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As part of INARF’s continuing commitment to ensuring members are informed, we have compiled updates on key issues and activities in which the INARF Board of Directors, Governmental Affairs Committee, and Staff have been engaged in on your behalf. Have a question or want to share your perspective on the issues below? Please contact Kim Opsahl for assistance. Have an issue or concern that is impacting your business that is not listed in this update? Please let us know by clicking here. Rate Restoration – SGL Update: INARF recently received clarification from the Office of Medicaid Policy and Planning (OMPP) regarding group home rate restoration. It appears that in preparation for extending the rate reduction through 2017, the State completed a State Plan Amendment (SPA) to obtain approval from the Centers for Medicare and Medicaid Services CMS). This action took place prior to the passage of the Biennial Budget Bill, which included language fully restoring Supervised Group Living and ICF/DD rates. In order to implement the planned 1% restoration, another SPA is required. At this time, OMPP has not yet secured the necessary approval from CMS to implement the restoration. Until that occurs, the rates cannot be restored. We are currently working with OMPP to assess when the SPA is submitted and anticipated timeframe for approval. Once a State Plan Amendment is submitted CMS has up to 90 days to either approve the amendment or “stop the clock” by submitting formal questions to the state for response. We have been advised that once approval from CMS is received, providers will be notified via IHCP Bulletin, restored rates will be published, and mass adjustments will begin to retro-actively apply the restored rates to July 1, 2015. INARF will continue to work with OMPP to receive updates on the Medicaid State Plan review process and will advise members as more information is available. Waiver Re-Write and Amendments: Over the past couple of weeks, teams have been hard at work preparing for the transition to daily rates, effective August 1st. This is an important effort that will help the system move toward a greater focus on outcomes and creating natural supports for the individuals we collectively serve. We are appreciative of the Division’s support in moving in this direction and in the hard work that has been done to implement this important systems change. In INARF’s continuing dialogue with the Division, we have received clarification on the following points which may be helpful in your continuing efforts to prepare for this change. In situations, where two individuals live together and one individual is potentially eligible for the daily rate and the other individual is not and the do not share Residential Habilitation and Support (RHS) services, the potentially eligible housemate should not transition because while they meet the eligibility criteria for the RHS Daily rate relative to Algo level, they are not “sharing” staff in the sense contemplated by the daily rate. If you have individuals in this situation who have been targeted to transition to the daily rate, please do the following: Using the Advocare Provider Portal, confirm that the individual’s living situation is listed correctly (i.e. not sharing RHS staff). If it is incorrect, please request a change using the Update Requests tab in the portal (see instructions beginning on page 3). If it is listed correctly, please contact the INSITE Helpdesk to advise them of the issue and request assistance. In limited instances, the Individual Support Team may believe that moving to the Daily Rate is not in the individual’s best interest due to a unique need that prevents them from being supported under the daily rate. When this is the case, the IST should use the Budget Request Questionnaire process to articulate the individual’s specific service needs and how they are not adequately addressed through the daily rate, as well as to provide appropriate justification and supporting documentation. For individuals who currently receive more than 10 hours/month of Community Integration and Habilitation Individual from their RHS Daily Provider, the Individual Support Team should be meeting to discuss ways in which the individual’s services could be modified in order to fit within this limitation. Options might include exchanging excess CHIO hours for other services that meet the individual’s support needs (i.e. Community Integration and Habilitation Group) or selecting another provider for the excess CHIO hours. In limited instances where the IST believes that preserving the current CHIO usage is in the best interest, the IST should use the Budget Review Questionnaire process to articulate how the individual’s specific service needs are not addressed through the daily rate, including appropriate justification and supporting documentation. For individuals whose CCBs have day services and/or behavior management services that are over the “DAYS-Reserve” or “BMAN-Reserve” funds and are using funds from the “Other” OBA bucket, because the “Other” bucket will be used in total for RHS daily rate, there are not funds left to cover any day services or behavior management services from August 1 thru the end of the CCB. As a result, these individuals will be eligible for a daily rate at the start of their next annual CCB. There are a few young adults who are no longer in school but their “DAYS-Reserve” funds have not been increased by the $5,000 from the “in school” status to adult day services. BDDS suggests that providers contact the CMs and request that they submit BRQs to BDDS to for this change to be made in the OBAs. These individuals may then be eligible for the RHS daily rate. For individuals who are currently shifting resources from their Other Allocation into DAYS or BMAN Reserve, but have not fully utilized those reserves, INARF is working to clarify the impact of conversion. Through this process, it has been noted that a few individuals are receiving Behavior Management services but have a Behavior Algo score of 0. BDDS has suggested these teams determine if the individual needs the BMAN services and, if so, the CMs could submit a BRQ with justification for increasing the Behavior Algo score. If the Algo is increased, the OBA would be increased with dollars in the “BMAN-Reserve”. These individuals may then be eligible for the RHS daily rate. It is important to note that a few individuals have been determined to be “High Cost” or have a “Special Ruling” OBA (such as allowing “DAYS-Reserve” funds to be used for RHS services). These individuals have been