-wide waiting list. Currently there are 1,178 people waiting for services. There is a waiting list lawsuit that continues to be litigated. The lawsuit challenged both Nebraska’s practice of wait-listing individuals and its methods of authorizing community funding. In addition, the state is striving to strengthen HCBS waiver quality management in response to CMS review of the operation of its waivers.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” 2,372 2,504 2,490 2,558 2,550 2,458 2,386
“Supports” 0 0 0 192 595 664 937
Total Participants 2,372 2,504 2,490 2,750 3,145 3,122 3,323
“Supports” Waiver % of Total Participants 0% 0% 0% 7.0% 18.9% 21.3% 28.2%

Between 2000 and 2006, total Nebraska waiver enrollment will have increased by increased by 40.1%. In general, waiver expansion since 2003 has been via the day services waiver. Enrollment in the comprehensive waivers has declined slightly.

NEBRASKA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M)* $74.6 $83.9 $90.8 $98.9 $105.1 $110.8 $120.6
   Per Participant $31,449 $33,446 $36,483 $38,668 $41,229 $45,082 $50,526
“Supports” ($M)** $0 $0 $0 $0.4 $5.9 $7.8 $8.6
   Per Participant $0 $0 $0 $2,069 $9,865 $11,745 $9,158
Total Expenditures ($M) $74.6 $83.9 $90.8 $99.3 $111.0 $118.6 $129.1
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0.4% 5.3% 6.6% 6.7%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 5.4% 23.9% 26.1% 18.1%
Blended Cost Per Participant $31,450 $33,427 $36,466 $36,109 $35,294 $37,988 $38,881
* The HCBS Comprehensive and Residential waivers. ** The HCBS Day Services waiver.
NEBRASKA WAIVER EXPENDITURES ($M)

Total waiver expenditures will have increased by 73.2% between 2000 and 2006. While comprehensive waiver per-participant costs have increased significantly year-over-year, the blended per-participant cost has remained relatively stable since waiver expansion has been concentrated on the day services waiver.

NEBRASKA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Nebraska Health and Human Service Developmental Disabilities System Main web site for Developmental Disabilitieshttp://hhs.state.ne.us/dip/ded/dedindex.htm

Document Inventory

  • Approved waiver applications for residential and day services waivers
  • Nebraska HHS Manual for HCBS and TCM and the child model waiver
  • 2006 CSP Waiver Application
STATE CONTACT INFORMATION
Name Pam Hovis Disability Services Coordinator
Agency Nebraska Health and Human Services Developmental Disabilities System Aging and Disabilities Services
Address P.O. Box 98925 Lincoln, NE 68509-8925
Telephone   402-479-5247
E-mail pam.hovis@hhss.ne.gov

OHIO

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Level One Waiver Supports 0380 3,344 03/2003 Initial
Individual Options (IO) Waiver Residential Facility Waiver (RFW) Comprehensive 0231 0291 11,634 02/1996 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children and adults with MR/DD who have natural or informal supports in place. Individuals with aging caregivers are identified as a priority population.
Funding Limit No fixed limit.
Funding Parameters While the waiver does not have a fixed limit, groups of services are subject to dollar limits. In particular, homemaker/personal care, respite and transportation are subject a $5,000/annual benefit limit.
Exceptions to Funding Limit Supplemental funding up to $8,000 over a three year period is available to respond to emergencies. Such funding may take the form of additional personal care services.
Transition to Comprehensive Waiver Based on the availability of IO Waiver slots.
Self-Direction No.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Ohio Waiver Services
Case Management/Service Coordination N [TCM services are furnished through County Boards of MR/DD]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Homemaker/Personal Care
Respite Y Respite Care
Day Supports Y Day Habilitation
Health Related Y Nutrition, Home-Delivered Meals
Supported Employment N  
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Specialized Medical Adaptive Assistive Equipment and Supplies; PERS
Vehicle Repair/Modification N  
Clinical Services N  
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N  
Family and Caregiver Training N  
Other Y Emergency Assistance

Background Information: Supports Waiver

Ohio launched the Level One waiver in 2003 in order to provide a basic package of community services and supports to children and adults with developmental disabilities who live with their families or otherwise have other supports available to them. The waiver also was designed to leverage county property tax mill levy dollars to obtain additional federal Medicaid dollars to expand services in Ohio. The waiver was one element of Ohio's Medicaid Reform strategy that has an overall goal of expanding access to community services. Historically, Ohio has relied more extensively on public/private ICF/MR services than is typical nation-wide and underutilized the HCBS waiver program to meet the needs of people with developmental disabilities. Medicaid reform envisioned a major expansion of waiver services to meet service demand.

The Level One Waiver provides a dollar-limited amount of personal care/ homemaker/respite services in addition to day habilitation services and the coverage of home modifications and other equipment/supplies. The waiver also provides for supplemental emergency assistance funding to address situations when a person's primary caregiver is unable or unavailable to meet the needs of the individual.

The Level One Waiver operates side-by-side with the IO Waiver that offers a full-range of community services to participants, including supported living. Ohio is in the last stages of phasing out its RFW. RFW underwrites the costs of services in community residences. RFW services and participants are being shifted to the IO Waiver. In addition, in 2005 Ohio terminated its Medicaid state plan coverage of day habilitation and certain other therapeutic services to address compliance issues raised by CMS. The coverage of day habilitation was added to both the IO and Level One Waivers.

Ohio also is making major changes in the operation of its waivers in response to CMS concerns about inter-county variability in the authorization and delivery of waiver services. All waiver services are delivered through Ohio's county boards of MR/DD. Counties had employed different policies and procedures in authorizing and paying for waiver services. CMS was concerned that these practices resulted in disparate treatment of waiver participants county-to-county. One element in this effort is instituting a new rate/reimbursement system that is designed to ensure greater uniformity in waiver payments. Ohio has not yet implemented participant-directed features in its waivers.

Major Issue(s):

The extent to which Ohio is satisfying the demand for waiver services is unclear. Waiting lists by waiver are maintained by counties but are not compiled statewide. One report in July 2007 suggests that there are 19,510 people waiting for community services. There is longstanding but still unresolved litigation (Martin v. Taft) concerning access to Medicaid funded services and enabling people served in ICFs/MR to access alternative services in the community. The Martin v. Taft lawsuit was originally filed in federal court in 1989. By September 2006 the comprehensive waiver stretched to 11,715 and the support waiver reached 3,984.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006** 2007 2008
“Comprehensive”* 5,666 6,050 9,188 10,278 11,342 11,705 11,634 9,535 12,578
“Supports” 0 0 0 100 470 1,791 3,344 5,172 5,224
Total Participants 5,666 6,050 9,188 10,378 11,812 13,498 14,978 14,707 17,802
“Supports” Waiver % of Total Participants 0% 0% 0% 1% 4% 13.3% 22.3% 35.2% 29.3%
* Includes the IO Waiver and the RFW. ** Ohio Department of Mental Retardation and Developmental Disabilities projection.

Between 2000 and 2005, total Ohio waiver enrollment increased by 138.2%. By 2008 this rose an additional 76.0% with the successful waiver renewals in January 2007 and careful examination of eligibility and waiver membership. As can be seen expansion of the Supports Services Waiver accounts for most of the enrollment growth from 2004 on.

OHIO WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006* 2007 2008
“Comprehensive” ($M) $188.0 $212.1 $340.0 $4212.9 $466.7 $563.5 $563.5 $315.9 $577.1
   Per Participant $33,189 $35,055 $36,985 $40,173 $41,147 $48,141 $48,435 $33,125 $45,886
“Supports” ($M) $0 $0 $0 $0.07 $1.0 $10.3 $76.0 $81.7 $89.9
   Per Participant $0 $0 $0 $729 $2,127 $5,733 $22,733 $15,798 $17,213
Total Expenditures ($M) $188.0 $212.1 $340.0 $413.0 $467.7 $573.8 $639.5 $397.6 $667.1
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0% 0.2% 1.8% 11.9% 20.6% 13.5%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 1.8% 5.2% 11.9% 46.9% 47.7% 37.5%
Blended Cost Per Participant $33,189 $35,055 $33,985 $34,590 $32,017 $42,516 $42,696 $27,035 $37,468
* Ohio Department of Mental Retardation and Developmental Disabilities projection.
OHIO WAIVER EXPENDITURES ($M)

In Ohio, total waiver expenditures increased by 205.2% between 2000 and 2005. In 2005, Support Services Waiver expenditures accounted for 1.8% of total expenditures even though 13.3% of all waiver participants were served in the Support Services Waiver. Supports Services Waiver per participant expenditures were 11.9% of Comprehensive Waiver per participant spending. The increased implementation of the Support Services Waiver resulted in notable reduction in overall spending per waiver participant. These same trends are projected to continue with 95.9% additional total waiver expenditure expansion by 2008. The Support Waiver will then account for 13.5% of total expenditures and 29.3% of all waiver participants were served in the Support Services.

OHIO EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Ohio Department of Mental Retardation and Developmental Disability Main web portal for Ohio MR/DDhttp://odmrdd.state.oh.us/
Level One Waiver (support waiver) Ohio’s support waiver for individuals with developmental disabilitieshttp://odmrdd.state.oh.us/Includes/Waivers/LevelOne/ Level1Waivers.htm
Ohio’s Waivers for DD Ohio’s waiver information for developmental disability waivershttp://odmrdd.state.oh.us/Includes/Waivers/Waivers.htm
Ohio’s New Waiver Reimbursement System: The Basics You Need to Know Ohio’s Reimbursement Systemhttp://odmrdd.state.oh.us/Includes/Press_Releases/WaiverReimbursementDec...

