The questions and answers contained in this document are a compilation of the questions submitted relative to the rate setting study report. If there were multiple questions of a similar nature, the questions and responses were combined.
Requests for feedback on scenarios specific to a provider agency will be addressed in technical assistance provided by DDA and/or JVGA, whichever is most appropriate. These were not included in this document.
- What are program support costs?
Program Support costs are those costs that are necessary to support the people in the service setting that are not direct support or supervision, do not fall into any of the other categories (transportation or training) and generally are shared equally among the individuals. These costs include program supplies, professional consults, supervision of habilitative staff, quality initiatives, clinical oversight, environmental costs and adaptations (excluding modifications), and anything required for the setting to adequately respond to the needs, safety and support of the people being served.
- Does Personal Supports include hours where staff are serving more than one person?
No. Going forward, Personal Supports refer to services provided to an individual in their home or apartment. Supportive Living refers to services provided to two or more people in their own home or apartment.
- What impact will the new rate structure have on Self-Directed services?
Individuals who self direct their services will continue to have a budget authority to set wages based on reasonable and customary standards.
- The rates for Behavioral Support Services appear to be an hourly rate instead of a “per contact” rate. Please clarify the reason for this change.
Current Behavioral Support Services are based on a fixed rate or on an hourly rate, not on a “per contact” basis. Therefore, there is no change in the reimbursement methodology.
- How many adult providers did you model this plan with and what were the findings?
The consultant group, Johnston, Villegas-Grubbs and Associates (JVGA) analyzed general ledgers from approximately 70 service providers in the development of the rate structure and the proposed rates. A preliminary impact analysis was performed on the 70 providers which identified some outliers.
- How will agencies be reimbursed for transportation services that are provided via Uber / Lyft?
Transportation, as the stand alone waiver service, includes a variety of supports including orientation services, accessing mobility, travel training, transportation services (such as Uber), mileage reimbursement, and purchase of prepaid vouchers and cards. These services are billed as a lump sum for reimbursement. Some services already include transportation coverage in the rates, such as in Day Habilitation, Community Living, and other services. The DDA will not reimburse for transportation if it would be duplicate funding within the rate for these services.
- What rate will be used to bill for transportation for congregate day program runs, etc.? When will the billing unit start and end?
The transportation component of day program rates was increased from approximately seven (7) percent as indicated in the ledgers to 49 percent using a broader approach to its calculation based on time. It is included in all hours billable under the day habilitation service code. The actual hours that are billable for day programs is based on the service definition and not the rate set. The proposal is that the billable hour begins at contact with the person using the service and likewise, ends when contact with the person ends.
- Since the matrix score will be phased out, what tool will be used to determine the number of hours of support a person needs?
The matrix score will be replaced by the Person-Centered Planning (PCP) process, the Health Risk Screening Tool (HRST), the Supports Intensity Scale (SIS), and other documented supports. The hours of support identified by these assessment tools will then be used in conjunction with the standard rates proposed in the rate study. Over the years, the stakeholder community has expressed concerns about the adequacy of the matrix system of determining the true cost of providing services. The number of support hours will be based on assessed needs and the Person-Centered Plan process, and consequently, the number of hours of service.
- When will the assessment tool be explained to individuals and providers as
to how it will work?
The DDA and the PCP Work Group have presented how the new person-centered planning process and Person-Centered Plan will work. A presentation was done on Dec. 1, 2017 at the Maryland Association of Community Services conference and again at the Southern Maryland Provider Meeting held on Dec. 12, 2017. The DDA and the PCP Work Group will be training individuals in service, their families, Coordinators of Community Services, and DDA Regional Staff beginning January 2018.
- What is an acuity differential?
Acuity is meant to reflect additional oversight and professional services in the rate (i.e. it is an increase in the program support percentage) and not additional direct care support hours. The increase is due to clinical needs of the people being served. JVGA recommended a higher Program Support percentage to create a rate specifically for people with these special needs.
- How will the need for the acuity differential be determined?