determined not eligible for the RHS daily rate. Lastly, we are continuing to work to clarify documentation standards for RHS Daily. Over the next couple of weeks, we anticipate the Division will continue to publish additional guidance and clarification. As this information is available, we will share broadly with the membership. Wellness Coordination: INARF continues to work with the Division to clarify guidance / instruction to providers on Wellness Coordination requirements. During the Community Supports Section meeting scheduled for August 20th in conjunction with the Quarterly Professional Interest Section meeting, we will share feedback from members who have recently been through Wellness Coordination audits and provide updates on the recommendations submitted in June. Family Support Waiver and EPSDT Services: During the approval process for the Family Support Waiver (FSW), CMS advised that the State need to make greater assurances that certain waiver services available to children under the age of 21 were being used only to supplement not replace services the State is obligated to provide under the EPSDT (Early Periodic Screening Diagnosis and Treatment) Program. As a condition of approval, the State agreed to make these changes; including taking immediate action to make necessary adjustments to its State Medicaid Plan and the FSW to ensure children received services through the appropriate source. The Division is waiting for guidance from CMS to clarify which services need to be addressed; they are also working to understand the potential fiscal impact of shifting services currently provided under the FSW to EPSDT Program. Day/Employment Services: On July 1st the Vocational Rehabilitation Services Hybrid Model was implemented. Information and resources regarding the changes, including new forms, have been posted to the Bureau’s website. The Bureau of Rehabilitation Services (BRS) has set a meeting with the VR Rate Reform Work Group in August to begin post-implementation monitoring and analysis. Should you have questions as implementation moves forward, please forward them to VRProvider@fssa.in.gov. If you have issues or concerns that you believe the VR Rate Reform Work Group should address, please send them to Kim Opsahl at kim@inarf.org. FSSA / DDRS Litigation: FSSA and the Division are engaged in litigation on three key areas – the use of the Level of Care Screening Instrument (LOCSI), the policy of moving individuals from the Aged & Disabled Waiver to the Family Support Waiver, and concerns with the Objective Based Allocation Program. On the LOCSI litigation, the State has entered a settlement agreement which will result in the selection and implementation of a new level of care screening tool. On the A&D Waiver policy litigation, the District Court recently entered an order finding in favor of the State. The plaintiffs in these cases have filed an appeal with the Seventh Circuit. On the OBA litigation, the plaintiffs have filed their response to the State’s motion to decertify the class. They have also filed a motion to exclude or limit the State’s expert testimony. The State has subsequently filed their response to this motion. Group Home Advocacy Update: INARF’s Group Home Advisory Work Group recently meet with BDDS Director Cathy Robinson and Director of Institutional Services Cindy Carter to discuss issues related to the vacancy / referral process and general communication / collaboration / coordination at the local level. The discussion was very productive with commitments to gather additional information about the concerns raised and reconvene for further discussion in early September. The ESN Work Group continues to meet with the Division. At this time, the group has finalized recommendations on policies governing referrals, visits, admissions, meeting responsibilities, and discharges and are awaiting final approval. At this time, the work group will continue to meet to discuss related issues. As a result, INARF will be working to implement a third workgroup to begin a broader systems discussion on the role of the group home program moving forward and how INARF and the Division can partner to support that role. Waiver Rate Reform 4.0: In an effort to begin address compliance with the HCBS settings rule and to build a more sustainable system in light of systems issues and trends, the Division of Disability and Rehabilitative Services is embarking in an effort to redesign residential services for individuals on the Community Integration and Habilitation Waiver. With a focus on designing services around where an individual wishes (or in some case’s needs) to be supported, the Division is seeking to design at least four pathways for individuals seeking support, including supporting individuals living with family, supporting individuals in traditional supported living settings, supporting individuals with high support needs who require intensive staffing, and supporting individuals who live on their own but require drop in type services / supports. The Division will be working with a team of consultants to assist with systems design, project management, and communication. Of particular note, the Division is exploring cost-based reimbursement approach for individuals in traditional supported living settings. To assist the Association in understanding these approaches in order to inform the Association’s position, the Rate Reform Workgroup has been reconstituted. The workgroup recently met with the Division to further understand the goals and expectations for this approach. As the prospective model begins to take shape, the workgroup anticipates providing the Division with feedback and perspective. The Division is planning to host forums across the state to gather additional feedback from both providers and families and self-advocates. These forums will be held in September in each BDDS District. Provider forums will be held during the day, with family forums held in the evening. DDRS is mailing an initial notice of these forums to families within the next week. The notice will include information on the purpose and where to go on the state website for forum dates and locations. As more information is available, it will be shared broadly with the membership. The Association plans to establish additional workgroups to explore the remaining pathways, assist the Association in developing its position(s), and provide feedback to the Division. No Wrong Door Initiative: With support from an Administration for Community Living planning grant, the Division of Aging is developing a three-year implementation plan to transform state long term