Document Inventory

  • Individual Options (Comprehensive) Waiver 2004, 2002 and 2003 Level One (Support) Waiver
  • Residential Facility Waiver (RFW) (comp waiver) 2000
  • Community Access Model Initial Waiver 2004
  • April 4 2006 Teleconference Big Picture Perspective
STATE CONTACT INFORMATION
Name Linda Lewis-Day
Agency Division of Medicaid Development and Administration Ohio Development of Mental Retardation and Developmental Disabilities
Address 1810 Sullivant Avenue Columbus, OH 43223-1239
Telephone   614-728-2736
E-mail linda.lewis-day@dmr.state.oh.us

OKLAHOMA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
In-Home Child Support Waiver Supports 0351 237 07/1999 On-going
In-Home Adult Support Waiver Supports 0343 740 07/1999 On-going
Community Waiver + Homeward Bound Comprehensive 0179 & 399 3,041 07/1986 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Child Support Waiver: Children with developmental disabilities ages 3-17 who reside in the family home and who have critical support needs that can be met through a combination of non-waiver and Medicaid state plan resources available to the individual within the waiver funding allowance. Adult Support Waiver: Adults with developmental disabilities age 18 and older who reside in the family home or own home who have critical support needs that can be met through a combination of non-waiver and Medicaid state plan resources available to the individual within the waiver funding allowance.
Funding Limit Child Support Waiver: $12,360/year. Adult Support Waiver: $18,540/year.
Funding Parameters Amount authorized based on individual plan.
Exceptions to Funding Limit Additional funding may be approved due to participant changes or circumstances.
Transition to Comprehensive Waiver If the person’s needs cannot be adequately met through the supports waiver program, services may be offered through the Community Waiver when openings are available.
Self-Direction No. Oklahoma may add self-direction to the In-Home Support Waivers during the renewal process in 2006. Individuals and families, however, exercise choice in the selection of waiver services and supports under the funding limits.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Oklahoma Waiver Services
Following Services Offered in Both In-Home Support Waivers
Case Management/Service Coordination N [Furnished by state Developmental Disabilities Service Division employees]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Homemaker Services, Habilitation Training Specialist
Respite Y Respite Care
Day Supports Y Pre-vocational Habilitation, Community-Based Skill Development Habilitation
Health Related N  
Supported Employment Y Supported Employment
Transportation Y Transportation Service
Person Directed Goods and Services N  
Equipment/Supplies Y Assistive Technology, Specialized Medical Equipment
Vehicle Repair/Modification N  
Clinical Services Y Therapy Services including Audiology, Physical Therapy, Occupational Therapy, Speech Therapy
Environmental Accessibility Adaptations Y Environmental Accessibility, Architectural Modifications
Financial Management Services N  
Family and Caregiver Training Y Family Training
Other N  
Following Services Offered Only in the Adult In-Home Support Waiver
Health Related Y Prescribed Drugs, Dental Services, Nutritional Services, Home Health Care Services, Physician Services (Psychiatric)
Person Directed Goods and Services Y Self-Directed Supports
Equipment and Supplies Y Specialized Medical Equipment, Adaptive Equipment Service
Clinical Services Y Psychology Services, Audiology Services

Background Information: Supports Waiver

Oklahoma launched its two In-Home Support Waivers in 1999. The implementation of these waivers was based on a 1997 study of Oklahoma's waiting list conducted by Oklahoma State University. The study surveyed the entire waiting list to identify the services people most needed. The findings showed that 82% of the individuals on the waiting list lived in their own or family homes and that the most needed services were help with daily living activities, respite care, and vocational services. The purpose of the waivers was to reduce the waiting list by offering limited supports to adults and children who lived with their families. The rationale for and design of both In-Home Support Waivers was influenced by Colorado's Supported Living Services Waiver.

Oklahoma also operates two comprehensive waivers: the Community Waiver and the Homeward Bound Waiver. The latter waiver serves persons placed from state institutions into the community as a result of the Homeward Bound et al. v. The Hissom Memorial Center lawsuit. Approximately 950 individuals are served in this waiver. Both comprehensive waivers provide a full array of services, including out-of-home around the clock residential supports

Both supports waivers operate under funding limits. The adult waiver limit is approximately $6,000 greater than the child waiver limit. The difference in the two limits stems from: (a) the fact that special education services are furnished to children but adults require waiver-funded day supports and (b) children have access to more robust Medicaid state plan benefits through the Early and Periodic Screening, Diagnosis and Treatment program. In 2004, average annual participant outlays were approximately $3,300 below the adult waiver funding cap but roughly at the cap for the child waiver.

The In-Home Supports Waiver programs operate differently from the comprehensive waivers. Individuals and families have flexibility in selecting services and supports, based on the person-centered plan. Participants may train their own providers and have the authority to sign a "Certificate of Competency" for the provider in lieu of the provider completing state mandated training, if the family chooses to exercise this option. Case management required contacts in the In-Home Support Waiver program are less intensive than the comprehensive waivers. This reduced oversight role allows a higher caseload ratios for case managers of individuals in the In-Home Support Waiver programs. State officials observe that the supports waivers have helped lower the average cost per participant for services while affording more flexibility in tailoring services to consumers and families. The supports waivers have proven beneficial in shifting their system to a supports model that assists individuals to remain in their own or family home. The Community Waiver has come to be the waiver used in emergency situations and when a person has complex and/or residential needs.

Oklahoma also operates the Family Support Assistance Payment Program, which provides a cash payment to families who are raising children with developmental disabilities under the age of 18. In June 2005, this program was furnishing assistance to 1,735 children. In addition, in 2005, Oklahoma implemented the "Katie Beckett" Medicaid eligibility option to extend Medicaid benefits to children with disabilities by waiving the deeming of parental income. As a result of this program, there are 950 children living at home with their families.

Once an individual is enrolled in the In-Home Support Waiver, additional supports can be provided on a temporary basis to deal with emergencies. While the state does not place a time limit on these additional funds, the intent of the additional funding is to maintain the person's current situation. If, over time, the In-Home Support Waiver programs can no longer meet the needs of the individual, the person may potentially move to the Community Waiver. Decisions about movement from one waiver to another are made on an individual basis. Oklahoma reserves Community Waiver capacity to serve high-priority individuals identified as needing emergency placement.

Oklahoma also operates the Family Support Assistance Payment Program, which provides a cash payment to families who are raising children with developmental disabilities under the age of 18. In June 2005, this program was furnishing assistance to 1,735 children. In addition, in 2005, Oklahoma implemented the "Katie Beckett" Medicaid eligibility option to extend Medicaid benefits to children with disabilities by waiving the deeming of parental income. As a result of this program, there are 950 children living at home with their families.

Major Issue(s):

In June 2005, there were 4,204 people on the waiting list. In its 2005 session, the Oklahoma Legislature appropriated additional funds to move 400 people off the waiting list during FY 2005-2006, principally by expanding the In-Home Supports Waivers. As of January 2006, the number of people on the waiting list had been reduced to 3,204.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000* 2001* 2002 2003 2004 2005
“Comprehensive”* 2,780 3,010 3,065 3,012 3,020 3,041
“Supports” 47 174 269 287 263 237
Total Participants 137 516 691 719 735 740
“Supports” Waiver % of Total Participants 6.2% 18.6% 23.9% 25.0% 24.8% 24.3%
* Includes Community and Homeward Bound Waivers. All participant counts based on Oklahoma Department of Human Services Annual Reports.

As can be seen, waiver enrollment in Oklahoma was flat between 2002 and 2005. In 2006, enrollment will grow by 400 persons (about 10%) as a result of additional funds appropriated to reduce the waiting list.

OKLAHOMA WAIVER ENROLLMENT
EXPENDITURES BY YEAR*
Waiver 2000 2001 2002 2003 2004 2005
“Comprehensive” ($M)** $157.5 $188.5 $214.5 $200.3 $205.0 $199.4
   Per Participant $56,645 $62,639 $69,968 $66,515 $67,866 $65,383
“Supports” ($M) $1.3 $6.5 $10.6 $11.6 $13.1 $12.9
   Per Participant $7,063 $9,437 $11,094 $11,747 $13,124 $13,167
Total Expenditures ($M) $158.8 $195.0 $225.1 $212.2 $218.1 $212.2
“Supports” Waiver % of Total Expenditures 0.8% 3.3% 4.7% 5.6% 6.0% 6.1%
Cost Per Participant: % Supports to Comprehensive 12.5% 15.1% 15.9% 17.7% 19.3% 20.1%
Blended Cost Per Participant $53,568 $52,714 $55,926 $52,803 $54,269 $52,821
* Expenditures by waiver from: Steve Eiken, Brian Burwell and Eileen Walker (May 2005). Medicaid HCBS Waiver Expenditures, FY 1999 through FY 2004. Cambridge, MA: MEDSTAT. 2005 expenditures from Department of Human Services Annual Report. ** Includes Community and Homeward Bound Waivers.
OKLAHOMA WAIVER EXPENDITURES ($M)

Between 2002 and 2005, total Oklahoma waiver funding was largely unchanged. Comprehensive waiver per-participant costs reflect the relatively high costs associated with operating the Homeward Bound Waiver. Supports waiver spending will increase as a result of the waiting list reduction initiative.

