The Medical Care Advisory Committee met on August 11, 2022, to hear updates on CHIP and HPAC, rule proposals, and public comments over several topics including the Home and Community-based Services Program, Texas Home Living Program, Multiple Disabilities Program, SHARS, and Transition Assistance Services. A video of the recording can be found here and the meeting agenda can be found here.
This report is intended to give you an overview and highlight of the discussions on the various topics taken up. It is not a verbatim transcript of the discussions but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.
Opening Remarks
- Vice-Chair Mary Tieken will be presiding as chair while Chair Colleen Horton is out today
- Jacquelin Thompson introduced as new member of ACCO staff
Consideration of the February 10, 2022 and May 12, 2022, draft meeting minutes
- No edits or changes heard – meeting minutes approved
Medicaid and Children’s Health Insurance Program (CHIP) activities update
Emily Zalkovsky, Texas CHIP Representative
- Update on Medicaid and CHIP services
- June 1 Collaborative Care Benefit was enacted for physical and behavioral healthcare
- Carve in to Managed Care will be delivered by Medicaid health plan
- Emergency Triage and Transportation will be enacted due bill from last legislative session
- HB 4 makes telehealth benefit from COVID permanent, effective September
- Home and community-based settings compliance guidance coming
- Getting ready for 88th legislative session, presenting at various hearings
Hospital Payment Advisory Committee (HPAC) update
Diana Strupp, Chair of HPAC Committee
- Met on August 4th, no rules required a vote
- CHIRP (COVID related claim exclusion on small subset and reprocessing); had to do quality reporting and plans to give provider data
- Medicaid calculations on limitation cap this fall, HHSC convened a work group
- Uncompensated care program under 1115 waiver program hospitals asked if they could pay recoup payments early; yes is permissible by HHSC and moving up payment date to September
- Jimmy Blanton, quality director of HHSC, saw concern over PPC 2021 data due to collection methods; directed 3M to exclude COVID related claims
- Other Medicaid supplemental medication programs: CMS asked for additional info in December and working to address questions on HARP, had more questions in July
- Salil Deshpande – Can you talk about HARP and how it’s different from CHIRP?
- Similar, but HARP is a state plan amendment based on percentage add-on and a fee for service program
Rule Proposals
Submitted to the Texas Register – Administrative Procedures Act public comment period has not closed:
Item 5ai – Individualized Skills and Socialization in the Home and Community-based Services Program and Texas Home Living Program – Rule Proposal
Dana Williamson, Director of Program Policy at Medicaid CHIP Services
- Rule shift for Chapter 260 in Title 26 introduces individualized skills and socialization to replace day habilitation
- Deaf Blind individuals typically do on-site day activity for skills development, but new service has requirements in compliance with Title 42:
- On-site services with more self-direction, want to see lower individual to staff ratios
- Off-site portion in the community including physical activities outdoors matched to each person’s needs and desires
- States have until March 2023 to comply
- Agency received some appropriation for changes to automation, long-term care staff, and licensure; day habilitation providers do not work directly with HHSC but sub-contractors
- Extended time for comment, received 61 comments from 10 stakeholders centered around rates and ratios
- Will publicize when rate meetings will occur
- Providers expressing difficulty complying with newly required ratios difficult with staffing challenges
- Base ratios based on level of need so there’s concern people will need to be grouped by level of need to meet requirements
- No changes to Deaf Blind disability rules but discussing with providers, removing on-site ratios but keeping off-site ratios
- August 12- Sept 12 public comment open; trying to make as many changes as possible based on provider concerns and still meet compliance guidelines
- Member Dr. Deshpande – Is the expectation that existing providers will be doing on-site services? That’s our hope; the pandemic and staff shortages have been a real challenge to providers; hope as many will adopt it as possible
- Off-site services expected from the same providers, even those who didn’t previously offer off-site services? Need work with providers and regulators to be flexible because its difficult if some providers don’t have transportation infrastructure available
- What’s motivation for staffing ratios you created? Focus on health and safety for vulnerable population, especially when off-site, so creates a base expectation; never been ratio guidance before
- Is HHSC also entity that will license providers? Yes
- Member Deshpande expresses concern over HHSC issuing licenses as policymaker rather than licensure organization; Williamson will talk with licensure partners about this
- Chair Tieken – Emphasis on trafficking should be included in this process; Understands she wants training required of providers on this
- Asks for guests to respond to questions/requests from committee within 5 days; Williamson commits to 5 days and may say she needs more time to respond to questions
Public Comment on Agenda Item 5ai
Carroll Smith
- Not present, though pre-registered
Donna Kotzur, President and CEO at ARK of San Antonio
- Draft rules miss intent, negating individual needs and desires
- Integration and community settings not defined
- Need to raise $1.2M to cover costs of transition from policy
- Without collaborative input on these policies, rules can be over-burdensome on organizations like hers
- Member Deshpande – More specific detail about requirements could add more costs and constraints so need to leave it open to provider interpretation a bit; Can you give examples of what you would like to be included?
