Exploring Options for Addressing the Wait List for the DDS Alternative Community Services (ACS) Waiver Program for the Intellectually Disabled and Developmentally Delayed

1. 1
Proprietary and Confidential
Arkansas Health Care Reform
Task Force – ID/DD Wait List
Exploring Options for Addressing the Wait List for the DDS Alternative
Community Services (ACS) Waiver Program for the Intellectually
Disabled and Developmentally Delayed
March 2016

2. 2
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Executive Summary
• TSG reports what a new waiver benefit would look like for the
2,640 people on the ID/DD wait list
• Top-5 benefits except Supportive Living

3. 3
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Agenda
• Review historical spending for Waiver program
• Report results of a survey of households on the wait list
• Model the effect of alternative capped a range of alternative
waiver programs
• Recommend path forward

4. 4
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Waiver Background
• Improve the quality of services through Home and Community
Based Waiver Services provided under a 1915 waiver for a
limited number of individuals as an alternative to ICF/ID
placement
• Serving targeted populations: mental illness, and intellectual,
developmental or physical disabilities with an age of onset
before age 22
• Participation capped at 3,9881, with turnover, served 4,127
different individuals in SFY2015
• Wait list of 2,640
1 - http://humanservices.arkansas.gov/ddds/waiverDocs/ACSWaiverGuidebook.pdf

5. 5
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Services
• Supportive Living – enable beneficiaries to live in their own
homes, with their family, or in an alternative residence
• Respite Services – short-term benefits for beneficiaries unable
to care for themselves due to absence of non-paid caregivers
• Supportive Employment – enable beneficiaries who need
intensive ongoing support to perform in a competitive work
setting
• Adaptive Equipment – equipment to increase, maintain or
improve functional capabilities to perform daily life tasks
• Vehicle Modifications – adaptations to an automobile or van
to accommodate the special needs of the beneficiary
• Environmental Modifications – modifications made to or at
the beneficiary’s home

6. 6
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ArkansasBureauofLegislativeResearchMarch2016
Services (cont.)
• Specialized Medical Supplies – items necessary for life support
not otherwise available under Medicaid
• Supplemental Support Service – enable community living, in
response to crisis, emergency or life threatening situations
• Case Management Services – assistance in gaining access to
needed services, in or out of the Waiver
• Consultation Services – clinical and therapeutic services
• Crisis Intervention Services – in the beneficiary’s home or
other local community site by a mobile intervention team
• Community Transition Services – set-up expenses for
beneficiaries who are transitioning from an institution

7. 7
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
SFY2015 Services by Claim Amount
Supportive
Living
0
25
50
75
100
125
150
175
200
225
Millions
Waiver Spending by Service
Transition
Respite Care
Consultative
Specialized Medical
Supplies
Adaptive Equipment
Supported
Employment
Case Management
Supportive Living
Claims data from SFY2015 federal Expenditures Report
81%
Cummulative
100%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
100
200
300
400
500
600
700
0-10,000
10,000-20,000
20,000-30,000
30,000-40,000
40,000-50,000
50,000-60,000
60,000-70,000
70,000-80,000
80,000-90,000
90,000-100,000
10,0000-110,000
110,000-120,000
120,000-130,000
130,000-140,000
140,000-150,000
150,000-160,000
160,000-170,000
170,000-180,000
180,000-190,000
190,000-200,000
>200,000
NumberofBeneficiaries
Annual Claims Amount by Beneficiary
Spending Levels by Beneficiary
96% of Waiver Spending is for Supportive Living
20% of beneficiaries spend less than $20,000 – 80% less than $70,000

8. 8
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Spending by Service Type
Service Type
Total Waiver
Claims
Amount
Unique
Beneficiary
Count
Average
for Those
Claiming
Benefit Percent
Supportive Living 196,404,211 4,013 48,979 95.9%
Case Management Services 5,550,856 4,094 1,357 2.7%
Supportive Employment 668,300 103 6,617 0.3%
Specialized Medical Supplies 642,407 925 696 0.3%
Consultation Services 453,751 733 621 0.2%
Adaptive Equipment -ACS 392,835 155 2,568 0.2%
Respite Services 380,605 153 2,521 0.2%
Environmental Modifications 238,010 52 4,760 0.1%
Supplemental Support Service 16,462 17 1,097 0.0%
Adaptive Equipment - PERS Monthly Fee 13,733 31 474 0.0%
Adaptive Equipment - PERS Installation 479 6 120 0.0%
Total 204,761,648 4,124 49,675 100.0%
Claims data from SFY2015

9. 9
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Supportive Living Averages $49,000
82%
99%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
100
200
300
400
500
600
CumulativePercentofBeneficiaries
NumberofBeneficiaries
Total Waiver Claim Amount per Person -- SFY 2015
Supportive Living
Frequency Cummulative
Claims data from SFY2015

10. 10
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Cost of Services Other Than
Supportive Living
1,357
6,617
696 621
2,568 2,521
4,760
1,097
474
120 0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
0.0
1.0
2.0
3.0
4.0
5.0
6.0
CaseManagement
Services
SupportiveEmployment
SpecializedMedical
Supplies
ConsultationServices
AdaptiveEquipment-
ACS
RespiteServices
Environmental
Modifications
SupplementalSupport
Service
AdaptiveEquipment-
PERSMonthlyFee
AdaptiveEquipment-
PERSInstallation
Average
Annual($Millions)
Historic Total and Average Costs of Services Other Than Living
Total Waiver Claims Amount Average for Those Claiming Benefit
Claims data from SFY2015