OKLAHOMA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Oklahoma Developmental Disability Services Division Web site for the waiver operating agencyhttp://okdhs.org/ddsd/
What is the Medicaid Waiver? Web page that describes the four Oklahoma waivershttp://okdhs.org/ddsd/Division/Resources/what_is_a_medicaid_waiver.htm

Document Inventory

  • 2006 Community and Homeward Bound Waiver renewal applications
  • HCFA 372 Annual Reports
  • 2005 Amendment In-Home Support Waiver for Children
STATE CONTACT INFORMATION
Name Kristi Blackburn
Agency Oklahoma Department of Human Service Developmental Disability Services Division
Address Sequoyah Memorial Office Building P.O. Box 25352 Oklahoma City, OK 73125
Telephone   405-521-6257
E-mail Kristi.Blackburn@okdhs.org

OREGON

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Supports Services for Adults Supports 0375 3,266 07/2001 On-going
24-Hour Comprehensive Supports Waiver (CSW) Comprehensive 0117 5,597 12/1981 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Adults age 18 and older with developmental disabilities who do not reside in a community-based home/residence licensed or certified by the State of Oregon. The state employs the 300% of SSI special income eligibility standard.
Funding Limit $20,000/year.
Funding Parameters All participants are eligible for base funding of $9,600/year. Funding may be increased to $14,400 or $19,999 based on Basic Supplement Criteria Inventory (BSCI) score. The BSCI assesses long-term health needs, physical needs, need for behavioral supports, and caregiver circumstances. As of July 2005, participants who have personal care needs may receive a supplement of up to $2,467 (previously, waiver participants were eligible to receive 20 hours of personal care through the Medicaid state plan).
Exceptions to Funding Limit Emergent services may be furnished to individuals who are in jeopardy of losing their living situation due to inability or unavailability of the primary caregiver and no alternative resources are available. Services are short-term, for up to 270 consecutive days in 12 consecutive months to prevent a permanent out-of-home placement. Services necessary to maintain the individual in the community and stabilize the situation include short-term residential placement or additional support services. The amount of the emergent services in combination with other services may exceed the $20,000 per plan year limit.
Transition to Comprehensive Waiver Entrance to 24-Hour CSW is limited to individuals experiencing crisis. Oregon provides for modest year-over-year increases in CSW capacity to accommodate individuals who are not experiencing crisis.
Self-Direction Full-Featured Self-Direction. Waiver participants engage personal agents through Support Services Brokerages. Personal agents employ a person-centered planning process to help participant and/or family identify support needs. Individuals/families exercise choice and control over services/supports included in the plan. Support brokerages furnish financial management services. Brokerages are IRS Fiscal/Employer Agents for participant hired workers. Brokerages function as “fiscal agents” by assisting participants to manage funding, keeping track of funds used, and paying workers or agencies that provide services.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Oregon Waiver Services
Case Management/Service Coordination Y Support Service Brokerage [County developmental disability program performs intake, eligibility determination and approves Individual Support Plan]
Supports of Participant Direction (Support Broker) Y Support Service Brokerage
In-Home Services Y Community Living Supports, Homemaker; Chore Services
Respite Y Respite
Day Supports Y Community Inclusion Supports
Health Related Y Special Diets
Supported Employment Y Supported Employment
Transportation Y Non-Medical Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Specialized Medical Equipment and Supplies; PERS
Vehicle Repair/Modification N  
Clinical Services Y Specialized Supports; Physical Therapy; Occupational Therapy; Speech/Hearing/Language Services
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services Y Support Service Brokerage
Family and Caregiver Training Y Family Training
Other Y Emergent Services

Background Information: Supports Waiver

Oregon's Supports Services for Adults Waiver was a direct outgrowth of the Staley et al. v. Kitzhaber lawsuit that was filed in January 2000. The lawsuit alleged that Oregon's failure to provide Medicaid services with reasonable promptness to eligible individuals violated federal Medicaid law and the Americans with Disabilities Act. The lawsuit stemmed from the large waiting list for services. In December 2000, the federal court approved a settlement agreement that was based on the Universal Access Plan which, in turn, had been previously proposed as a means of ensuring that all eligible adults with developmental disabilities receive at least a basic level of supports. The settlement agreement committed Oregon to design and implement the supports waiver and eliminate its waiting list for services over a multi-year period.6 The original settlement provided for eliminating the waiting list by the 2007-2009 biennium by extending services to an additional 4,600 individuals. Due to budgetary shortfalls, the agreement was modified in 2004 to stretch out the period for eliminating the waiting list to the 2009-2011 biennium.

Oregon was influenced by Colorado's waiver design of operating separate supports and comprehensive waivers. The Supports Services Waiver design also was significantly influenced by self-determination principles. System stakeholders played a critical role in shaping the waiver. The state and stakeholders saw the new waiver as an opportunity to make improvements in service delivery and stakeholders continue to be actively involved through the Staley Implementation Group. Consumers were already seeking more flexible alternatives to the traditional services system including options to self-direct services. The Supports Services Waiver offers flexible in-home supports to consumers and families that are intended to prevent out-of-home placement and thus reduce comprehensive waiver enrollment pressures. Consumers and families enter into contracts directly with providers, affording a high degree of choice and control over the nature of the services. The new waiver also adopted a different approach to management through the development of Support Service Brokerages to assist the person in the development of a plan, including an individualized budget, and identifying service providers. The Supports Brokerage Personal Agent facilitates person-centered planning, assists participants in selecting and purchasing services, performs day-to-day oversight and monitoring of the services, and furnishes additional assistance to help participants access other services. Oregon counties (which provide full-range case management in the Comprehensive Waiver) perform play a more limited role in the Supports Services Waiver. Counties perform eligibility reviews, approve the individual plan for Medicaid compliance, provide protective services, and assist in crisis management. These services are billed under Medicaid administration.

The waiver operates under a $20,000 per-participant funding cap. Waiver participants are eligible for a base funding allotment of $9,600. Individuals with more intensive support needs may receive additional funding. The need for additional funding is determined by administering the BSCI.7 In August 2005, 34% of participants had plans that were funded in excess of $9,600. In addition, Oregon provides that “emergent services” in excess of the $20,000 cap may be authorized for individuals in crisis. In August 2005, 4% of service plans exceeded $20,000. Also in August 2005, plan authorizations averaged $767/participant/month ($9,204 per year) while average monthly expenditures per participant $613/month ($7,356 per year).

Some 95% of waiver participants have intellectual disabilities and frequently have multiple disabilities (e.g., behavior dysfunction and other health impairments). About 79% of participants live with their families; 9% live on their own. Two-thirds of waiver participants are between the ages of 21 and 40.

Order of selection criteria regulate the selection of individuals for entrance to the waiver. Currently, the order of selection is: (a) individuals experiencing crisis; (b) persons with aging (over 75) caregivers; (c) persons aging out of Oregon's two model waivers for children; (d) persons transitioning from school; and (e) persons on the general waiting list. Since inception and through October 2005, 1,553 individuals have entered the waiver from the adult waiting list. Other enrollees included persons who entered the waiver from other programs (e.g., child family support, high school transition) where funding would have stopped due to aging out or other reasons. Absent the waiver, 56% of enrollees would have remained on the waiting list or been wait-listed. About 44% of participants are persons who had been receiving services that qualified for waiver funding.

Waiver expenditures are concentrated in two waiver services: community living supports (a form of in-home supports) (39%) and community inclusion supports (a form of day supports) (39%). Respite care accounts for 8% of expenditures, supported employment for 7% and non-medical transportation for 6%. All other covered services account for only 1% of expenditures.

The Oregon CSW furnishes services primarily to individuals who reside in various types of community residential settings, including group homes and supported living arrangements. A small number of waiver participants are served in the family home. The CSW does not include self-direction features. Oregon operates only one small public institution that serves approximately 40 individuals. There are no privately-operated ICFs/MR in Oregon. Under the terms of the Staley settlement, persons who experience crisis must be offered CSW services. Since inception, 221 Supports Waiver participants have transitioned to the CSW. Oregon also operates two small model waivers for children: one supports children who have intensive behavioral challenges while the other serves children with extraordinary medical needs.

In 2004, there were 2,270 people waiting for Oregon's Supports Services Adult Waiver. In 2006, the number waiting was somewhat lower--about 2,000 individuals. The number of persons waiting for the CSW was 1,500.

Major Issue(s):

System-wide, Oregon is experiencing a significant increase in the number of individuals experiencing crisis. This is causing funding stress within both waivers.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006 2007* 2008*
“Comprehensive” 5,688 5,821 6,343 6,125 5,437 5,597 5,808 5,886 5,935
“Supports” 0 0 999 1,661 2,646 3,266 4,122 5,122 6,697
Total Participants 5,688 5,821 7,342 7,786 8,083 8,863 9,930 11,008 11,632
“Supports” Waiver % of Total Participants 0% 0% 13.6% 21.3% 32.7% 36.8% 41.5% 46.5% 53.0%
* Oregon Department of Human Services projections.

Between 2000 and 2005, total Oregon waiver enrollment increased by 55.8%. The next three years through 2008 adds another 66.3%. As can be seen expansion of the Supports Services Waiver accounts for all net enrollment growth since 2002.

OREGON WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006 2007 2008
“Comprehensive” ($M) $227.5 $257.2 $282.3 $292.2 $293.7 $305.1 $319.5 $326.6 $332.4
   Per Participant $39,907 $44,186 $44,497 $47,704 $54,015 $54,516 $55,000 $55,000 $55,000
“Supports” ($M) $0 $0 $4.4 $15.5 $22.5 $27.2 $35.1 $44.4 $50.4
   Per Participant $0 $0 $4,405 $9,313 $8,508 $8,338 $8,505 $8,675 $7,527
Total Expenditures ($M) $227.0 $257.2 $286.7 $307.7 $316.2 $332.3 $354.6 $371.0 $382.8
“Supports” Waiver % of Total Expenditures 0% 0% 1.5% 5.0% 7.1% 8.2% 9.9% 12.0% 13.2%
Cost Per Participant: % Supports to Comprehensive 0% 0% 9.9% 19.5% 15.8% 15.3% 15.5% 15.8% 13.7%
Blended Cost Per Participant $39,909 $44,185 $39,049 $39,520 $39,119 $37,493 $35,746 $33,703 $30,304
OREGON WAIVER EXPENDITURES ($M)

In Oregon, total waiver expenditures increased by 46.4% between 2000 and 2005. Expenditure growth slowed in 2003, due to effects of the downturn in the Oregon economy. In 2005, Support Services Waiver expenditures accounted for 8.2% of total expenditures even though more than one-third of all waiver participants were served in the Support Services Waiver. Supports Services Waiver per-participant expenditures were 15.3% of Comprehensive Waiver per-participant spending. The implementation of the Support Services Waiver resulted in stabilizing overall spending per waiver participant. These same trends are projected to continue with 22.2% additional total waiver expenditure growth by 2008. The Support Waiver will then account for 13.2% of total expenditures even though 53.0% of all waiver participants were served in the Support Services Waiver.

