1 iBudget Florida Stakeholders’ Meeting October 23, 2009
Dec 30, 2015
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iBudget FloridaStakeholders’ Meeting
October 23, 2009
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Assessment Instrument
Main question:
How should we get information about people to know their needs?
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Assessment Instrument
Current system:• Previously used the Florida Status
Tracking Survey (FSTS) and the Individual Cost Guide (ICG)
• Now uses the Questionnaire for Situational Information (QSI)
• Covers physical, functional, and behavioral areas
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Assessment Instrument
APD Recommendations:
• QSI be used as assessment instrument
• QSI improvements be ongoing
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Assessment Instrument
Decisions needed:• How and when to request reassessment• How and when to appeal results
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Assessment Instrument
Feedback so far:• Want information on the QSI’s
validity and reliability• Concern that it does not identify
certain needs of individuals
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Assessment Instrument
Your thoughts:• What are your concerns about the
QSI?• How can we make people more
comfortable with the QSI?
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Services
Main question:
What services and flexibility should be available to consumers?
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Services
Current system:• 27 services in Tiers 1, 2, and 3• 13 services in Tier 4• Providers must be Medicaid enrolled
(except for CDC+ program)• Statewide rates with some geographic
differentials• Need for a service is determined
through prior service authorization
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Services
APD Recommendations:• Must use Medicaid enrolled providers• Services allow more flexibility• Rates be neutral• Same set of services available to all
individuals
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Services
Decisions needed:• Potentially combining services for
greater simplicity and flexibility• Limits, if any, for each service
– Dollar amount – Hours – Need proven (prescription or assessment)
• Provider qualifications
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Services
Feedback so far:• Make additional services available in
Tier 4• Want flexibility to use greater amounts
of services
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Services
Your thoughts:• How could service options meet
consumers’ needs better?• What limits on control or other
safeguards might be important for health and safety?
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Waiver Support Coordination
Main question:What should the waiver support coordinator’s role be?
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Waiver Support Coordination
Current system:• Waiver support coordination is a required service• Children have limited waiver support coordination;
adults have limited or full coordination• Waiver support coordinators have lots of required
paperwork – Very little is processed electronically—heavily paper
based
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Waiver Support Coordination
APD Recommendations:• Waiver support coordinator’s role will
shift to more of a facilitator and guide• Will be seeking to reduce paperwork
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Waiver Support Coordination
Decisions needed:• Waiver support coordinators’ specific
tasks• What waiver support coordinator service
options will be available• How we will streamline forms and
processes • What additional training, if any, to require
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Waiver Support Coordination
Feedback so far:
Questions about what the role should be
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Waiver Support CoordinationYour thoughts:• What should the waiver support coordinator’s
role be?• What should the split of individual, family, and
waiver support coordinator responsibilities be?• What concerns are there about the waiver
support coordinator’s role in a more self-directed system?
• What options would a waiver support coordinator have if he or she felt an individual was making bad choices?
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Prior Service Authorization (PSA)
Main question:
How do we best ensure that individuals receive the services that they need within allowable waiver coverage?
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Prior Service Authorization
Current system:
• All services must be approved through prior service authorization
• Reviews are performed by area staff and a contracted provider – It’s time-intensive
– It’s complex
– It’s paperwork-intensive
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Prior Service AuthorizationAPD Recommendations:The process as we know it go away—be
minimized or eliminated as much as possible while meeting federal requirements
• Streamlined paperwork• More flexibility• Personalized approach
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Prior Service Authorization
Decisions needed:• Situations requiring a review• The process for requesting reviews• Who will perform reviews
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Prior Service Authorization
Feedback so far:Scaling back is great but we need something to meet federal requirements for assessing medical necessity of services
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Prior Service AuthorizationYour thoughts:
What service approval process is appropriate for:
•Medical services•Therapies•Behavioral services•Extraordinary needs
•Meaningful day activities•Residential habilitation•Supports in the home
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Consumer and Family Control
Main question:
What would be reasonable limits on individual control?