services and supports access programs and functions into a “no wrong door” system for all populations and all payers. To support this effort, the Division of Aging is work with netlogx and the University of Indianapolis Center for Aging and Community to conduct a survey to gain consumers’ views on the current state of the LTSS system, as well as to hear about their hopes for future improvements. To ensure this survey reaches as broad an audience as possible, all INARF members are encouraged to share the link to the survey with the individuals and families you serve through e-mail, your website, social media, etc… A link to the survey along with a brief explanation is included below: http://www.in.gov/fssa/4936.htm The Division of Aging is working to create an integrated “No Wrong Door” system that will help all Hoosiers make informed choices about their Long Term Service and Support needs. In order to do so, they need to hear from you! Please take this short survey about your views on Indiana’s current system of long term services and supports. The survey will take 10-15 minutes and no personal information will be collected. The results will be used to help plan a better and more connected system for all of Indiana. In addition, INARF Staff participated in a focus group with other statewide organizations for the purpose of provide feedback on the current system and developing the plan for integration across the LTSS system. U.S. Department of Labor Overtime Rules: INARF staff will be participating in ANCOR’s workgroup tasked with formulating comments to the Department of Labor's recently published overtime rules. The proposed rule will more than double the salary level under which virtually all workers qualify for overtime pay whenever they work more than 40 hours in any given week. That threshold, now $23,660, [would] rise to $50,440. U.S. Department of Labor Guidance on Misclassification of Independent Contractors: ANCOR recently reported that the Department of Labor (DOL) Wage and Hour Division released Administrator's Interpretation No. 2015-1, which outlines the Department's expectations for the standard to be applied when determining whether a worker is an independent contractor or an employee covered by the Fair Labor Standards Act (FLSA). The guidance seeks to help workers and employers determine whether a worker is truly in business for themselves (and thus not covered by the FLSA) or if he or she is substantially dependent on his or her employer's business (and thus covered by FLSA protections). As reported by ANCOR, the guidance lays out the Department's clear expectation that most workers are to be covered by wage and hour protections of the FLSA, and that the definition of employment should be construed broadly. The guidance sets forth several questions to be considered in determining true economic independence for independent contractors. These are: Is the work an integral part of the employer's business? Does the worker's managerial skill affect the worker's opportunity for profit or loss? How does the worker's relative investment compare to the employer's investment? Does the work performed require special skill and initiative? Is the relationship between the worker and the employer permanent or indefinite? What is the nature and degree of the employer's control? The guidance notes that many employers focus too much on the "control" factor when determining that a worker is an independent contractor, without adequately evaluating additional factors. The guidance includes several examples of situations that would or would not meet the economic realities test. It concludes by saying that "most" workers are employees under the FLSA's broad definitions. Further, "The factors should not be analyzed mechanically or in a vacuum, and no single factor, including control, should be over-emphasized." It ends by saying, "The correct classification of workers as employees or independent contractors has critical implications for the legal protections that workers receive, particularly when misclassification occurs in industries employing low wage workers."
Lastly, we are continuing to work to clarify documentation standards for RHS Daily. Over the next couple of weeks, we anticipate the Division will continue to publish additional guidance and clarification. As this information is available, we will share broadly with the membership. Wellness Coordination: INARF continues to work with the Division to clarify guidance / instruction to providers on Wellness Coordination requirements. During the Community Supports Section meeting scheduled for August 20th in conjunction with the Quarterly Professional Interest Section meeting, we will share feedback from members who have recently been through Wellness Coordination audits and provide updates on the recommendations submitted in June. Family Support Waiver and EPSDT Services: During the approval process for the Family Support Waiver (FSW), CMS advised that the State need to make greater assurances that certain waiver services available to children under the age of 21 were being used only to supplement not replace services the State is obligated to provide under the EPSDT (Early Periodic Screening Diagnosis and Treatment) Program. As a condition of approval, the State agreed to make these changes; including taking immediate action to make necessary adjustments to its State Medicaid Plan and the FSW to ensure children received services through the appropriate source. The Division is waiting for guidance from CMS to clarify which services need to be addressed; they are also working to understand the potential fiscal impact of shifting services currently provided under the FSW to EPSDT Program. Day/Employment Services: On July 1st the Vocational Rehabilitation Services Hybrid Model was implemented. Information and resources regarding the changes, including new forms, have been posted to the Bureau’s website. The Bureau of Rehabilitation Services (BRS) has set a meeting with the VR Rate Reform Work Group in August to begin post-implementation monitoring and analysis. Should you have questions as implementation moves forward, please forward them to VRProvider@fssa.in.gov. If you have issues or concerns that you believe the VR Rate Reform Work Group should address, please send them to Kim Opsahl at kim@inarf.org. FSSA / DDRS Litigation: FSSA and the Division are engaged in litigation on three key areas – the use of the Level of Care Screening Instrument (LOCSI), the policy of moving individuals from the Aged & Disabled Waiver to the Family Support Waiver, and concerns with the Objective Based Allocation Program.