OREGON EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
The Road Map to Support Services, Oregon Advocacy Center, Oregon Council on Developmental Disabilities, Oregon Department of Human Services Consumer-focused publication that provides a complete description of support serviceshttp://ocdd.org/support_services.htm
Descriptive Information Concerning Support Services for Adults Waiver, Oregon Department of Human Services Web page describes the waiver and contains links to additional, more detailed informationhttp://oregon.gov/DHS/dd/adults/supports.shtml
Support Services Administrative Rules Oregon Administrative Rules governing the operation of the Support Services Waiverhttp://dhs.state.or.us/policy/spd/rules/r11_340.pdf
Supports Services for Adults Waiver Renewal Application CMS-approved waiver applicationhttp://egov.oregon.gov/DHS/spd/qa/ssa_waiver_icfmr.pdf
Staley Settlement Agreement and Associated Materials A description of the Staley settlement agreementhttp://oregon.gov/DHS/spd/pubs/dd/staley/staley.shtml The most recent (2005) status report concerning the implementation of the agreement. The status report provides robust information concerning enrollments in the waiver.http://oregon.gov/DHS/spd/pubs/dd/staley/2005_report.pdf

Document Inventory

  • Oregon's Personal Outcome Statements and Indicators of Brokerage Services
  • 2003 Adult Comprehensive Waiver Renewal Application
  • The ARC of Oregon description of the Self Directed Support Services
  • 372 Reports for Comprehensive and Support waivers from 2000 to 2005
  • 2004 Report on Statewide HCBSS Waiver Quality Review
  • 2004 Fragile Child Model Waiver
  • 2004 five year Support Services Waiver Renewal
  • 2003 Oregon's Response to HCFA Regional Office Protocol
STATE CONTACT INFORMATION
Name Deanna J. Hartwig
Agency Office of Developmental Disabilities Seniors and People with Disabilities Oregon Department of Human Services
Address 500 Summer Street, NE, E02 Salem, OR 97301-1073
Telephone   503-947-1180
E-mail deanna.j.hartwig@state.or.us

PENNSYLVANIA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Person and Family Direct Support (P/FDS) Waiver Supports 0354 7,445 07/1999 On-going
Consolidated Waiver Comprehensive 0102 13,821 07/2000 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population The P/FDS Waiver program targets persons with mental retardation age three or over who do not need licensed community residential services. As such, the program is aimed at furnishing services and supports to individuals who live with their families and/or have other available supports that--in combination with HCBS--enable their needs to be met short of placement in community residence. Most individuals expected to participate in this program are persons who presently receive some services but need additional support or who receive no supports at all.
Funding Limit $21,225/year.
Funding Parameters Amount authorized is based on individual plan.
Exceptions to Funding Limit Yes. [State funds are used to supplement as necessary. Waiver does not provide for exception to limit.]
Transition to Comprehensive Waiver Individuals are transferred to Consolidated Waiver as slots are available.
Self-Direction Employer Authority. Personal care workers can be chosen by participants and their families. Waiver participants and their families may exercise employer authority through the use of two different models of Intermediary Service Organizations (ISOs) --Agency with Choice and Vender/Fiscal. Availability of ISO varies by county. In January 2007, the state will contract with one or more vendor/fiscal administrative ISOs to ensure state-wide availability.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Pennsylvania Waiver Services
Case Management/Service Coordination N [Case management is furnished through TCM coverage]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Residential Habilitation, Homemaker/Chore, Personal Support
Respite Y Respite
Day Supports Y Day Habilitation
Health Related Y Visiting Nurse
Supported Employment N  
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Adaptive Applicances/Equipment
Vehicle Repair/Modification N  
Clinical Services Y Physical Therapy, Occupational Therapy, Speech/ Language Therapy, Behavioral Therapy, Visual/Mobility Therapy
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N [Employer authority supported via state-contracted ISOs]
Family and Caregiver Training N  
Other N  

Background Information: Supports Waiver

The P/FDS Waiver was developed as part of Pennsylvania's multi-year strategic plan to rebalance the state's mental retardation service delivery system. Rebalancing included downsizing/closure of state facilities and expansion of HCBS. A key goal was to reduce the waiting list and position the system to meet future demand. Stakeholders in collaboration with the Office of Mental Retardation Services (OMRS) and Department of Public Welfare (DPW) leadership developed a five-year plan to reduce the waiting list that was endorsed by then Governor Ridge and the Pennsylvania legislature. The design and implementation of the P/FDS Waiver was an important waiting list reduction initiative element. The waiver's design also was intended to introduce self-determination principles into the delivery services and supports.

The P/FDS Waiver was approved by CMS in 1999. By 2005, this waiver was supporting 7,361 participants at an average yearly expenditure of $14,592 per participant. When initially implemented, the program was designed to support about 3,300 individuals. In addition to this waiver, the Pennsylvania operates two other HCBS waiver programs for people with mental retardation.8 The “Consolidated Waiver” served 15,149 in 2005 at an average annual cost of $67,574 per participant. Most Consolidated Waiver participants reside in licensed community residential living arrangement. Pennsylvania also operates a “zero-to-three” HCBS waiver program for infants, toddlers, and their families.

The P/FDS Waiver was designed to offer a limited array of services and supports to complement family caregiving and reduce demand for community residential services. DPW/OMRS leadership recognized that it would be impossible to achieve significant waiting list reduction and address future service demand by relying solely on the expansion of the much more costly Consolidated Waiver where per-participant costs were in excess of $50,000.

The P/FDS Waiver embraced person-centered planning methods to assure that “each person is able to live where and with whom they want, with the home and community-based support they need.” The introduction of person-centered planning through the P/FDS Waiver paved the way for its extension to the Consolidated Waiver. The P/FDS Waiver contains several features intended to strengthen the role of the individual or family in selecting and managing services.

P/FDS is defined as an “array of habilitation and related services and supports that is directed by persons receiving this assistance, in conjunction with their family and others that is directed by persons receiving this assistance, in conjunction with their family and others whom the person chooses.” The waiver support plan takes into account both HCBS and other generic or informal supports available to the person and details the health and safety responsibilities of family, friends, and providers.

Pennsylvania reports several positive impacts from the waiver. Many families who were seeking for out-of-home placement have found that their needs of their relative could be met in the family home through the P/FDS Waiver. Furthermore, families have expressed appreciation for the greater flexibility and control they have in selecting and procuring services. Some families, especially in rural areas where the cost of transportation is higher, have encountered difficulty in balancing the many needs of the individual and the family. Overall, Pennsylvania reports that the P/FDS Waiver is popular with families; the state would like to raise the participant cap but lacks the funds to do so.

Current Issues/Changes Underway

Pennsylvania continues to face persistent waiting lists for community services. Pennsylvania classifies people waiting for services as: (a) emergency “needing services now;” (b) critical (needing services within the year); and (c) planning (needing services somewhere between one and five years out). In April 2006, there were a total of 2,833 people termed emergency, 9,173 termed critical, and 10,905 termed planning for a total of 22,911 people waiting. The waiting list is not broken down by type of waiver.

Pennsylvania presently is implementing major changes in the operation of its waivers. CMS has required that the state standardize Consolidated Waiver operations across counties. Some of these changes include a new operating agreement with counties (local administrative agents), development and implementation of a standardized rate-setting methodology, implementation of a process to address changes in need, use of a standardized needs assessment (Supports Intensity Scale “Plus”) implementation of a new provider dispute resolution process, development of a state-wide administrative vendor/fiscal ISO, and development of a new state-wide provider qualifications process. Many of these same issues also will need to be addressed in the P/FDS Waiver.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” 11,588 12,946 13,417 13,703 13,922 13,821 15,149
“Supports” 2,400 5,009 6,247 7,036 7,337 7,445 7,478
Total Participants 13,988 17,955 19,664 20,739 21,329 21,266 22,627
“Supports” Waiver % of Total Participants 17.2% 27.9% 31.8% 33.9% 34.4% 35.0% 33.0%

Between 2000 and 2006, total enrollment in Pennsylvania's waivers for persons with mental retardation increased by 61.7% between 2000 and 2006. Expansion of the P/FDS Waiver accounted for 58.8% of the overall increase in waiver enrollment. In 2006, about one-third of all waiver participants were enrolled in the PFDS waiver.

PENNSYLVANIA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M) $614.0 $705.8 $809.7 $874.1 $875.4 $964.0 $1,023.7
   Per Participant $52,882 $54,517 $60,347 $63,789 $62,565 $69,751 $67,574
“Supports” ($M) $9.2 $35.6 $57.0 $72.5 $80.0 $76.8 $95.2
   Per Participant $3,832 $7,105 $9,127 $10,299 $10,904 $10,321 $12,738
Total Expenditures ($M) $623.2 $741.4 $866.7 $946.6 $955.4 $1,040.8 $1,118.9
“Supports” Waiver % of Total Expenditures 1.5% 4.8% 6.6% 7.7% 8.4% 7.4% 8.5%
Cost Per Participant: % Supports to Comprehensive 7.2% 13.0% 15.1% 16.1% 17.4% 14.8% 18.9%
Blended Cost Per Participant $44,552 $41,292 $44,075 $45,643 $44,941 $48,942 $49,450
PENNSYLVANIA WAIVER EXPENDITURES ($M)

Between 2000 and 2006, total Pennsylvania HCBS waiver expenditures grew by approximately 80%. In 2006, P/FDS Waiver expenditures are 8.5% of total expenditures even though P/FDS participants account for one-third of all participants. In 2006, P/FDS participant costs were 18.9% of the costs of supporting a person in the Consolidated Waiver and significantly below the P/FDS funding limit of $21,225. When the two waivers are blended, the average cost participant in Pennsylvania increased across the period but remain below the Consolidated Waiver cost per participant in 2000.

