Preview of New DD Payment System in ND May 16,2016 Presented to Families and Guardians

How payment works now: Medicaid is the primary source of payment for residential, day, and family support services. The ND Department of Human Services reimburses licensed DD providers monthly after services are provided. Payments are set according to service needs in different ways; people in ISLA have individual contracts, group homes and day supports have group rates. Most rates are daily, except Family and Day Supports, which are hourly.

Current System is Retrospective: Interim group program rates are set at the beginning of the fiscal year, with a total allowed limit, plus a 5% cash flow cushion. At year-end we send in a cost report of actual expenses. 1-3 years later, the State (DHS) sends preliminary final rates, which we can dispute within timelines. Final rates are then set, and providers generally have to pay back at least 5%, depending on occupancy.

Why change is needed: The 2009 legislature required the NDDHS to contract with a consultant to study the DD payment system. Burns and Associates were hired and reported back that ND had the most complex, antiquated payment system in the country, and that it did not effectively tie medical and behavioral needs to reimbursement. The 2011 legislature required DHS to develop a new payment system using a new client assessment, the SIS (Supports Intensity Scale).

Assessments are standardized: The Rushmore Group from SD was hired to conduct assessments on all individuals served in the DD system across ND. SIS assessments have been done on all individuals aged 16 and over. Children under 16 are assessed with the ICAP. In the future the Child SIS will be used instead.

What if needs change? New assessments will be done every 3 years. A major change in support needs could trigger a new assessment to be done earlier. The person’s individual team can request a new assessment.

Converting SIS scores to funding: SIS scores will help to inform individualized hours of support. Subsection scores are weighted to determine an overall score. (sections A, B, E, and 3a and 3b.) A multiplier is applied to calculate how many hours of support a person receives for each service. Hours of support are multiplied by the standardized rate per day or hour for each service. Each person will have an annual Individual Budget Allocation (IBA)based on the above process.

How were the service rates developed? A consultant group, JVGA, or John Villegas-Grubbs and Associates, was hired to create the new structure. A steering committee of providers and state officials has been meeting regularly since 2011 to inform the process. The ND Dept. of Human Services makes the final decisions. Initial unit rates were developed by JVGA for each service, informed by average costs incurred by providers.

Component rate structure: Each service rate considers components of costs: The direct support average wage for an hour of service drives the rate calculation. For each hour of direct support, JVGA added: 35.1% for employment-related costs, such as benefits 14% for relief staff, currently called labor pool A varying % for program supports (ie: Q, SW, Nursing, etc.) 10% of the rate is for administrative costs

Service categories are changing: ICF/IDD will have 2 rates; regular and “nursing intensive”. Rates will be daily. Residential Habilitation will cover all residential supports to people needing a contact each day, including TCLF group homes, ISLA and FCOIII. Rates are per day. Independent Habilitation will cover people who don’t need daily contact, including some SLA people. Rates are per hour.

Service categories continued: Day Support rates are hourly. Providers will bill separately for: Day Supports Prevocational services Individual employment supports Small group employment supports Family Support rates are set for respite and in-home supports, billed hourly, based on contracts such as those used now, with negotiated support hours. The SIS/ICAP will not be used to determine number of hours.

There will be Outliers: Those with extraordinary support needs due to medical and behavioral concerns may qualify for consideration for extra hours of support. Specific criteria will identify possible outliers, in cases where there are imminent health and safety concerns. More detailed assessments will occur. Extra hours of support will be negotiated with the regional and state DD offices, based on individual team recommendations. (Process is not yet finalized).

What does this all mean for people served by DD providers? Teams need to be realistic about individual needs during assessment interviews – don’t overestimate skills. Individual Budget Allocations are “portable”- the funds attached to a person move with them, no matter who their provider is in ND. Some people will get more staffing approved than they have now, and others may get less, depending on outlier status. Some providers will lose money over all and others will gain, depending on their mix of services.

Projected Impact on DHI Services: DHI anticipates a reduction in revenues starting Jan. 1, 2017, when new rates take effect. DHI has a strong commitment to continuing quality services to people. Some individuals may get fewer hours of supports in a day, or have to share some staff, especially at night. We need to remain open to environmental changes that allow more shared staffing. DHI will be making operational and administrative changes to save money.

What’s Next: New state regulations will be out for public comment soon. Anyone can send in written comments or attend a public hearing. The comment period is 30 days. We will start to identify possible “outliers”, hopefully by fall of this year. Teams will begin to look at possible changes in hours of support or environments. We will keep you posted of any changes.