HCBS Division of Aging Rate Methodology Project Frequently Asked Questions
Introduction:
These frequently asked questions relate to the Family & Social Services Administration Division of Aging’s Home- and Community-Based Services rate methodology project, where the division, in coordination with the broader FSSA organization, is developing a structured and transparent approach to establishing new rates for its Medicaid HCBS waiver program services. The new methodologies will enable FSSA to achieve its policy goals and be in compliance with the Centers for Medicare and Medicaid Service’s requirements for sound and rigorous payment methodologies.
The FAQs relate to questions and comments received from stakeholders as of May 1, 2019. This FAQ will be updated at selected intervals based on newly submitted questions and comments.
Division of Aging Rate Methodology Project - General
- Will State Plan home health services (under PA) be included in the division's rate methodology project?
No, the project will only update HCBS waiver services, not state plan services. A list of all of the covered services under the Division of Aging’s Aged & Disabled and Traumatic Brain Injury waiver programs can be found here.
- Can you note how many total participants are currently on the A&D waiver? Why has it grown so quickly? (more funding? more access?)
The A&D waiver program enrollment has been steadily increasing – there were approximately 19,200 participants as of December 2018, which is approximately double the A&D waiver program enrolment from 2012. Enrollment increase has been driven by a number of factors, including changes in demographics, increased demand for non-institutional care, and state policy supportive of access to community supports.
- When would the new rates be implemented?
New rate methodologies are subject to a state approval process (from the State Budget Agency and State Budget Committee), which would be followed by an official public comment and response period of at least 60 days, followed by an approximately three month Federal approval process (from CMS). As such, the earliest date that rates could be updated is January 1, 2020.
- Why have the waiver program rate methodologies not been updated more recently given CMS' requirement to update at least every five years?
Indiana’s waiver program rate methodology updates to date have been generally ad hoc and targeted for specific services. Recently, CMS has employed a more rigorous process during its review of waiver applications and programs to assure that states are in compliance with CMS guidance that, “Rate setting methodology must be reviewed, and updated if appropriate, every 5 years in accordance with the renewal cycle.” Thus, FSSA is taking the initiative to work across divisions and waiver programs, including the Division of Aging’s programs, to develop structured and transparent approaches to establishing rates across covered services.
HCBS Waiver Program Cost Neutrality
- What is the CMS cost neutrality requirement, and how does it impact Medicaid HCBS spending?
“Cost neutrality” refers to a federal requirement that HCBS waiver program costs do not exceed the estimated cost to serve the same population in an institutional setting. Indiana must demonstrate to CMS that it meets this requirement on an annual basis.
- Are State Plan services included in cost neutrality?
Indiana’s cost neutrality demonstration includes all Medicaid costs for the waiver program populations, including both waiver services and state plan services. For example, in the case of a waiver participant, costs would include the cost of waiver services, physician services, prescribed drugs, home health services received through prior authorization, durable medical equipment such as a wheelchair, supplies such as diabetes testing strips or compression stockings, and other services for which Medicaid pays.
- How does the A&D waiver program’s enrollment increases (under Olmstead) affect cost neutrality?
Because it relies on the average cost per participant, Indiana’s cost neutrality expenditure limit expands when HCBS waiver program enrollment expands. As such, adding more participants to the waiver programs by itself does not adversely affect the state’s ability to demonstrate cost neutrality.
Division of Aging Rate Methodologies
- To the extent Medicaid HCBS reimbursement is driving down average wages in public data sources, how will you take this into account?
The division is evaluating several public data sources for the labor component of fee schedule rates, including wages paid in other states or private pay. The division will also consider whether current wage levels are sustainable (per one of the division’s project goals). The provider survey is another source the will be used to understand current wage levels and whether they support retention.
- To provide a check on whether tiered rate level of care is being applied consistently, is there a way to review distributions of levels by provider?