PENNSYLVANIA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Person/Family Directed Support Waiver Web page describes the P/FDS Waiverhttp://dpw.state.pa.us/Disable/HomeCommServices/003671641.htm
Consolidated Waiver for Individuals with Mental Retardation Web page describes the Consolidated Waiverhttp://dpw.state.pa.us/Disable/HomeCommServices/003671640.htm
Community Living Advisory Committee Web page describes the Community Living Advisory Committeehttp://dpw.state.pa.us/Disable/HomeCommServices/Clac/
HCBS Stakeholder Planning Team Web page describes the HCBS Stakeholder Planning Team and has other links of interesthttp://dpw.state.pa.us/Disable/HomeCommServices/HCBSTeam/
Mental Retardation Services Web page describes services for individuals with mental retardationhttp://dpw.state.pa.us/Disable/MentalRetardationServices/
STATE CONTACT INFORMATION
Name Kelly Svalbonas Statewide Waiver Coordinator
Agency Pennsylvania Department of Public Welfare Office of Mental Retardation
Address Health & Welfare Building, Room 512 P.O. Box 2675 Harrisburg, PA 17105-2675
Telephone   717-783-1003
E-mail ksvalbonas@state.pa.us

SOUTH DAKOTA

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Family Support Waiver Supports 0403 409 03/2000 On-going
Home and Community-Based Services Program Comprehensive 0044 2,009 05/1982 On-going
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children and youth with developmental disabilities under age 22 who live full-time in the family home. Parental income and resources are not deemed.
Funding Limit No fixed limit; general target is $5,000 annual cost or less each year.
Funding Parameters Based on individual plan.
Exceptions to Funding Limit The state may make exceptions in individual situations because of circumstances or changes.
Transition to Comprehensive Waiver Individuals may select the comprehensive waiver with state approval.
Self-Direction No. However, the waiver operates under family support principles and stresses family direction of services.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N South Dakota Waiver Services
Case Management/Service Coordination N [Case management is furnished by providers]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Personal Care, Companion Care
Respite Y Respite Care
Day Supports N  
Health Related Y Nutritional Supplements
Supported Employment N  
Transportation N  
Person Directed Goods and Services N  
Equipment/Supplies Y Adaptive Equipment, Diapers
Vehicle Repair/Modification Y Environmental Accessibility Adaptations
Clinical Services N  
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N  
Family and Caregiver Training N  
Other N  

Background Information: Supports Waiver

The Family Support Waiver was launched in 2000 in order to expand the availability family support for children with developmental disabilities in South Dakota. The Family Support Waiver operates side-by-side with South Dakota's longer-standing comprehensive waiver for individuals with developmental disabilities age six and above that has a principal (but not exclusive) focus on supporting adults with developmental disabilities and the provision of services outside the family home. The Family Support Waiver was designed around supporting families who have children with developmental disabilities. The Family Support Waiver operates within the general framework of the state's broader family support program.

Family support coordinators assist families to identify and access a broad range of natural and formalized services to meet their family's identified needs. One of the “hats” frequently worn by the family support coordinator is that of advocate on behalf of the family. The role of advocacy is best accomplished by someone independent of any agency or entity that might also be providing services for a family. Otherwise a family support coordinator might be placed in the precarious position of advocating for the desires of a family that are in direct conflict with the desires of one's employer.

Another very essential tenet of a family support program is a pool of flexible funds that can be utilized to purchase services or supports not otherwise available and to assist families with extraordinary expenses. For example, rather than establishing a formal program to provide for home modifications, the flexible funds can be utilized to purchase the needed modifications from private contractors. Another example would be assistance with extraordinary expenses such as the purchase of diapers or nutritional supplements.

Major Issue(s)/Current Situation:

South Dakota is noteworthy as a state that has avoided wait-listing individuals for services. South Dakota furnished Medicaid HCBS to individuals with developmental disabilities at a rate relative to population that is more twice the nation-wide average.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006*
“Comprehensive” 1,697 1,851 1,949 1,969 2,009 2,058 2,255
“Supports” 294 317 346 390 404 409 667
Total Participants 1,991 2,168 2,295 2,359 2,413 2,467 2,922
“Supports” Waiver % of Total Participants 14.8% 14.6% 15.1% 16.5% 16.7% 16.6% 22.8%
* Approved cap.

Between 2000 and 2005, total waiver enrollment increased by 23.9%. Since 2002, overall enrollment growth has been modest.

SOUTH DAKOTA WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M) $49.5 $53.3 $58.4 $61.9 $65.9 $72.2 $75.7
   Per Participant $29,191 $28,785 $29,986 $31,445 $32,818 $35,077 $33,581
“Supports” ($M) $0.5 $0.6 $0.5 $0.8 $0.9 $0.9 $2.7
   Per Participant $1,615 $1,840 $1,422 $2,126 $2,298 $2,193 $4,015
Total Expenditures ($M) $50.0 $53.9 $58.9 $62.8 $66.9 $73.1 $78.4
“Supports” Waiver % of Total Expenditures 1.0% 1.1% 0.8% 1.3% 1.3% 1.2% 3.4%
Cost Per Participant: % Supports to Comprehensive 5.5% 6.4% 4.7% 6.8% 7.0% 6.3% 12.0%
Blended Cost Per Participant $25,113 $24,862 $25,664 $26,579 $27,683 $29,631 $26,831
SOUTH DAKOTA WAIVER EXPENDITURES ($M)

From 2000 to 2005, waiver expenditures increased by 46.2%. Both comprehensive and support waiver expenditures per participant have been relatively stable. In 2005, Medicaid state plan expenditures for Family Support Waiver participants were $5,681 per participant or more than twice HCBS waiver expenditures.

SOUTH DAKOTA EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
South Dakota’s Family Support Web page describing South Dakota family support principles and systemhttp://state.sd.us/dhs/dd/family/index.htm
Family Support Waiver Web page provides an overview of the Family Support Waiverhttp://state.sd.us/social/MedElig/Families/FamSupport.htm
Comprehensive Waiver Web page provides an overview of the Comprehensive Waiverhttp://state.sd.us/social/MedElig/LTC/Disabled.htm

Document Inventory

  • HCFA 372 reports for both waivers: 2000-2005
  • 2003 Comprehensive Waiver Renewal
  • 2005 Amendment to Family Support Waiver
STATE CONTACT INFORMATION
Name Carol Ruen
Agency Department of Human Service Division of Developmental Disabilities
Address Hillsview Plaza East Highway 34 c/o 500 East Capitol Pierre, SD 57501-5070
Telephone   605-773-3438
E-mail carol.ruen@state.sd.us

TENNESSEE

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date Status
Self-Determination Waiver Program (SDWP) Supports 0427 63 01/2005 Initial
Statewide Mental Retardation Waiver Program Comprehensive 0128 4,806 01/2005* Initial
* Replaced previous waiver that first went into effect in 1987.
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population The target population for the SDWP consists of children and adults with mental retardation who meet ICF/MR level of care criteria and who are on the Division of Mental Retardation Services (DMRS) waiting list for community services. Enrollment in the program is prioritized and offered first to persons in the crisis wait list category, then to individuals in the urgent category, and then to persons in the active category up to the number of persons authorized to be served in the program each year. The SDWP serves persons who have an established non-institutional place of residence where they live with their families, a non-related caregiver or in their own home and whose needs can be met effectively by the combination of services available through this waiver program and the natural and other supports available to them. The SDWP does not include licensed residential services or supported living services.
Funding Limit Funding limits apply to categories of specified services. The total budget for all waiver services, including emergency assistance services, may not exceed $36,000 per year per participant. The amount of the participant’s initial individual budget may be increased to address newly identified needs or changes in the participant’s life circumstances, provided that the combination of service components does not exceed $30,000. Supports for Community Living Category. Funding is limited to $23,000 per year per participant unless an exception to the service limit is approved. This category of services includes Behavioral Respite Services, Respite, Personal Assistance, Day Services, Individual Transportation Services, Supports Brokerage, Financial Administration, Participant Designated Goods and Services. Professional and Technical Supports Service Category. A participant’s use of any service or combination of services in the Professional and Technical Supports Service Category is limited to $7,000 per year per participant unless an exception to the service limited has been approved. This category includes Occupational Therapy, Physical Therapy, Speech, Language, and Hearing, Nursing, Specialized Medical Equipment and Supplies and Assistive Technology, Behavioral Services, Vehicle Accessibility Modifications, Environmental Accessibility Modifications, PERS, Orientation and Mobility Training, Nutrition Services, Adult Dental Services. Exceptions to the limits on each group of services may be approved so long as the total amount of services initially authorized does not exceed $30,000.
Funding Parameters See above.
Exceptions to Funding Limit The waiver provides for temporary emergency assistance of up to $6,000 as an override to the overall $30,000 dollar limit. Emergency assistance is a temporary increase in the level of any waiver service for the purpose of preventing permanent out-of-home placement and provide an extra measure of protection when the person experiences a crisis or emergency situation that threatens his/her health and well-being.
Transition to Comprehensive Waiver Individuals may transition to the HCBS Waiver for Persons with Mental Retardation based on need and slot availability.
Self-Direction Yes. Individuals/families may elect to self-direct specified waiver services (personal assistance, respite, day services and certain others). For persons who self-direct, supports brokerage and financial administration (financial management) services are available.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Tennessee Waiver Services
Case Management/Service Coordination N [Case management furnished by state employees]
Supports of Participant Direction (Support Broker) Y Support Brokerage
In-Home Services Y Personal Assistance
Respite Y Respite, Behavioral Respite Care
Day Supports Y Day Services
Health Related Y Nutrition Services, Nursing Services, Adult Dental Services
Supported Employment Y Supported Employment
Transportation Y Individual Transportation Services
Person Directed Goods and Services Y  
Equipment/Supplies Y Specialized Medical Equipment, Supplies, and Assistive Technology, Personal Response System
Vehicle Repair/Modification Y Environmental Accessibility Adaptations
Clinical Services Y Behavior Services, Physical Therapy, Occupational Therapy, Speech, Language and Hearing Services, Orientation and Mobility
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations, Environmental Access
Financial Management Services Y Financial Administration
Family and Caregiver Training N  
Other N  

Background Information: Supports Waiver

The development and implementation of the Tennessee SDWP was a direct outgrowth of the 2004 Brown vs. Tennessee Department of Finance and Administration waiting list lawsuit settlement agreement. The settlement provided that Tennessee would create a new waiver that specifically targeted children and adults with developmental disabilities who were wait-listed for services and could be supported in the family home or other non-licensed living arrangements. The settlement recognized that Tennessee could not reduce its waiting list if it relied solely on the expansion of its existing HCBS waiver, which had relatively high per-participant costs. The settlement also required the state to design SDWP to incorporate “self-determination” principles. The settlement provided for phasing in the SDWP and furnishing “interim services” to persons on the waiting list until they are enrolled in SDWP or the existing waiver. As approved by CMS, SDWP waiver enrollment is expected to reach 1,500 persons in its third year.

