This is the first of two articles on the status of Medicaid’s Intellectual/Developmental Disability Waiver Program. Monday April 16: A recent court ruling causes apparent setback for plaintiffs in a federal civil suit.
CHARLESTON — The Dominion Post has reported several times during the past several years that changes to a state program for individuals with intellectual and developmental disabilities has led to them receiving less Medicaid funding than they require for their care.
But a different, more or less opposite problem is now gaining attention. It’s unclear at this point if a new system for calculating the program clients’ care budgets, which took effect April 1, will solve the additional problem.
The program is the Department of Health and Human Resources’ Medicaid Title XIX Intellectual/Developmental Disability (IDD) Waiver program, operated by DHHR’s Bureau for Medical Services. It serves 4,634 people enrolled and plans to add another 50 from its waiting list of about 1,300 based on budgeting changes undertaken in 2015 and the rollout of the new system, which will be described more in depth in a future story.
The new problem – not new in terms of time but in terms of gaining attention – is that some clients are budgeted far more money than they are permitted to use based on their education or program plans and their service caps.
And that budgeted but unusable money can’t be transferred to someone whose needs aren’t met by their budgets.
We’ll illustrate the problem then give DHHR’s answers to why the fix apparently isn’t as simple as it seems.
Charleston attorney Tom Basile, who has a daughter in the IDD program and has represented more than 50 waiver clients and free consultation for more in their budget appeals and disputes, drew The Dominion Post’s attention to the issue. He provided two affidavits provided for a class action suit regarding BMS’s previous budgeting methodology based on a contractor’s secret algorithm.
The affidavits are from officials of agencies that contract with BMS to provide services to waiver clients.
The first comes from an agency that serves 142 clients. The official reviewed budgets approved by APS (now Kepro, pronounced key-pro) though June 2016. APS approved a total $1.9 million budget money “above and beyond the cost of services requested by many of our clients.
The official said the problem has existed for many years and generally involves the same individuals who have not demonstrated need and haven’t requested services that would permit use of the excess. The money just sits in the budget.
The official writes, “APS has informed us that the excess budget money … cannot be shifted to other clients of ours who actually need additional services” but whose budgets don’t meet those needs.
The second affidavit comes from an agency that serves 72 clients. Through October 2016, clients had been budgeted $777,000 they couldn’t use and that the agency couldn’t transfer to other clients.
Basile asked, “What is going on with that money?” Is this a glitch or an intentional pattern, he wondered.
In Morgantown, Ashley Malott, program manager of I/DD Waiver Service Coordination and Behavior Support Professionals for Valley HealthCare, has similar concerns and questions.
Valley serves 174 waiver clients, she said: 34 minors and 141 adults. The clients who are budgeted more than they can use, she said, are invariably minors.
Basile noted that school-age clients typically live at home and spend part of their day in school so don’t require the 24-hour services many adults do. But it’s unclear why they are budgeted more than they can use.
She didn’t have a total figure for money clients couldn’t use but cited 11 examples totaling $475,157.96 for the 2017-2018 budget year. In the most extreme example, the client was budgeted $222,576.94 but, due to the program plan and service caps (typically caps on the amount of hours for a particular service such as direct care or respite time) was able to purchase only $40,679.20 worth of services – a $181,897.94 difference.
In the other 10 cases, the unusable budget ranged from $19,037.84 to $47,943.37 (this person was budgeted $95,727.35 but authorized to purchase only $47,783.98 worth of services).
DHHR’s perspective
First, a quick summary of how services are authorized.
APS/Kepro conducts an annual assessment for each client. Up until April 1, Kepro then applied its secret algorithm to determine the client’s budget. Under the new and old formulas, the client’s interdisciplinary team then meets to develop and individualized education plan (IEP, for school-age clients) or individualized program plan (IPP, for adults) to allocate services based on the budget.
Where the budget doesn’t meet the needs outlined by the team, clients would follow an appeals process. A federal judge determined the secret algorithm and previous process violated clients’ due process rights, leading to the new formula and appeals process.
Cindy Beane, BMS Commissioner, explained the factors behind the problem of clients receiving more than they can use and why it can’t be transferred.
Authorized services “do not relate to actual dollars and cents until the services are provided and billed,” she said in an email exchange. “At that time, West Virginia pays their portion of the claim and federal dollars are pulled down to pay the federal portion of the claim.”
Historically, services coordinators typically ask for 30 percent more than what is actually spent, she said.
Because budgets do not represent actual appropriated money, she said, “APS budgets are not ‘money’ that is ‘unspent.’ … Nothing happens to that money because BMS did not receive any money.”
Because the waiver program, approved by the federal Centers for Medicare and Medicaid Services, sets individualized budgets, she said, “It does not authorize an agency to just take an authorization from one person’s individualized budget and add it to another person’s individualized budget.
Asked to cite any specific code or rule prohibiting a transfer, she said, “There is no specific code or rule because it is not actual money that can be transferred from one account to another. When a member has their annual assessment, an individualized budget is generated. If a member needs more services than what can be purchased, then the individual member has the ability to ask for an exception and explain why. If unsuccessful, [under the old system] the member always has the ability to request a Medicaid Fair Hearing and have their request heard by an impartial hearing officer from the Board of Review.
The new system – built on a base budget determined by contracted actuaries and increased by add-ons according to various physical and behavioral conditions – contains a 20 percent stop-loss/stop-gain provision that will prevent a client’s budget from increasing or decreasing more than 20 percent of their current budget.
Asked if this might affect the over-budgeting issue or if BMS will adjust its policy to allow transfers, she said, “The stop-loss provision is a procedure that helps smooth the transition for a member who currently spent more in the 12-month period than what the new budget methodology determines the person needs. It is to ease the transition from a higher budget to a lower budget. In most of these cases (estimated to be 5 percent of the total group), the member may need the additional 20 percent of services and they will go through an exceptions process to explain why they need those additional services authorized.”