- As an independent contractor, the constraints that come with serving those with higher levels of need are burdensome
- Going off-site has numerous logistical and legal complications
- Member Svien – What would challenges be for off-site visits in rural communities with compliance?
- Lack of ADA accessibility, cost of entrance, and lack of options in area
- Organization would cover costs but only because they raise money for it
Item 5aii – Individualized Skills and Socialization in the Deaf Blind with Multiple Disabilities Program
Dana Williamson, Director of Program Policy at Medicaid CHIP Services
- Covered in chapter 262 and 263
- Wants providers to use formal comment periods based on ongoing conversations
- Focus on level of need and ratios to give more flexibility to providers
- Enhancement- ability to have an enhanced staff ratio of 2 staff to 1 individual built into rate methodology and rules
- Can be helpful but no ability to go 1:1 or use a larger ratio when appropriate
- Limited funding available but trying to be responsive
- In-home version of services not included in Deaf Blind with Multiple Disabilities Program but doesn’t require a license so different than center-based services; No rate specific to in-home despite lower ratio, still based on on-site center services rate
- When you have need for 1:1, rate enhancement doesn’t provide for it unless individual is of highest need
- Member Svien – Do program rules address transportation for off-site?
- It requires it but no rate attached to it, provider not reimbursed; assumes same rate as on-site services
Public Comment on Item 5aii
Ashley Ford, Director of Public Policy & Advocacy for Ark of Texas
- Noticeable oversights in rules as posted and have serious concerns about implementation
- ISS should help individuals achieve full integration and inclusion based on unique needs and capabilities, but rules as posted fail to do so
- Don’t support name of program- fear it’ll be called ISS- some individuals may have negative history of school discipline with ISS
- “Individualized” not defined, need more clarity on what this means
- “Community setting” needs more intention with definition to ensure “integration”, which is also not defined
- Meaningful daytime activities not well expressed but necessary
- Expresses disappointment with language and ability to implement
Tony Ritter, CEO and President of Advantage Care Services
- Providing on testimony of ISS proposed rules
- Agrees with spirit and concept of ISS’s intention
- Relies on community partners for off-site activities, but it’s expensive so can only do so through local grants and fundraising
- Still losing money annually when actual costs are 2-3x more than proposed state funding
- Has 1:4 ratio due to staffing shortages and it’s expensive to hire more staff
- Transportation costs are also very high for vans, gas, maintenance, repairs, etc.
- Community partners require waivers and liability insurance
- Restrictiveness with licensure also an issue when they don’t have a building, which is required for licensure
- Member Svien – If you’re in Bernie, do you get all your community services there or do you have to go to SA? We sometimes go into SA and drive 15+ miles; finding community partners can be more difficult in more rural areas
- Hadn’t considered insurance, are there any similar costs that aren’t currently covered? Longer trips include lunches, additional staff, etc.
- Chair Tieken – What staffing issues have you faced?
