Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.
[ More on DMA Public Comments. ]
Comment 292
To: Webmedpolicy, Dma
Cc: Bradshaw, Tammie
Subject: 8M policy
Sent: Thursday, August 11, 2011 9:59 PM
DMA,
I am writing in response to the proposed policy recommendations. I own my own Case Management Company, and serve individuals in Mecklenburg, and Pathways LME. I am deeply concerned over the policy recommendations as well as recent increased activity at the State level of changes or proposed changes that will effect folks I serve. I was very involved with advocating against the recently accepted HB 916, and am now seeing my concerns being played out with this proposal, and previous proposals within the last several months. I warned lawmakers (Rep. Earle, and Insko) of the dangers of the HB, and am seeing my predictions being played out even before implementation of HB 916. I have served folks with disabilities for over 25 years, and am disappointed in DMA/DHHS (divisions that are set up to assist folks with disabilities) put out policy that actually hurts the folks they are supposed to support. I have done an analysis of some of my cases (about 5) with the proposed changes in the 8M policy from current services in their cost summary to proposed changes under the 8M policy recommendations. The outcome has been a reduction in cost/services of about 25% per client (good job state!!) without any medical justification for a reduction other than a policy change as recommended by the State. I plan on laying out my issues in this e-mail from my careful review of the 8M policy so you will better understand my concerns as well as the people I support. In an attempt to save money I believe you all have lost sight in the people that are being served. Your attempt at trying to save money by reducing or eliminating services will backfire and create more cost to the state as Families will be forced to place their disabled family members in placements that will cost the State much more money. My issues will be laid out in the following order with reference to the page number in the 8m policy so as to easily follow my point.
1) Respite for Residential Support folks (can they get Respite or not? if so why not on the same day?)
2) Elimination of Home Supports
3) Elimination of Enhanced services
4) change from "guidelines" to "Criteria" in the proposal
5) limitation of Habilitative hours to 129 H/M (30 H/W) for adults/children when out of school
6) Limitation of Habilitative hours to 86 H/M (20 H/W) for school age children
7) Limitation on hours a month for Guardians and family members to 40 H/W or 5.8 H/D
I want to start out this analysis by looking at what was written into the policy. On page 4 of the 8M policy this statement was made "The waiver, Community Alternatives Program for Individuals with Intellectual/Developmental Disabilities (CAP-I/DD) is designed to give persons with intellectual and developmental disabilities, a cost-effective alternative to care in an intermediate care facility for persons with mental retardation (ICF-MR). The goal of this funding source is to enable individuals to have a choice of living in the community instead of in an institutional setting and to have effective support in creating a preferred lifestyle that challenges each individual to live to his or her fullest potential." This I imagine is the driving force behind the waiver. If so, the 8M policy and DMA seems to forget the mission as outlined here. This statement was found on page 5 of the 8M policy that is also significant. "Person-centered planning is a process of determining real-life outcomes with individuals and developing strategies and goals to achieve those outcomes. The participant, the legally responsible person, or both direct the process and share authority and responsibility with system professionals about decisions made" (page 5). These decisions made in this policy were not made by the people that matter (the clients or their team members, but by politicians or people who are not concerned about what is best for the individual served). Another qoute I want to use from the 8M policy is from page 39 under amount and duration of service. "The amount and duration of services provided are determined through the person-centered planning process with the participant’s planning team. Services are based on the needs and priorities of the participant, the availability of other formal and informal supports, and rules of the funding source. The planning team shall ensure that medical necessity criteria are met for Medicaid reimbursement as cited in 10A NCAC 22O .0301.
Authority G.S. 108A-25(b); 42 CFR 440.230(d). In and throughout the policy you put limits on services that are in direct conflict with what is written in the policy. Amount and duration of services is determined by the participants planning team, not DMA.
Point # 1: The 8M policy is unclear on its stand as to Respite for folks recieving Residential supports. On page 11 of the 8M policy it seems to indicate that Respite would not be allowed for RS clients, but on page 94 of the policy it states that it can not be billed on the same day as RS, and then later states that it cannot be billed on the same time time as day as RS. Either way it presents problems. If totally eliminated then staff would have to pay out of pocket for Respite, and then the State would find themselves in a sticky situation because they could not mandate Staff requirements for non Medicaid payment opening themselves for a huge liablity issues and potential lawsuit if the staff have a friend do respite that may potentially abuse the client, and the staff/provider would have to say they had to do that because of state policy requirements. The other matter regards to not doing RS and Respite on the same day presents another issues. If staff provide RS for anytime during the day, and bill for it, and then have someone provide Respite the Respite will be paid out of pocket as illustrated in previous statement (huge state liability). If RS staff do services during the day, and don't bill because they want to use Respite and Respite is billed, then it becomes a labor law issue because the State is mandated staff work free if they provide RS services, and respite on the same day. This once again opens up the State for lawsuit due to policy changes.