11. 11
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Services other than Supportive Living
Rarely Total More than $6,000
77%
90%
96% 99%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
500
1,000
1,500
2,000
2,500
3,000
3,500
CumulativePercentofBeneficiaries
NumberofBeneficiaries
Total Waiver Claim Amount per Person -- SFY 2015
All Claims other than Supportive Living
A program capped at $6,000 would meet 96% of needs other than Living Support
Claims data from SFY2015

12. 12
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
A Program Capped at as Little as $6,000 would
Cover Most Historic Claims -- Except Supportive
Living
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
22,000
AnnualClaimsAmount
Individual Beneficiaries
Spending by Current Waiver Beneficiary
(Other than Supportive Living)
100%
Claims data from SFY2015

13. 13
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Agenda
• Review current spending for Waiver program
• Report results of a survey of households on the wait list
• Model the effect of alternative capped a range of alternative
waiver programs
• Recommend path forward

14. 14
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Survey Method
• Survey invitation sent by US mail to 2,640 individuals on the
wait list
• Asked to rank the top 5 most important benefits from the list
• Respondents responded by using a web survey
• Asked for comments at the end of the survey
• Offered the opportunity to respond anonymously or provide
detailed contact information
• Respondents spent an average of 8 minutes responding (long
for a web-based survey). This suggests they took it seriously

15. 15
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Responses Covered the State
Note: 81% of responses provided name and address, only these are graphed
• 440 responses in
10 days—17%
response rate
• 81% provided
addresses
• All but one
provided a
comment
• Responses
represented the
entire state

16. 16
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
How the Services were Ranked
0
50
100
150
200
250
300
350
400
450
NumberofResponses
Services Ranking in the Survey
n=440
Rank 5
Rank 4
Rank 3
Rank 2
Rank 1

17. 17
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Services by Rank
0
50
100
150
200
250
300
350
400
450
Rank 1 Rank 2 Rank 3 Rank 4 Rank 5
NumberofResponses
Services Ranking in the Survey
n=440
Crisis Intervention Services
Vehicle Modifications
Specialized Medical Supplies
Community Transition Services
Supplemental Support Service
Adaptive Equipment
Consultation Services
Environmental Modifications
Supportive Employment
Case Management Services
Respite Services
Supportive Living

18. 18
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Summary Findings from Survey
• Supportive Living is #1, but not as strongly favored as the 97%
of current Waiver participants that claim for Supportive Living
• Respite and Case Management are clear #2&3 for those on
the wait list
• Responses are widely dispersed—strongly supporting the
notion of self-determination of services
• Response rate, and number, size and tone of comments all
suggest that the wait list is a very unhappy group, looking to
the legislature for quick relief
• Respondents would rather have some benefits even if it is less
that the whole Waiver program
• Respondents seek more self-direction
• The selection process should be faster, clearer and more
transparent

19. 19
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Agenda
• Review current spending for Waiver program
• Report results of a survey of households on the wait list
• Model the effect of alternative capped a range of alternative
waiver programs
• Recommend path forward

20. 20
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
What if…
• TSG has modeled a waiver like those in Indiana, Tennessee
and Kentucky. It would…
• Provide a benefit capped at an amount much smaller that the
average of claims for those already on the Waiver
• Allow recipients substantial latitude to spend up to the cap on
any of the services. Both models assume that for most
beneficiaries, the capped amount would not be sufficient to fun a
meaningful part of Supportive Living
• This model considered simply for the purpose of
understanding what might result from such a capped benefit

21. 21
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
TSG Developed the Model Based On
• Assumptions:
• Services usage based on survey responses
• Services cost based on historic Waiver claims
• Assuming the program would allow beneficiaries to claim services
up to the cap
• Excluding Supportive Housing from the value assessment, as we
know it averages $50,000, beyond other state caps
• Seeking to find out:
1.What services would beneficiaries likely spend the capped
amount on?
2.How far would the capped benefit go towards “buying” all of
their 5 highest ranked services?
3.How much would the two scenarios cost in total, assuming 2,640
people came off the wait list into the new waiver program

22. 22
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ArkansasBureauofLegislativeResearchMarch2016
0
3,000
6,000
9,000
12,000
15,000
18,000
21,000
24,000
27,000
30,000
AnnualEstimatedClaims
Simulated Beneficiary Claims
Rank 1 Rank 2 Rank 3 Rank 4 Rank 5
Self-Directed Benefit Simulation
72% of top-5 needs (other than Supportive Living) met by a cap of $12,000
86% by a benefit capped at $15,000
The #4 & #5-ranked services are often the more expensive ones
72%
86%

23. 23
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Agenda
• Review current spending for Waiver program
• Report results of a survey of households on the wait list
• Model the effect of alternative capped a range of alternative
waiver programs: Next Task Force Update
• Recommend path forward

24. 24
Proprietary and Confidential
ArkansasBureauofLegislativeResearchMarch2016
Full Cost of Capped Waiver for 2,640
on the ID/DD Wait List
Capped at
$12,000
Capped at
$15,000
Beneficiaries capped benefit: all services $31,680 MM $39,600 MM
Arkansas State Match Cost $9,504 MM $11,880 MM