The need for the acuity differential will be determined by the assessed level of support an individual requires including the use of the Health Risk Screening Tool (HRST), the behavioral plan, and other professional assessments.
- What are the specific criteria that “qualify” an individual with behavioral
challenges to receive the “acuity” rate?
The acuity differential is designed to compensate for clinical supports over and above the standard hour of support that are the result of medical, psychological, or behavioral issues requiring professional assistance (consult of oversight). It is not additional direct care support hours. JVGA recommends that some of the conditions be an automatic approval of the use of the acuity differential (ventilator dependence, non-ambulation combined with dependence on feeding assistance), because these are usually accompanied by clinical oversight. The need for professional oversight is typically captured in the Supports Intensity Scale using the medical and behavioral supplemental questions and can be captured by other assessment methods currently used in Maryland.
- Is acuity reevaluated and adjusted on a periodic basis? If there is change in behaviors, medications, level of independence does this trigger a change in the acuity rate status and if so, who makes this determination?
Yes it can be considered any time there is a change in health and behavior. The determination is made by the DDA based on the documentation of need.
- Based on the current number of individuals served by DDA, what percentage of individuals did the modeling suggest would be classified as receiving the acuity rate?
The modeling did not project the number of individuals who would require the acuity rate. The second phase of the study will explore the hours of support that are currently occurring in environments where there are clinical supports beyond standard habilitation. That phase begins in January 2018 and will proceed through June 2018.
- When will agencies be given the matrix to show who they are serving that is eligible for the acuity rate?
As noted in question 11, the application of the acuity rate will be based on the assessed needs of the individual. This will be done through the Person Centered Planning process.
- Please explain the tiers for Community Living.
The tiers were estimated. However, additional data has been requested and JVGA and the Technical Work Group will be revisiting this issue in January.
- What are Direct Support Professional (DSP) tiers?
In effort to create a career path for DSP’s that would lead to higher wages, improve the quality of services provided, and mitigate staff turnover, the DDA asked JVGA to build funding into the rate structure to support for this effort. This is a relatively new concept and therefore, data is limited. However, Maryland looked to a study conducted by the State of New York which explored ways to create a credentialing program that would lead to higher wages for direct support workers and to a better trained workforce. That report formed the basis of the recommendation that is incorporated into the JVGA rate structure.
DSP’s will be divided into 3 tiers, each with its own set of credentialing. As DSP’s earn credentialing, the rate of pay will increase. DDA will establish the credentialing required for each tier. Funding is included in the rate structure by estimating the percentage of DSP’s in each tier and calculating an average wage. Over time, as more DSP’s move from Tier 1 to Tiers 2 and 3, this information will be captured by providers and reflected in their wage costs. During future reviews of providers’ general ledgers, this cost will be included to support increases in the DSP wage used for the Brick.
- Is there an advantage to aligning ledgers with the new rate structure?
Yes. In the future, DDA will use providers’ general ledgers to analyze costs and determine whether or not the components need to be adjusted. JVGA refers to this as “re-basing.”
- In the Shared Living Host Home model, how will caregivers be paid for the services other than for room and board, such as meals, transportation, personal care, maintenance of records and case management?
Shared Living will transition during the first year to the new service scope of recruiting Host Home providers, facilitating recruitment and matching services, overseeing quality and monitoring, and compensating the Host Home for additional household cost. The new rate for Shared Living also includes a transportation component. In addition to Medicaid State Plan Services such as Community First Choice, the provision of other waiver services such as Personal Supports, Behavioral Supports, etc. can be provided by the Host Home or other service providers. This will be billed as separate waiver services.
- Shared Living - What about the ability to bill for 33 absence days?
Shared Living reimbursement is based on a monthly stipend and therefore, there is no absence or residential retainers fees.
- Shared Living - Caregivers currently receive respite during the year. Will they continue to receive this?
Yes. Respite is available as a separate authorized service.
- Will a new application need to be completed for the new nursing services?
