RCPA - Rehabilitation and Community Providers Association


PCPA, MH/MR Coalition, ODP, and CMS Meeting on ODP Waivers Rate Setting
September 30, 2010

Members of the MH/MR Coalition met with the Office of Developmental Programs (ODP) and the Centers for Medicare and Medicaid Services (CMS) September 24 to continue dialogue from a previous meeting August 13, regarding the ODP rate setting process for the state’s two mental retardation waivers and the impact of that process on waiver providers, both direct service and supports coordination.

An update was provided by ODP Deputy Secretary Casey on the status of several policies under development questioned by providers and advocates at the previous meeting. The outlier policy for high cost consumers is under review. ODP is discussing the possibility of doing a clinical review of the individual’s needs and the Individual service Plan (ISP) to determine service and budget needs. There are 65 one-bed group homes that are very high cost. Disability Rights Network CEO Ilene Shane reminded ODP that the issue isn’t that the ISP and rates don’t match, but that the ISP should be used to determine the person’s needs and not start with the rate setting process and cuts to providers.

Beginning the week of September 20, ODP will issue final 2010/11 rates to providers. It is anticipated they will include a rate decrease of 2.5 percent, called a Rate Adjustment Factor (RAF). The week of September 27, ODP will issue the 2009/10 fourth quarter revenue reconciliation payment or request a recoupment from each waiver provider. The MH/MR Coalition has contacted Department of Public Welfare (DPW) Acting Secretary Mike Nardone for assistance in eliminating the RAF.

CMS is beginning to understand issues providers and advocates have with the RAF. According to ODP, it is being implemented due to the department budget not having enough funds to cover the 2009/10 increase in “changing needs” authorizations, and an increase in therapeutic leave days from the 30 allowed by Medical Assistance to an additional 18 covered by state-only dollars. The main issue is that it is the state’s responsibility to pay for the “changing needs” of consumers enrolled in the waivers. It is not the role of the providers to take rate decreases/cuts to pay for these changing needs. The RAF being used by ODP to shift the responsibility for changing needs funding to the providers is not consistent with the cost-based Prospective Payment System being implemented. The coalition has asked CMS to determine if the RAF is an appropriate payment methodology under the waiver.

Deputy Secretary Casey did indicate that ODP needs to place controls on the authorization process, had not done so in 2009/10, and the annualization of these increases will impact the 2010/11 budget needs. The coalition has sent a formal request to Casey to provide the total cost of these additional authorizations to determine the need for greater funding from the legislature for these services.

PCPA presented the issue of the Supports Coordination rate setting methodology and the numerous responsibilities the state places on the supports coordinator. Casey has repeatedly remarked that CMS has questioned the “high” rates for Pennsylvania’s supports coordination services. CMS emphatically denied urging ODP to move to $10-12 per unit rates. According to CMS’ Nancy Klimon, it is the state’s responsibility to recruit providers and establish rate setting methodology and rates to maintain those services and supports. CMS indicated it understands that states have varied responsibilities for supports coordination services and they do not have guidance, standards, or recommended rates for this service.

Casey agreed that Pensylvania has higher job responsibilities and expectations than many other states. PCPA had already offered at previous meetings to work with ODP on reviewing supports coordinator responsibilities and suggesting revisions. This will be very important as ODP moves toward a fee schedule for rates for SCOs, which will be addressed September 30 at an ODP Forum for SCOs. PCPA questioned Casey on the use of state set rates and questioned how rates could be realistically set if the ODP data on SCO rates is questionable.

CMS indicated they will further review and determine their role in resolution of these issues:

  • RAF,
  • Revenue Targets,
  • Outlier Policy, and
  • SCO Rates and Expectations.
(MH/MR Coalition members working on the IDD issues are PCPA, PARF, PAR, UCP, DRN, The Arc PA, and the PA Waiting List Campaign.)

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