Point #2: In the 8M policy it recommends elimination of Home Supports for individuals who live in their own home and recieve services from their Guardian or Family Member with replacement of HCS and personal care services. This is the biggest issues I have with this policy, and where most of the cuts are effected. Many individuals who recieve Home Supports do so because their Family Members have decided to quit their fulltime job to care for their loved one with a disability. Now the State wants to put an additional burden on these families because they consider them natural supports, and it is "their duty to care for their loved one" and so they decide to cut services. This puts an undue burden on the Families to provide the same quality of care with less support. Many of these Families provide this service because of past abuse by staff or because they live in an area that is hard to staff, or the individual has such intense needs no one would work with them. I will cover this in another area, but when the 8M policy limits the habilitative hours to 129 H/M, and the person recieves Day Supports (typically utilized at 30 H/W) then their is no more habilitation to be used even though the consumer needs it so Families are left to use PC, and only 40 H/W or 5.8 H/D of services. Many of these consumer require 12-20 H/D of services so this policy forces Families to care for their family members much more than they are compensated. The end result will be that Families will have to utilize other options such as institutionalization to care for their family member as they will not be able to take on the additional stress of caring for their loved one and meeting the daily responsibilites of paying their bills. This will result in cost increases at the state level.
Policy #3: In regards to elimination of enhanced services I believe that once again the State has failed to take in consideration the individual served and has decided to look at the cost savings. People recieve enhanced services primarily due to behavioral or medical issues that warrant intense need. By eliminating the enhanced services staff and/or Family will have to care for the the needs of the individual without appropriate commpensation due to the additional training required or additonial liability they take on. The long term effect will be an inabilty of providers or Family to provide well trained staff to provide services once again forcing alternative placement that will increase state costs
Policy #4: I am not clear on the differientiation between "Guidelines" and "criteria" when it pertains to limits on services. My understanding is that Guidelines are recommendations, and criteria is limits. Just need clarification
Policy #5: I have concerns that the limitation on Habilitation hours to 129 H/M conflicts with the concept of Person centeredness, and seriously effects folks recieving Home supports. 129 H/M limits folks to 4.2 H/D of habilitation of services if they recieve services 7 days a week. If folks get Day supports (typically done at 30 H/W) it would eliminate any habilitation being done at the home, only PC. This would force families, and staff in providing uncompensated work beyond what is needed to the individual. This has potential labor law issues, and rights violation issues for the State. This will directly effect adult consumers who live at home who reieve additional servcies, and will result in a cut in services. This policy recommendation also appears to comflict with other things in the policy that states that adults may recieve up to 12 H/D of Habilitative services in one day. Many of these individuals served have a treating physician stating they need more services beyond 129 H/M, and yet the State wants to limit services regardless of what the treating Physician states.
Policy #6: Regards to the Policy recommendation on Limitation of Habilitative hours to 86 H/M (20 H/W or 3 H/D) for school age children. I have concerns because it seems to conflict with other things in the policy that states kids can recieve up to 6 H/D of habilitation services (129 H/M) or other places that says they can recieve up to 12 H/D on non school days.
Policy #7: Regards to the policy Limitation on hours a month for Guardians and family members to 40 H/W or 5.8 H/D. As stated earlier this puts an undue burden on Families who have quit their jobs to care for their adult child, and are now looking at a huge reduction in services, and are expected to continue to provide supports, but under the heading of natural supports (because that is what Families should do). This Policy recommendation will seriously effect Families who provide home supports. Many of those adult individuals also recieve Day Supports, and because of the other limitation recommendation of 129 H/M these families will only be able to provide PC which in many case is not sustainable given what they gave up to care for their child forcing many members to rethink caring for their loved one in their which will result in an increased cost at the State level. I have many Family members who provide well over 10 H/D of services due to intense needs of their family members who will now be forced to resign their day jobs or place their Family members in a group home/AFL/Institution due to service limitations put forth in this policy.
I hope I have been clear in my deliberation on my concerns and issues, and my desire to support the individuals, and Families I represent. If you have any questions or need to speak to any of my families on how these policy changes will directly effect tehm please call me at 704-249-7418.
Sincerely,
Paul Peters
Owner
Covenant Case Management Services, LLC