- Why was the regional/demographic adjustment not included in the proposed rate structure?
A regional or demographic differential was not proposed by JVGA because the costs were not apparent in the general ledgers. However, JVGA is revisiting this issue with providers.
- The ratios for Day Habilitation and Community Development Services only include 1:1, 2:1 and 1:4. How will agencies bill when services are provided in different ratios like 1:3 and 1:5, for example?
Currently the day rate is expected to be a blend of 1:1 and 1:4 which averages to the 1:3 overall ratio indicated to the team as the prevailing ratio. The providers would not bill specifically for other ratios because they are subsumed in the ones selected as averages. However, the Technical Work Group, consisting of providers, has indicated a need to further test these ratios.
- How will rounding occur with hourly billing?
There will be no rounding. It will be based on hours of service.
- The meetings between JVGA and the Coalition of Community Coordination (CCC) providers indicated an agreed to need for 18 training days per year based on information provided. The JVGA Report only includes 12 training days. What is the background to this change? How will the need for 18 training days be addressed?
The Targeted Case Management (TCM) rate was not developed using the 12 training days. This expression came from the service descriptions. The TCM rate is based on an the average number of hours of case management per person in the case mix of a case manager, with an assumption of a caseload of 40 individuals. The actual number of hours per person on the caseload included the assumption of “on board” time, which goes beyond the training days indicated in the service definitions.
- The TCM rate of $76.88 appears to be based on 40 hours of work per year for each client in a 1:40 ratio. Many providers report only billing 30-32 hours per year for each individual on average. Please explain and provide details as to methodology.
The efficiency with which the TCM providers are able to capture billing is sometimes referred to as a “productivity” measurement. There is a difference in actual hours and hours that have been billed historically. The rate does not incorporate any measurement of productivity or billing efficiency, but focuses on the hours needed. This is regardless of how many hours are or were billed.
- JVGA Final Report includes non-billable time of Holidays and Annual Vacation Days. Most providers also provide Sick Leave absences and other paid absences to case managers. How will sick leave and other paid leave, non-billable time be factored into the TCM rate?
These are taken into consideration in a multi-pronged approach. First (and simplest) is the coding of expenses such as those in the general ledgers as employment-related component costs. These are featured in the calculation of that percentage. Sometimes these costs are not identified as employment related expenses in the ledger. Therefore, the team subjects the Employment Related Expenses (ERE) percentage to a series of “reasonableness checks.” In the case where the calculated ERE percentage appears low, it may be explained by the absence of these identified costs. This was the case in Maryland. The recommendation by JVGA for Maryland was to use the highest demonstrable percentage for all providers, for all services.
- How is or how will other non-billable time events be factored into the rates? Examples include staff meetings, travel, meetings with supervisors, administrative tasks, including tasks required by DDA, services provided after death, etc.?
The best way to address this question is by identifying what this rate system is and what it is not. It is a method of developing rates based on the relationships of cost components (or categories) that are meaningful to service standards, that are then ‘pegged’ to an updated direct support wage. This is what is called the “Brick”. The brick (a fully loaded hour of support) is then translated to a rate by using it to set the value of the billable unit (day, hour, event, or fifteen-minute increment). Actual payments occur as a result of authorizing what is or is not a billable unit, rather than setting the value of each unit.
The rate system does not address each possible event, assign a value to each of those events, and then calculate the total of those events. Such an approach would mandate that all providers perform all events in order to be paid.
By proxy, the system captures them by studying the cost components of all the ledgers and assuming that the average of them represents the whole of the possible costs. Some events need a policy decision to allow billing using the brick system, because they are not costs that are categorized under the cost study. Sometimes revenue is needed, but no billing can occur under the definition of billable unit.
- How are we going to keep people independently in the community if we need to continuously drop in on them to recoup rates?
The PCP will identify individual’s goals, level of service needs and supports including community, family, and waiver services. As a Medicaid Waiver program, services are reimbursed based on actual services provided on a fee-for-service basis.
- What are the chances that the rates will be changed or adjusted before implementation?