For tiered rate services based on the Level of Service assessment (such as Assisted Living, Adult Family Care and Structured Family Care), the division is evaluating the distribution of tiers by provider. There are legitimate reasons for this to vary by provider.
- The focus of the rate methodology seems to be on reconstructing costs. How will this be balanced or offset by examining what providers are being paid by private pay clients for the same services?
Yes, consistent with CMS guidance on rate sufficiency, the division will consider how draft rates benchmark to rates for similar services, including those from other state Medicaid programs and Indiana private pay rates.
- Have you quantified the unmet need for services? Have you analyzed authorized services provided vs. actual units provided? The change in the number of waiver providers compared with participants?
Milliman is conducting analyses of trends in participant enrollment, provider enrollment and units of service provided. Results of these analyses will be shared with stakeholders and considered in development of the final rate methodology.
- How will the rate methodologies account for facilities and meals expenses?
Facility expenses related to home office and administration and meals explicitly covered by the waiver programs can be included in the proposed operational and program support adjustment under the fee schedule methodology. As described in the rate methodology stakeholder meeting, provider survey responses on total administration and program support costs will be reflected in rate development.
Other room and board services are not covered under the waiver and are not allowable under federal/CMS guidance, and must be excluded from the rate development process.
- Will new rates result in waiver program expenditure increases, or will budget limitations be considered when developing rates?
Budget impacts may be considered, although it has not yet been determined how they will affect rates. Ultimately rate methodologies and rates must be approved by the State Budget Agency.
- Given the time since the last rate methodology update, can we assume all rates will increase?
We cannot commit to rate increases for all services.
Value-Based Purchasing
- How might Value Based Purchasing be used for the HCBS payments, and will there be both downside and upside risk?
We will consider various approaches to VBP, which involves linking payments to improved provider performance. VBP programs generally start with upside risk only and move along the continuum over time. The division welcomes suggestions about potential VBP approaches and related quality measures.
Provider Survey
- Where can we find the provider survey webinar and PDF (with instructions)?
The provider survey webinar and PDF can be found here. We encourage providers to review the PDF first before entering the information in the web-based survey which can be found at https://www.surveygizmo.com/s3/4917097/Indiana-FSSA-Division-of-Aging-2019-HCBS-Provider-Survey.
- How frequently does the Division of Aging plan to release this survey?
The division plans to release the provider survey to support its updates to rate methodologies, which will occur at least every five years. The division does not plan to release this survey on an annual basis.
- How will the Division of Aging tie back the survey responses to each provider?
The provider survey requests a provider NPI, EIN, or other identifying information. Please note that the provider survey responses will be held confidential, and the division will not share individual provider responses. The division may share aggregated data, that is combined across providers.
- For providers with multiple locations and NPIs, should we submit multiple survey responses?
Please provide separate survey responses for each location if possible. If you are only able to provide consolidated information, please specify in the survey comments that your information is consolidated.
- In the “Monthly Participant and Staffing Information” section, for agencies that provide transportation services should we report drivers’ hours and wages in the “Direct Care Worker Staff”, or separately?
If transportation is provided by direct care staff, please include the transportation hours in the “Direct Care Worker Staff” line. If transportation is provided by drivers who are separate from the direct care staff, please report their hours separately in the “Other” line.
- In the “Monthly Participant and Staffing Information” section, where do we report accredited staff hours and wages (ex: QMA) for staff who are not specified in the employee types on the survey?
Please report other accredited staff on the “Other” line.
- In the “Program-Related Cost Information” section, can we provide additional cost information not included in the survey, such as room and board costs, to demonstrate the full costs incurred by our provider?
If you wish to share supplemental cost information, such as room and board or other non-program related costs, please provide it in the provider survey comments or separately via email at HCBS.Ratemethodology@fssa.IN.gov. Per CMS requirements, room and board and other non-program related costs cannot be included in the five cost categories in the provider survey.
- In the “Program-Related Cost Information” section, can we provide information related to additional costs we expect to incur in the future due to new requirements, increased labor market pressures, or other factors?