The implementation of the SDWP waiver was affected by the state's need to resolve a variety of long-standing CMS-identified problems in the operation of its comprehensive HCBS waiver (Statewide Mental Retardation Waiver Program). CMS limited new waiver enrollment to individuals in crisis until those problems were resolved. Finally, in January 2005, CMS approved a replacement waiver for the comprehensive waiver and the SDWP. In March 2005, CMS approved a resumption of waiver enrollments. As consequence, enrollment in SDWP did not begin until June 2005.

SDWP serves Tennessee citizens with mental retardation who have moderate service needs that can be satisfactorily met with a cost-effective array of HCBS that complement other supports available to them in their home and the community, including personal assistance and day supports. SDWP affords participants the opportunity--based on individual preference and the willingness to assume the responsibilities that accompany self-determination--to lead the person-centered planning process and directly manage services, including the recruitment and management of service providers. Participants and families (as appropriate) who elect self-determination are empowered and have the responsibility for managing a self-determination budget that affords flexibility in service design and delivery. During the development of the Individual Support Plan (ISP), individuals and families receive an orientation to self-determination, including information concerning the added responsibilities and benefits of self-determination. When self-determination is selected, the ISP details the services that are participant managed and the participant's responsibilities. Participants and families who prefer may elect to receive some or all of their services through the standard service delivery method through which an enrolled service provider chosen by the individual hires and manages the staff, delivers the services in accordance with the ISP and is paid directly by the state.

SDWP funding is limited to $30,000. The waiver provides for funding limits on two groups of services. However, the group limits may be exceeded so long as the overall funding limit is not exceeded. The grouping of services was patterned after similar groupings in the Texas Home Living supports waiver. In addition, Tennessee provides that the $30,000 limit may be exceeded up to $6,000 in the event of crisis or emergency. Emergency funding may be used to purchase additional services covered in the waiver.

Major Issue(s):

Tennessee continues to face high demand for waiver services due to large part to the states historically low level of effort in funding services. Between June 2005 and January 2006, about 200 additional persons per month sought services. Despite enrolling approximately 1,500 individuals to its HCBS waivers, the state saw its waiting list grow from 3,762 persons to 4,036 persons, although the total number of individuals on the waiting list appears to have stabilized. However, absent the SDWP, the state would be facing an even larger waiting list.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” 4,311 4,537 4,311 4,263 4,390 4,806 6,123
“Supports” 0 0 0 0 0 63 834
Total Participants 4,311 4,537 4,311 4,263 4,390 4,869 6,957
“Supports” Waiver % of Total Participants 0% 0% 0% 0% 0% 1.3% 12.0%

During the period 2000-2004, Tennessee waiver enrollment was affected by CMS moratorium. Enrollment resumed in March 2005. Enrollment in SDWP started in June 2005.

TENNESSEE WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006
“Comprehensive” ($M) $159.9 $201.3 $182.7 $187.1 $245.1 $279.0 $369.7
   Per Participant $37,100 $44,357 $42,373 $43,885 $55,829 $58,062 $60,385
“Supports” ($M) $0 $0 $0 $0 $0 $0.2 $15.1
   Per Participant $0 $0 $0 $0 $0 $2,563 $18,051
Total Expenditures ($M) $159.9 $201.3 $182.7 $187.1 $245.1 $279.2 $384.8
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0% 0% 1.3% 3.9%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 0% 0% 4.4% 29.9%
Blended Cost Per Participant $37,091 $44,369 $42,380 $43,889 $55,831 $57,342 $55,311
TENNESSEE WAIVER EXPENDITURES ($M)

The resumption of enrollments in the comprehensive waiver and the initiation of SDWP enrollment will result in a significant increase in waiver expenditures during 2006. Support waiver costs per participant in 2006 reflect phased-in enrolled. At full build out, per-participant costs are estimated at $31,000/year.

TENNESSEE EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Family Handbook: A Road Map to State Services for Adults and Children Who have Mental Retardation Handbook provides an overview of services, including the Self-Determination Waiver Programhttp://state.tn.us/dmrs/consumer_services/FamilyHandbook.pdf
Annual Report: DMRS Report describes changes in services during FY 2005, including implementation of Self-Determination Waiver Program and changes in waiting listhttp://state.tn.us/dmrs/newsroom/AnnualReportfinal103105.pdf
Brown v. Tennessee Settlement Agreement Full text of settlement agreement which directed Tennessee to establish Self-Determination Waiver Programhttp://state.tn.us/dmrs/compliance/brown_settle_agree.pdf
Self-Determination Waiver Application and Related Materials Website contains application and related materialshttp://state.tn.us/tenncare/ltcare/ltcdd_waiver1.htm
Statewide MR Waiver Application and Related Materials Website contains waiver renewal application and related materialshttp://state.tn.us/tenncare/lecare/ltcdd_waiver2.htm

Document Inventory

  • Comprehensive Waiver 372 reports for 2002, 2003 and 2004
  • Self-Determination Waiver Program Application
STATE CONTACT INFORMATION
Name Donna Allen Director of Planning and Development
Agency Division of Mental Retardation Services Department of Finance and Administration
Address Andrew Jackson Building, 15th Floor 500 Deadrick Street Nashville, TN 37243
Telephone   615-532-6540
E-mail donna.allen@state.tn.us

TEXAS

WAIVERS
Waiver Title Type CMS Waiver # Participants (2006) Start Date Status
Texas Home Living (TxHL) Waiver Supports 403 1,933 03/2004 Initial
Home and Community-Based Services (HCS) Program Comprehensive 110 10,104 09/1985 Ongoing
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population Children and adults with mental retardation who meet Level 1 ICF/MR level of care criteria, live on their own or with their families, and do not require intensive supervision.
Funding Limit $10,000/year.
Funding Parameters Service costs are controlled by the overall $10,000 funding limit. Under this limit, costs are further subject to limits on two groups of waiver services: a $2,000 cap on Professional and Technical Support Services (e.g., therapies) and an $8,000 limit on the Community Living Services (e.g., day services). So long as the overall $10,000 limit is not exceeded, services may be authorized above the group service limits.
Exceptions to Funding Limit None.
Transition to Comprehensive Waiver Participants may transition to comprehensive waiver based on need, availability of waiver slots and position on the waiting list.
Self-Direction Not at present. State plans to amend the waiver to add self-direction, including the employer and budget authorities.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Texas Waiver Services
Case Management/Service Coordination N [Service coordination is furnished under TCM coverage]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Community Support
Respite Y Respite
Day Supports Y Day Habilitation, Employment Assistance
Health Related Y Dental, Nursing, Dietary
Supported Employment Y Supported Employment
Transportation N  
Person Directed Goods and Services N  
Equipment/Supplies Y Adaptive Aids
Vehicle Repair/Modification N  
Clinical Services Y Behavioral Support, Physical Therapy, Occupational Therapy, Speech and Language Pathology, Audiology
Environmental Accessibility Adaptations N Minor Home Modifications
Financial Management Services N  
Family and Caregiver Training N  
Other N  

Background Information: Texas Home Living Waiver

The TxHL Waiver was implemented in 2004 in order to provide a limited array of services and supports to individuals who are on the general waiting list for waiver services. The program was designed to be self-financing. That is, the enrollment of individuals already receiving waiver-like services would permit releasing state funds that would serve as match to expand waiver services to roughly the same number of individuals on the waiting list. The TxHL Waiver operates side-by-side with the longer standing HCS Waiver for persons with mental retardation. HCS offers a full range of community services, including residential services.

The TxHL Waiver targets persons with mental retardation who meet Level 1 ICF/MR level of care criteria. Such individuals have less intensive needs than other persons who require a higher level of ICF/MR care criteria. The waiver offers day and other supports that complement natural and other community supports. Access to the waiver is through the state's network of Mental Retardation Local Authorities (MRLAs). MRLAs conduct intake and furnish service coordination, including assisting individuals and families in developing service plans. MRLAs also manage provider enrollment, including the enrollment of consumer-identified providers, and conduct waiver quality management functions. Individuals who accept Home Living waiver services retain their position on the HCS waiting list. That is, individuals receive Home Living waiver services may transfer to the HCS Waiver when their names rise to the top of the HCS list and slots are available.

The waiver has funding limits on two “clusters” of waiver services. The application of funding limits to clusters of waiver services reflected the CMS policy that was in effect when the waiver was submitted that a state could not impose an overall limit on the total amount of waiver services but could apply dollar limits to groups of services. This CMS policy has since been replaced with explicit authority for states to apply an overall limit on the total amount of waiver services.