- Shut down September to June due to staffing issues, despite posting widely; people want higher wages; It takes time to train people
Isabel Casas, Texas Council of Community Centers & PPAT
- Removing ratios for on-site, providing in-home services, and providing multiple levels of need at once are all appreciated
- Need ample time for implementation, more than 3-7 months; hiring staff, updating documents, etc. take time
- Smaller provider network will result and reduce access to critical services
- Stand ready to work with HHSC staff to find solutions
- Member Svien – 30,000-40,000 people need changes to their documentation and service plans through this policy, is that right? Yes, documents and meetings for each person would be needed, which takes a great deal of coordination and staffing time
- Why lower the requirement for people? In support of next ruleset; Workforce crisis means if providers can’t staff-up, updating the plans intentionally will take much longer; Has heard of providers not moving forward as ISS provider due to too many unknowns (ratios in place, costs, and rates)
- Chair Tieken – Is there no flexibility in March implementation date?
- Challenge in that CMS may not let them delay, trying to understand what flexibility there is from federal level
Sandra Batton, Providers Alliance for Community Services of Texas
- Removing ratios for on-site, providing in-home services, and offering multiple levels of need at once are all appreciated
- Prescriptive staffing ratios and enhancement triggering 1:2 ratio, lack of provision for 1:1 ratio
- Concerns for viability of program from providers, especially considering staffing shortages
- Don’t want to lose providers who can’t get licensure that don’t have physical space and are entirely off-site
Item 5aiii – LIDDA Service Coordination Qualification
Anne McGonagle, Intellectual and Disability Services
- Reporting workforce challenges in service coordinators, who need a BA to be eligible; suggests Associates degree replacement and allowing work experience to replace education
- Expanding qualifications for individuals with intellectual disabilities could broaden access to these jobs
Chair Tieken
- Amendment was requested by a third-party and did not publish draft rules; public comment period will end August 22
Public Comment on Item 5aiii
Isabel Casas, Texas Council of Community Centers & PPAT
- Appreciate these proposed rules as they address the staffing shortage crisis
- Member Svien – What is the implementation day of the rule and effect on the applicant pool? Would a phased-in approach help?
- In November, it will be an extreme challenge and there’s no guarantee this will increase the applicant pool enough to meet current needs
- Timeline of hiring on staff is about 90 days; phased in approach with as much latitude as CMS could provide would be preferable
Item 5aiv – School Health and Related Services (SHARS) 504 Audiology Services and Parental Consent
Leslie Smart, HHSC
- Allows local education agencies Medicaid reimbursement or direct transportation medical services for IEP students
- Proposed rules implement HB 706 86(R) to permit SHARS providers to bill and receive reimbursement for audiology services students who have a section 504 plan
- Clarifies federal requirement for SHARS to receive parental consent before accessing student’s Medicaid funds
- Public comment will close on September 5; will go into effect October 1 of this year
- Chair Tieken – How closely are rules aligning with federal statute
- Rules require parental consent; is based on the consent portion in federal disabilities act
- Member Svien – Appreciate this rule “has been a long time coming”
Not yet submitted to the Texas Register for APA public comment:
Item 5bi – Home and Community-based Services Program
HHSC Staff
- Are ensuring compliance with federal regulations specifically regarding the person-centered planning process
- Must reflect services preferential to the individual through assessment of functional need
- Already required an annual re-assessment of the individual’s person-centered plan
- Included language by the federal government concerning the definition of home community-based setting
- Have already had room and board agreements; developed guidelines around a “residential agreement” and references to landlord/tenancy laws
- Are a lot of concerns about this section of the rule; this part of the rule was an issue brought forward by providers
- Informal public comment noted rule had language in the rules that could have been interpreted as narrower concerning types of living settings would apply
- Removed language and added language related to federal guidance
- Federal government revised guidance emphasized the heightened scrutiny process to investigate and determine if a particular setting is home-and-community based
- Providers will incur an expense if they must install locks on rooms or if there are any costs related to legal representation to process residential agreement eviction
- Codified level of need increase, included language changes monitoring requirements when official is on a service suspension (proposed change from 90 days to 30 days)
- Added translation requirements of case documentation
- Added language to implement Chapter 531 related to HB 4 which requires HHSC to look at if it is cost effective, option to receive telehealth services
- Included waiver eligibility assessments and another assessment are in person
- Is a cost to local authorities
- Had over 1000 informal comments and most were about home-and-community-based determination
- Member Svien – Appreciate changes related to lease agreements; have opportunity to discuss heightened scrutiny issue; supervision/monitoring could be a telehealth service?