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Consumer and Family Control
Current system:• Waiver support coordinators work with
individuals and families to support choice• Individuals and families have little insight
into spending of funds for supports• Prior service authorization is required
before service amounts are increased
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Consumer and Family Control
APD Recommendations:
• Training be provided to consumers and families on choice-making
• Consumers and families have greater control over the amounts and types of services they get
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Consumer and Family Control
Decisions needed:• Limits on spending to ensure that funds
last through the year • What to do if a person overspends but
still needs services• How to provide training on making
good choices
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Consumer and Family Control
Decisions needed :• What information consumers need to
make good decisions • How to help consumers track spending• What support to give to consumers who
don’t have unpaid help in decision-making• If funds can be carried over to a future
year like in CDC+
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Consumer and Family Control
Feedback so far:• Some individuals don’t have sufficient
support to exercise self-direction• Concern that some providers may not
cooperate or may be manipulative
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Consumer and Family ControlYour thoughts:• What information and training do consumers
and families need to make good decisions?• How could they get that information?• How can we help those who don’t have families
or friends to help them make choices?
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Consumer and Family ControlYour thoughts:• How might we limit spending to ensure that
funds remain through the year? Should we do this?
• How are pro’s and con’s of allowing carryover of unused funds to another year?
• How can we find out if any providers are uncooperative or manipulative, and what penalties might be assessed?
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Extraordinary and Changed Needs
Main question:
How do we ensure that people with extraordinary or changed needs get enough funding?
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Extraordinary and Changed Needs
Current System:• Individuals are assigned to tiers, which
cap spending• If needs are believed to have changed,
the waiver support coordinator requests a prior service authorization review for additional services and/or a tier change
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Extraordinary and Changed Needs
Decisions needed:• Process to identify people with
extraordinary needs and set their budgets
• Process to handle requests for funding due to changed needs and determine the funds required
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Extraordinary and Changed Needs
Decisions needed:• How to identify people with extraordinary or
changed needs – Statistician will help when the model is more developed
• How to set their budgets• How to decide if needs have changed• How to calculate funds needed for changed needs
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Extraordinary and Changed Needs
Feedback so far:
Want to ensure that funds are available for people with changed needs or extraordinary needs
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Quality Assurance
Main question:
How do we monitor to ensure health, safety, and good outcomes?
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Quality Assurance
Current system:• Contracted provider (Delmarva) performs quality
assurance activities in conjunction with APD staff• Contracted provider uses desk reviews, on-site visits, and
consumer interviews to assess provider performance and consumer outcomes
• Medical Case Management Team and/or WSCs determine if additional review is required for health and safety
• Support planning, annual reports, and quality assurance contractor determine if individuals are progressing toward goals
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Quality Assurance
APD Plans:• New quality assurance contract uses different
measures• Florida is joining National Core Indicators
initiative
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Quality Assurance
Decisions needed:• What might change under a new contract
in a more self-directed system• What might trigger any special health and
safety reviews
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Quality Assurance
Feedback so far:
Support revision of the quality assurance system to be more understandable, less bureaucratic, and more person-centered
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Quality Assurance
Your thoughts:• What are your concerns regarding quality
assurance in a more self-directed system?• How should consumer outcomes be
assessed in a more self-directed system?• What should be done if the consumer is
making poor choices and their health and safety are at risk?
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Overall System Financing
Main question:
How do we make budgets predictable and sustainable for consumers and the agency?