Individuals with other developmental disabilities (related conditions) are served through a separate waiver (Community Living Assistance and Support Services (CLASS) Waiver). There is no equivalent supports waiver for persons with related conditions. Texas has an especially large ICF/MR service sector. In 2004, 12,300 individuals received ICF/MR services, including nearly 5,000 persons in state institutions. About 4,800 individuals receive ICF/MR services in smaller six-bed group home facilities. Texas accounted for 11.8% of nationwide ICF/MR utilization in 2004.

Major Issue(s):

Texas has a very large waiting list for community services. In February 2006, there were nearly 29,000 individuals waiting for waiver services or almost three times the number of people with mental retardation who were receiving waiver services. In Texas, people who seek waiver services are placed on an “interest list.” Movement off the interest list is on a “first come, first served” basis. When a person's name rises to the top of the interest list, an eligibility determination is made. Approximately 90% of the individuals who are on the interest list are found to be eligible when offered waiver services. The number of people on the interest list has been growing year-over-year.

For the 2006-2007 biennium, the Texas legislature earmarked additional funds to reduce waiting lists across all waiver programs. With respect to waivers for persons with mental retardation, funding was earmarked to offer services to approximately 2,900 more individuals on the HCS waiting list by June 2007. In September 2002, a lawsuit (McCarthy v. Hawkins) was filed in federal district court challenging the wait listing of individuals for home and community services. This litigation has not yet been resolved. The plaintiffs are demanding that Texas commit to a multi-year plan to eliminate the waiting list for both HCS and CLASS Waiver services.

Statistical Profile

WAIVER PARTICIPANTS BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006**
“Comprehensive”* 5,420 6,133 6,951 7,268 8,932 9,040 10,104
“Supports” 0 0 0 0 0 1,482 1,933
Total Participants 5,420 6,133 6,951 7,268 8,932 10,552 12,037
“Supports” Waiver % of Total Participants 0% 0% 0% 0% 0% 14.1% 16.1%
* Includes MRLA and Home and Community-Based Services OBRA (HCS-O) Waiver participants through 2003. These waivers were terminated and the participants shifted to HCS. ** Texas Department of Aging and Developmental Disability Services (DADS) projection.

As can be seen, waiver enrollment increased modestly between 2000 and 2003. Since 2003, waiver enrollment has stepped up due to the combined impact of the implementation of the TxHL Waiver and the appropriation of additional funds to reduce the waiting list.

TEXAS WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005 2006**
“Comprehensive” ($M)* $200.5 $227.4 $262.5 $290.2 $317.5 $325.7 $378.7
   Per Participant $37,000 $37,072 $36,771 $39,938 $35,548 $36,038 $37,480
“Supports” ($M) $0 $0 $0 $0 $0 $1.5 $16.8
   Per Participant $0 $0 $0 $0 $0 $1,928 $8,669
Total Expenditures ($M) $200.5 $227.4 $262.5 $290.2 $317.5 $328.6 $395.5
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0% 0% 0.9% 4.2%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 0% 0% 5.3% 23.1%
Blended Cost Per Participant $37,000 $37,072 $37,771 $39,938 $35,548 $31,239 $32,857
* Includes the HCS with MRLA and HCS-O Waiver expenditures through 2003. ** Estimate.
TEXAS WAIVER EXPENDITURES ($M)

Between 2000 and 2006, the total Texas waiver expenditures will have nearly doubled. There will be a substantial increase in spending between 2005 and 2006 as a result of the additional funds appropriated to reduce the interest list. HCS expenditures per participant are relatively low for a comprehensive waiver. This is due in part to Texas limiting HCS enrollment to persons whose service needs can be met at less than the cost of ICF/MR services. In 2006, TxHL Waiver per-participant costs are running at 87% of the $10,000 funding limit.

TEXAS EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Texas Home Living Waiver Web page has the original approved Home Living waiver applicationhttp://dads.state.tx.us/business/mental_retardation/txhml/TexasHomeLivin...
Texas Department of Aging and Disability Services Main web page for Texas DADShttp://dads.state.tx.us/
Home and Community-Based Services (HCS) Program Web site contains information about the HCS waiverhttp://dads.state.tx.us/services/dads_help/mental_retardation/ HCSprofile.pdf

Document Inventory

  • Description of HCS Program
  • History of Numbers of People Served Community System FY 1990 through FY 2003 in Texas, and Utilization and Expenditure Summary from Texas
STATE CONTACT INFORMATION
Name Beverly Sawyer Program Specialist
Agency Texas Department of Aging and Disability Services
Address 701 West 51st Street Austin, TX 78751
Telephone   512-438-3530
E-mail beverly.sawyer@dads.state.tx.us

WASHINGTON

WAIVERS
Waiver Title Type CMS Waiver # Participants (2005) Start Date* Status
Basic Waiver Supports 0408 3,407 04/2004 Initial
Basic Plus Waiver Supports 0409 2,202 04/2004 Initial
Core Waiver Comprehensive 0410 4,185 04/2004 Initial
Consumer Protection Comprehensive 0411 403 04/2004 Initial
* Waivers replaced Community Alternatives Program (CAP) waiver which started in 1984.
BASIC SUPPORT WAIVER FEATURES
“Supports” Waiver Target Population The Basic Waiver targets children and adults with developmental disabilities living with family or in their own homes who have strong natural supports systems but may be at risk of more restrictive placement due to needs for physical, mental health or behavioral services or need for support to a caregiver. The Basic Plus Waiver program targets children and adults with developmental disabilities living at home with family or in another setting with assistance. These individuals are at high risk of out-of-home placement or loss of their current living situation due to issues such as abuse and neglect, serious medical problems requiring close monitoring, challenging behavior, and/or mental health or substance abuse concerns. The individuals served through the Basic Plus Waiver program also generally have substantial functional limitations resulting in need for frequent assistance to remain at home or participate in community activities and/or the individual has need for protective supervision due to impaired judgment. The Basic Plus Waiver also covers services in generic living arrangements such as adult foster care settings.
Funding Limit Each support waiver is subject to different funding limits. In both waivers, there are funding limits that apply to groups of certain services:
Service Group. Respite care, environmental accessibility adaptations, transportation, specialized medical equipment and supplies, physical therapy, occupational therapy, speech, hearing and language services, behavior management and consultation, staff/family consultation and training, specialized psychiatric services, and community guide. Basic Waiver Limit. $1,425/year. Basic Plus Waiver Limit. $6,070 [N.B., Basic Plus also includes skilled nursing in this group.
Service Group. Person to Person, Supported Employment, Community Access, Pre-vocational Services. Basic Waiver Limit: $6,500/year. Basic Plus Waiver Limit: $9,500, but may be increased to $19,000 based on assessed need.
In addition, participants in both waivers are eligible for Medicaid state plan personal care services and waiver-funded supplements to personal care. The amount of such services is determined through the application of the state’s Comprehensive Assessment Reporting Evaluation functional assessment tool. The amount of respite care is authorized through a separate assessment.
Funding Parameters See above.
Exceptions to Funding Limit Both waivers provide for temporary emergency assistance of up to $6,000 as an override to the dollar limits that apply to the service groups above. Emergency assistance is a temporary increase in the level of any waiver service for the purpose of preventing permanent out-of-home placement. Emergency Assistance is provided in one of the following emergency situations: involuntary loss of present residence for any reason, including death of a caregiver or changes in the caregiver’s mental or physical status resulting in the caregiver’s inability to perform effectively for the individual; significant changes in the emotional or physical condition of the individual that necessitate substantial expanded accommodations.
Transition to Comprehensive Waiver Individuals may transition to the Core or Consumer Protection waiver based on need and slot availability.
Self-Direction Limited. Community guide and person-to-person services are similar to “support broker” services. Participants or families may hire, fire, and supervise personal care workers.
SUPPORTS WAIVER SERVICES
Support/Service Category Y/N Washington Waiver Services
Case Management/Service Coordination N [State-operated case management is furnished as a Medicaid administrative activity]
Supports of Participant Direction (Support Broker) N  
In-Home Services Y Personal Care (supplement to Medicaid state plan personal care services)
Respite Y Respite Care
Day Supports Y Person-to-Person, Community Access, Pre-vocational Services
Health Related N  
Supported Employment Y Supported Employment
Transportation Y Transportation
Person Directed Goods and Services N  
Equipment/Supplies Y Specialized Medical Equipment and Supplies
Vehicle Repair/Modification N  
Clinical Services Y Specialized Psychiatric Services and Behavior Management. Physical Therapy, Speech, Hearing, and Language Services, Occupational Therapy are furnished as supplements to Medicaid State Plan services.
Environmental Accessibility Adaptations Y Environmental Accessibility Adaptations
Financial Management Services N  
Family and Caregiver Training Y Staff/Family Counseling and Training
Other Y Emergency Assistance, Community Guide
The Following Services are Only Available in the Basic Plus Waiver
Health Related Y Skilled Nursing
Other Y Adult Foster Care, Adult Residential Care

Background Information: Supports Waiver

In January 2004, Washington replaced its single CAP HCBS waiver for persons with developmental disabilities with four new waiver programs. The four replacement waivers are: Basic Waiver, Basic Plus Waiver, Core Waiver, and Community Protection Waiver. The Basic and Basic Plus waivers are supports-type waivers; the Core waiver is a comprehensive waiver offering a full array of services, including residential services; and, the Community Protection waiver targets individuals who have been charged with and/or convicted of certain type of crimes, including violent crimes or sex offenses.