- Did not take that into consideration; could look into that
- Member Svien – Have one provider specifically who has been pushing for that
Public Comment on Item 5bi
Mark Olson, Self
- Comments also cover the Texas Home Living update
- Part of an advocacy group that protects the rights of those with IDDs to live in their chosen setting
- Pleased HHSC adopted changed rule concerning final settings rule
- Ask the committee to review their proposed rule changes relating to other aspects to the final settings rule
- Remote monitoring is a good way to reduce cost of service
- HHSC Staff – Do not see anything in his proposal we would have issue with including
- Member Svien – Is there a reasonableness of having visitors at any time?
- HHSC Staff – Reasonable that those living in the home can determine when they can have visitors; cannot be a provider decision
Donna Slocum, Self
- Parent to an adult with severe autism; advocates for the use of intentional communities
- Need options so the needs of different individuals can be met; need to expand HCS living options
- Member Svien – Example of a non-traditional environment you are talking about?
- Apartment-style houses in the same area
Dr. Elisa Stickney, Self
- Parent of 25-year-old man with Autism
- In favor of expanding in-home HCS residential options because individuals with disabilities deserve options as to how they want to live, not just in group homes and institutions
- Agrees all planning should be person-centered
Leslie Russel, Self
- Speaking on behalf of 24-year-old daughter with multiple disabilities and behavioral challenges
- Options slowed after high school due to limited behavioral intervention options with customized support
- HCS day-programs and group homes aren’t the right fit and wants a person-centered plan for her daughter
- Asks to allow families to have more choices with HCS funding
Isabel Casas, Texas Council of Community Centers & PPAT
- Wants families to have more choices with HCS funding for more housing options
Ashley Ford, Ark of Texas
- Requests more housing options for people with IDDs who need and want to live outside of their homes to give them more freedom and control over their housing options
- Give them options to interact with people without IDDs
Debra Caudy, 29 Acres
- Represents her 24-year-old son with autism, founder of 29 Acres (independent living facility), and a physician
- Facility allows individuals with IDDs to choose to live there with independence based on their needs and capabilities
- Thanks HHSC, in favor of heightened scrutiny for living arrangements to increase housing options in Texas for people with IDDs
- Should hold providers accountable for providing quality care
- Chair Tieken – Wants more knowledge about rule with tweaking; asks room to raise hand if they’re in favor with tweaking and majority of people in the room raise their hands
- Chair Tieken – With tweaking, can we make this work
- Williamson – Certainly; asks for opportunity to publish in register their commitment to work with interested stakeholders
- Expresses there’s still a step of heightened scrutiny communities need to go through
- Item 5bi on Home and Community Services Program approved by committee
Item 5bii – Home Living (TxHmL) Update
Dana Williamson, Director of Program Policy at Medicaid CHIP Services
- Taking into consideration language around person-centered planning and right to control
- Long-term care regulatory taking control of some rules
- Requests ACA approval
- Item 5bii on TxHmL approved by committee
Mark Olson, Self
- Suggested changes discussed with Ms. Williamson wants to see in Texas home waiver
Item 5biii – Transition Assistance Services
Dana Williamson, Director of Program Policy at Medicaid CHIP Services
- TAS funding helps individuals moving from institutional setting into the community
- Administrative transfer process didn’t allow for many changes, now replacing and cleaning up some rules
- Received comment to adopt approval of providing transition services to Deaf Blind individuals, but saw it as outside the scope of this project
- Said it could be provided in setting with independent living with multiple roommates
- Suggests approval
- Member Svien – emphasizes importance of this project to help support individuals financially as they transition out of institutions
- Item 5biii on TAS approved by committee
Proposed next meeting: November 10, 2022, at 9:00 a.m.
Adjourned