HCBS Division of Aging Rate Methodology Project Frequently Asked Questions

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.

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.

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.

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.

“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.

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.

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.

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.

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.

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.

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.

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.

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.

We cannot commit to rate increases for all services.

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.

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.

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.

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.

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.

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.

Please report other accredited staff on the “Other” line.

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.

You may separately provide supplemental cost information, such as projected cost increases, in the provider survey comments or separately via email at HCBS.Ratemethodology@fssa.IN.gov. Please only include historical program-related costs from your specified time period in the five cost categories in the provider survey.