Washington used a step-up approach in designing these waivers. Funding scales upward based on the service need intensity/profile of the individuals that each waiver serves as illustrated by the following 2005 per-participant costs for each waiver:

Waiver Estimated Per Capita Cost (Year 1)
Basic $11,890
Basic Plus $15,913
Core $53,111
Community Protection $94,781

The Basic Waiver provides participants with day supports funding plus a modest amount of additional funds to purchase other services. Basic Plus provides steps up funding for both day support and other services. Except for the addition of skilled nursing and payment for generic community residential services in the Basic Plus waiver, both waivers have the same service package. The Core Waiver includes comprehensive specialized residential services in addition to the Basic Plus waiver service package. The Core Waiver does not include funding limits on groups of services.

The decision to split the predecessor CAP waiver into four distinct waivers was an outgrowth of CMS Olmstead Letter #4 which provided in part that all services offered under a waiver must be available without limit to all participants in a waiver. State officials determined that continuing to operate a single waiver that spanned individuals who have differing need/situational characteristics would be problematic in light of Olmstead Letter #4. Dividing the CAP waiver into four separate waivers subject to differential funding limits emerged as a means for the state to ensure compliance with Olmstead Letter #4 and ensure that waivers could be managed within available funds. Washington officials decided that they needed to better tools to “sort out” what are the appropriate services for an individual and manage access to the full range of services for those most in need. The reconfiguration of the waivers led the state to clarify under what conditions individuals are eligible for a specific array of supports and services. The multiple waiver strategy and entrance criteria make it clear to consumers and families that not everyone will receive full around the clock supports, but supports and services are tailored to individual situations and need.

The Basic and Basic Plus imposition of funding limits on groups of services rather than the total amount of waiver services reflected CMS policy at the time that Washington reconfigured the CAP waiver. In order to establish funding limits, CMS required that a state impose dollar limits on the amount of services that could be authorized rather than impose an overall limit.9 Washington is in the process of establishing waiting list criteria for entrance into the reconfigured waivers.

Statistical Profile

WAIVER ENROLLMENT BY YEAR
Waiver 2000 2001 2002 2003 2004 2005
“Comprehensive”* 8,984 9,413 9,063 8,685 8,260 4,588
Basic Support Waiver 0 0 0 0 0 3,407
Basic Plus Support Waiver 0 0 0 0 0 2,202
Total Participants 8,984 9,413 9,063 8,685 8,260 10,197
Both “Supports” Waivers % of Total Participants 0% 0% 0% 0% 0% 55.0%
* The comprehensive waiver in 2005 is not comparable to the prior five years due to the reconfiguration of the predecessor CAP waiver.

During the period 2000-2005, waiver enrollment in Washington increased by 12.8%. The drop in comprehensive waiver enrollment in 2005 is an outgrowth of the redistribution of CAP Waiver participants to the new waivers.

WASHINGTON WAIVER ENROLLMENT
EXPENDITURES BY YEAR
Waiver 2000 2001 2002 2003 2004 2005
“Comprehensive” ($M)* $195.1 $203.1 $237.9 $247.8 $190.6 $260.5
   Per Participant $21,723 $21,573 $26,255 $28,533 $23,081 $56,771
“Supports” ($M) $0 $0 $0 $0 $0 $76.2
   Per Participant $0 $0 $0 $0 $0 $13,581
Total Expenditures ($M) $195.1 $203.1 $237.9 $247.8 $190.6 $336.7
“Supports” Waiver % of Total Expenditures 0% 0% 0% 0% 0% 22.6%
Cost Per Participant: % Supports to Comprehensive 0% 0% 0% 0% 0% 23.9%
Blended Cost Per Participant $21,723 $21,573 $26,255 $28,533 $23,081 $33,020
* The comprehensive waiver in 2005 is not comparable to the prior five years due to the reconfiguration of the predecessor CAP waiver.
WASHINGTON WAIVER EXPENDITURES ($M)
WASHINGTON EXPENDITURES PER PARTICIPANT
WEB-ACCESSIBLE RESOURCES/ADDITIONAL INFORMATION
Resource Description/Web-Address
Washington Home and Community-Based Waiver Program Web page describing Washington’s HCBS Waivershttp://www1.dshs.wa.gov/ddd/waivers.shtml
Chapter 388-845 WAC--HCBS waiver rules Web page with links to waiver ruleshttp://aaps.leg.wa.gov/WAC/default.aspx?cite=388-845
Basic Waiver Document http://www1.dshs.wa.gov/pdf/adsa/ddd/BasicWaiver.pdf
Basic Plus Waiver Document http://www1.dshs.wa.gov/pdf/adsa/ddd/BasicPlusWaiver.pdf
Core Waiver Document http://www1.dshs.wa.gov/pdf/adsa/ddd/CoreWaiver.pdf
Fact Sheet Washington Developmental Disabilities Waiver Plan (rev. May 2005) Fact sheet that summarizes Washington’s four developmental disabilities waivershttp://www1.dshs.wa.gov/word/adsa/ddd/waiverFacts.doc
Washington’s Waivers for Developmental Disabilities Two page brochure describing Washington’s HCBS waivershttp://www1.dshs.wa.gov/pdf/Publications/22-605.pdf

Document Inventory

  • 2004 Core, Basic, Basic Plus, & Community Protection Waiver Documents (as initially approved by CMS)
  • Power Point on Support Waivers
  • 2005 Description of Individual Living Options
  • 372 reports for four waivers for 2005
  • Basic Plus Amendment #4 2006
  • CMS 372 initial reports for 2005
  • 2006 Basic Waiver Amendment #3 Final
STATE CONTACT INFORMATION
Name Shannon Manion
Agency Washington State Department of Social and Health Services Division of Developmental Disabilities Aging and Disability Services Administration
Address P.O. Box 45310 Olympia, WA 98504-5310
Telephone   360-725-3445
E-mail maniosk@dshs.wa.gov

ACRONYMS

ASPE   Office of the Assistant Secretary for Planning and Evaluation
 
BSCI   Basic Supplement Criteria Inventory (Oregon)
 
CAP   Community Alternatives Program (Washington)
CCB   Community Centered Board
CLASS Waiver   Community Living Assistance and Support Services Waiver (Texas)
CMS   Centers for Medicare and Medicaid Services
CSLA   Community Supported Living Arrangements
CSP   Community Supports Program (Nebraska)
CSW   Community Support Waiver (Missouri)Comprehensive Supports Waiver (Oregon)
 
DADS   Department of Aging and Developmental Disability Services (Texas)
DD Waiver   Developmental Disabilities Waiver (Indiana)
DMRS   Division of Mental Retardation Services (Tennessee)
DPW   Department of Public Welfare (Pennsylvania)
 
FICS   Family and Individual Consultation and Support (Connecticut)
FSL Waiver   Family and Supported Living Waiver (Florida)
 
HCB-DD Waiver   Home and Community-Based Services for the Developmentally Disabled Waiver (Colorado)
HCBS   Home and Community-Based Service
HCFA   Health Care Financing Administration
HCS Program   Home and Community-Based Services Program (Texas)
HCS-O Waiver   Home and Community-Based Services OBRA Waiver (Texas)
HHS   Health and Human Services (Nebraska)
 
I&DD   Intellectual and Developmental Disabilities
ICF/MR   Intermediate Care Facility for Persons with Mental Retardation
IFS Waiver   Individual and Family Support Waiver (Connecticut)
IO Waiver   Individual Options Waiver (Ohio)
ISO   Intermediary Service Organizations (Pennsylvania)
ISP   Individual Support Plan (Tennessee)
 
LAH Waiver   Living at Home Waiver (Alabama)
 
MOCDD Waiver   Missouri Children with Developmental Disabilities Waiver
MR/DD   Mental Retardation and Other Developmental Disabilities
MRLA   Mental Retardation Local Authorities (Texas)
 
NASDDDS   National Association of State Departments of Developmental Disability Services
NOW   New Opportunities Waiver (Louisiana)
 
OBRA   Omnibus Budget Reconciliation Act
OMRS   Office of Mental Retardation Services (Pennsylvania)
 
P/FDS Waiver   Person and Family Direct Support Waiver (Pennsylvania)
PERS   Personal Emergency Response System
 
RFW   Residential Facility Waiver (Ohio)
 
SDWP   Self-Determination Waiver Program (Tennessee)
SLS Waiver   Support Living Services Waiver (Colorado)
SSI   Supplemental Security Income
 
TCM   Targeted Case Management
TxHL Waiver   Texas Home Living Waiver

NOTES

  1. Robert Prouty, Gary Smith, and K. Charlie Lakin (in press). Residential Services for Persons with Developmental Disabilities: Status and Trends Through 2005. Minneapolis, MN: University of Minnesota, Research and Training Center on Community Living.

  2. Alabama, Colorado, Connecticut, Florida, Indiana, Louisiana, Missouri, Montana, Nebraska, Ohio, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas and Washington have approved supports waivers.

  3. Olmstead Letter #4 was issued by CMS in January 2001. Among its other provisions, this letter made it clear that states must furnish any services covered in a waiver to any participant who needed the service. As a practical matter, this meant that states could not limit participants to receiving a narrow package of services with a waiver (e.g., operate a “waiver within a waiver”). Olmstead Letter #4 prompted some states (e.g., Montana) to startup supports waivers to preserve narrow in-home packages.

  4. When a state was unable to provide 2006 enrollment data, 2005 waiver enrollment was carried forward.

  5. For background information concerning the Systems Change Project, see Gary Smith, John Agosta, and Reena Wagle (2002). An Evaluation of the Colorado Systems Change Project. Tualatin, OR: Human Services Research Institute. Available at: http://cdhs.state.co.us/ohr/dds/HSRI%20-%20Systems%20Change%20Evaluation....

  6. See Gary Smith (2006). Status Report: Litigation Concerning Home and Community Services for People with Disabilities. Portland, OR: Human Services Research Institute.

  7. Located at http://egov.oregon.gov/DHS/dd/adults/benefitlevels.shtml.

  8. In Pennsylvania, services for persons with related conditions are furnished through separate programs.

  9. The Texas Home Living, Ohio Level One, and Tennessee supports waivers are similarly structured.

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