It is possible that some adjustments to the rates may occur based on new information or data that was not available or provided during the study. New proposed rates for Employment Services (ES), Community Development Services, Career Exploration, Day Habilitation, Community Living- Group Home and Community Living- Enhanced Supports will be implemented on July 1, 2019.
- How do the rates for Employment Services promote employment?
Employment Services include a variety of supports to promote employment including discovery and customizations based on an enhanced training component for certified staff, milestone payments for deliverable performance measures, ongoing job supports including job coaching and personal care, co-worker supports, and follow along supports based on need.
- Are there plans for additional payments or outcome-based payments related to securing employment and employment related outcomes?
No. The current proposal provides milestone payments for discovery components and profile, and self-employment business and marketing plan.
- What is the hourly DSP wage that was used to determine the rate for ES Follow-Along and Ongoing Services?
The wage was based on the Bureau of Labor Statistics Classification 21-1093 - Social and Human Service Assistant. The wage was accelerating to 2019 using the Medicaid CPI. The wage is $16.90/hour.
- Maryland, like other states, has a mandate from CMS to meet the Community Settings Rule, shifting from facility-based services to community-based services. The data collected for the study is based on services as they exist now. Did JVGA or DDA take into account the higher cost for community-based services?
Yes. Ratios for community integration services like Community Development Services and Day Habilitation were reduced to reflect the change in how these services will be delivered in the future. Transportation was also increased from approximately seven (7) percent, as indicated in the ledgers, to 49 percent.
- What challenges are other states experiencing when transitioning to the Brick Method?
The most challenging aspect of the rate system has always been, without exception, establishing accurate hours of direct support. Once those have been resolved and the system has been implemented, it has been found to be simpler and more meaningful than in the systems it replaced. It has been well liked by providers and state departments alike. According to JVGA, this method has not been abandoned by any state. It is the only rate system that had a class action lawsuit to require its implementation, rather than to stop it.
- Given the new rate will require infrastructure with new system and staffing to accurately handle hourly billing, does the G & A component of 10.8% address this need?
The rate system does not build the value of each and every activity by costing them our separately. The system captures them, by proxy, through studying the cost components of all the ledgers assuming that the average of them represents the whole of the universe of costs. Consequently, when providers’ general ledgers are studied in the future, any changes, increases or decreases, will be evident and will be reflected in changes in the percentage of the cost component.
- How did you calculate the average hours in each tier of Community Living Bricks?
The tiers based on an estimate of how many hours an individual in congregate living settings would use within a 24 hour period. However, a request for additional data has been made and JVGA and the Technical Work Group will revisit the proposed tiers.
- How will the flexibility of services in Employment Services be determined?
Services are based on the Person-Centered Plan.
- How many providers are in Group C (those that did not submit general ledgers or DSP hours)?
Approximately 80 providers did not submit general ledgers or DSP hours.
- Did you separate the cost of serving people based on level of need/acuity and if so, how?
The possibility of issues related to acuity was first suspected by evidence on the general ledgers when the Program Support percentage was much higher than the average. Once JVGA suspected that, the provider was called for confirmation. Also, JVGA asked the state to identify known providers who served people that experienced clinical issues. We isolated and studied their general ledgers as a group.
- Since the Rate Setting Study supports the Community Pathways Waiver Renewal, why was more time not allowed for the stakeholders to fully understand the impact of the proposed rates?
JVGA, with DDA’s input and cooperation, solicited public input by convening two groups to inform the research and development process: (1) the Technical Work Group; and (2) the Service Quality Work Group, composed of waiver participants and their families. The DDA held town hall meetings in each of the four (4) regions from Nov. 13 - 16, 2017. Also, DDA established a dedicated email address where questions could be submitted. Phase II of the Rate Setting Study involves the JVGA’s consultation with each provider on the impact of the proposed rate structure and the proposed rates. This phase will begin in January 2018 and continue through June 2018. Implementation of the new rate structure will begin July 2019.