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Overall System Financing
Current system:• Legislature appropriates funding
• Complex rules control individual cost plans and spending to seek to stay within the appropriation – Individuals are assigned to one of four tiers
– Rebasing for those with changed cost plans
– PSA determines medical necessity
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Overall System Financing
Current system:• Legislature cuts services and imposes other
requirements to control spending• About 25% of APD customers had cost plan
reductions under the tiers
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Overall System Financing
APD Recommendations:• System be fairer to consumers and be
sensitive to individual needsImportant to Remember:• State constitution requires balanced budget—
APD must stay within its appropriation• Legislature makes decisions on how to fund
the wait list
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Overall System Financing
Decisions needed:• How much funding to reserve for
extraordinary and changed needs • How tiers will mesh with this system
– Will be designing it without tiers
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Service Providers
Main question:
Who may provide services?
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Service ProvidersCurrent system: • Any provider meeting Medicaid requirements
can be enrolled and provide services• Must use Medicaid-enrolled providers unless in
CDC+• Currently more than 10,000 providers statewide• Range from single-person entities to large-scale
operations with multiple sites and hundreds of employees
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Service Providers
Current system: • Under waiver requirements, consumers must
have choice of providers• WSCs submit service authorizations to begin or
end services with a specific provider• Providers must complete paperwork: annual
reports, quarterly reports, individual plans, service logs, etc.
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Service Providers
APD Recommendation:• CDC+ option continue, although participants
will get iBudgets• Everyone else use Medicaid-enrolled
providers• Rates be neutral
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Service Providers
Decisions needed:• What competencies and standards that
providers would need to meet• What information or notice is given to
providers to begin or end services
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Service Providers
Feedback so far:• Ensure consumers have support and training• Need timely notice and payment• Self-directed system could pose management
challenges – Staffing, regulation compliance, revenue projections
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Service Providers
Your thoughts:• What opportunities does a more self-
directed system pose for providers that are creative and innovative?
• How can providers, consumers, and families work more cooperatively in a self-directed system?
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Administrative Issues
Main question:
How will the system work to make all this happen day-to-day?
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Administrative Issues
Current system:• Area office staffs manage at the local level• Cost plans run with the fiscal year • ABC is the main computer system• Paper-based
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Administrative Issues
APD Recommendation:
Wish to pilot or phase-in as CMS allows
– This will allow us to fine-tune before full implementation
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Administrative Issues
Decisions needed:• When during the year an annual budget begins• How iBudgets will be phased in
– Need to see range of impacts after algorithm is developed further
• Changes required to computer systems and other supporting processes
• What specific staff roles will be – Service approval? Calculating budgets?
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Administrative Issues
Feedback so far:• Support for phasing in over time• Concern that implementing this on top of
other recent changes might be too much• Concern that if we don’t do this soon, the
system will be in trouble
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Administrative Issues
Your thoughts:• How might we phase in iBudgets across
the state? • What is a reasonable implementation
timeframe, recognizing potentially strong interest in the Legislature for action?
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Algorithm
Main Question:What factors should be considered in the algorithm to determine funding?
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AlgorithmCurrent system:• Waiver support coordinators request services for
individuals• Complex system for approving requests
– Law requires use of certain factors to make tier assignments (such as living situation)
– For Tiers 2, 3, and 4, spending is capped – Rebasing – Limits in handbook
• Funding is total of services approved
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Algorithm
APD Recommendations:• Use regression model • Dependent variables are previous
years’ expenditures• Seeking individual budgets
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Algorithm
APD Recommendations:• Data for variables must be reliable and valid• Variables will make appropriate contribution
to model predictiveness• Review model to ensure that health and
safety are not at risk• Rates be neutral
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Algorithm
• Decisions needed
– Specific variables and their contribution
– How often to rerun and revise algorithm
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Algorithm
Feedback so far:• Build a model tailored to Florida• Concern that funding for meaningful day
activities will be eroded or insufficient• Concerns on using diagnosis in the model
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Algorithm
Feedback so far:• Want to know the model details, including
statistical details• How to ensure validity and reliability of data
used in model• Fairness to those living at home
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Algorithm
Your thoughts:• Factors that might be correlated with
costs• Data we might use
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Conclusion
Questions?
Comments?
Suggestions?
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Conclusion
• Adjourn • Thank you for your time and input!